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Settling in or just settling? Exploring older adults' narratives of relocation to assisted living Rockwell, Jasmyne 2017

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SETTLING IN OR JUST SETTLING?  E XPLORING OLDER ADULTS’ NARRATIVES OF RELOCATION TO ASSISTED LIVING by  Jasmyne Rockwell B.A. Simon Fraser University, 1998 B.S.W. Thompson Rivers University, 2005 M.S.W. The University of British Columbia, 2008  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Social Work)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver)   December 2017  © Jasmyne Rockwell, 2017 ii  Abstract   Since 2001, British Columbia has seen an expansion in the assisted living (AL) segment of supportive housing for older adults. Values associated with AL typically include independence, choice, self-direction, and autonomy, which position it as an attractive alternative to traditional residential care models or ‘nursing homes.’ Yet, there have been few studies that critically examine AL in the Canadian context. Such investigations are important because of the variation in AL facilities internationally. Also, there is lack of research generally on the significance of the transition to AL for older adults or what their experiences are once they have arrived.   The purpose of this study was therefore to explore older adults’ narratives of moving to AL, in order to learn about their relocation experiences and how they fit with the overarching goals and values of AL. To do this, the study employed thematic content analysis of 18 provincially-focused, publicly available documents about AL. Collectively, the documents addressed both service users and providers and spoke to expectations and regulations for service delivery.  The study also employed multi-level narrative analysis of four older adults' relocation stories, gathered over the period of a year.   Findings from the study indicate that there are tensions between the foundational values and purposes of AL, how these are operationalized at the facility level, and how they are experienced by those moving in. While participants were generally pleased with the supportive and health care services they accessed by relocating, their accounts also highlighted a lack of social connection within AL and restrictions to choice in a variety of areas including dining and recreational pursuits. However, the findings also illuminate positive and innovative practices that iii  can ease the transition to AL. Recommendations include: 1) finding avenues for residents to express their choices in meaningful ways, such as increasing resident input at an organizational level and expanding the type of activities offered; and 2) offering more deliberate facilitation of social and place connections in AL through an increased role for social workers in AL, peer support programs, and stronger community ties.   iv  Lay Summary  Since 2001, assisted living (AL) has become a popular type of housing plus supportive care for older adults in British Columbia. Values associated with AL typically include independence, choice, self-direction, and autonomy, which position it as an attractive alternative to traditional residential care models or ‘nursing homes.’ This study examined the relocation stories of older adults who had moved to AL, as well as documents related to advertising and regulating AL in this province. The findings show that there are some tensions between the guiding values of AL and how services are carried out in facilities. While participants were generally satisfied with the personal care services they received, they were less content with meals and the social and recreational opportunities offered. Participants’ insights were used to generate recommendations that could improve the relocation and settling in process older adults.     v  Preface This dissertation is an original intellectual product designed, conducted and written by the author, Jasmyne Rockwell.  Ethical approval for this research study was obtained from the University of British Columbia’s Behavioural Research Ethics Board. The certificate number for the study entitled ‘Settling in: Exploring older adults' narratives of relocation to assisted living,’ is H13-00043.  Links to internet pages and documents referenced in this dissertation have been checked for functionality as of September 18, 2017.  vi  Table of Contents  Abstract .......................................................................................................................................... ii Lay Summary ............................................................................................................................... iv Preface .............................................................................................................................................v Table of Contents ......................................................................................................................... vi List of Tables ..................................................................................................................................x List of Figures ............................................................................................................................... xi List of Abbreviations .................................................................................................................. xii Acknowledgements .................................................................................................................... xiii Dedication ................................................................................................................................... xiv Chapter 1: Introduction ................................................................................................................1 1.1 Point of entry................................................................................................................... 1 1.2 What is assisted living? ................................................................................................... 2 1.3 AL in British Columbia .................................................................................................. 5 1.4 Overview of the chapters ................................................................................................ 8 1.5 A note on language ......................................................................................................... 9 Chapter 2: Conceptual Context ..................................................................................................11 2.1 Guiding paradigms ........................................................................................................ 11 2.1.1 Critical theory ........................................................................................................... 12 2.1.2 Social constructionism .............................................................................................. 12 2.2 Discourses of ageing ..................................................................................................... 17 2.2.1 The biomedical discourse of ageing ......................................................................... 18 vii  2.2.2 The economic discourse(s) of ageing ....................................................................... 21 2.2.3 The discourse of successful ageing ........................................................................... 25 2.2.4 An alternative discourse of ageing ............................................................................ 31 2.2.5 Section summary ....................................................................................................... 38 2.3 Transition ...................................................................................................................... 39 2.3.1 Conceptualizing transition ........................................................................................ 41 2.3.2 Transition to AL in the literature .............................................................................. 47 2.3.2.1 Precipitating and contextual factors of relocation ............................................ 49 2.3.2.2 Effects of relocation .......................................................................................... 52 2.3.2.3 Influential features of life in AL ....................................................................... 58 2.4 Chapter summary and statement of research purpose ................................................... 64 Chapter 3: Research Design and Methodology .........................................................................67 3.1 Qualitative, critical and narrative methods ................................................................... 67 3.2 Data generation ............................................................................................................. 70 3.2.1 Participant recruitment .............................................................................................. 70 3.2.2 Documents ................................................................................................................ 73 3.2.3 Participant interviews................................................................................................ 74 3.2.4 Field notes and research memos ............................................................................... 76 3.3 Data analysis ................................................................................................................. 77 3.4 Validity and credibility ................................................................................................. 82 3.5 Introduction to the participants and AL sites ................................................................ 83 Chapter 4: Document Analysis: What is the Conceptual Story of Assisted Living? .............86 4.1 Selection of documents ................................................................................................. 86 viii  4.2 Analysis......................................................................................................................... 90 4.2.1 Seniors housing and care directories......................................................................... 92 4.2.2 Promotional material from three private AL operators............................................. 99 4.2.3 Provincial regulatory legislation and policy documents ......................................... 105 4.2.4 Vancouver Coastal Health Authority documents ................................................... 119 4.2.5 Site-specific subsidized AL facility handbooks ...................................................... 128 4.2.6 Discussion and summary ........................................................................................ 136 Chapter 5: Rose: Doing Something and Feeling Useful .........................................................139 5.1 Introduction ................................................................................................................. 140 5.2 About Rose.................................................................................................................. 143 5.3 Moving In.................................................................................................................... 147 5.4 Settling In .................................................................................................................... 156 Chapter 6: Ian: So What Are You Going to Do About It? ....................................................168 6.1 Introduction ................................................................................................................. 169 6.2 About Ian .................................................................................................................... 173 6.3 Moving in (and in, and in) .......................................................................................... 178 6.4 Settling in .................................................................................................................... 187 6.5 Forest Place: The Tour ................................................................................................ 195 Chapter 7: Findings: Bringing the Stories Together ..............................................................202 7.1 Linking participant narratives to AL discourses and policies ..................................... 203 7.1.1 Care and Service Plans............................................................................................ 203 7.1.2 `Food and dining ..................................................................................................... 212 7.1.3 Social and recreational opportunities ...................................................................... 221 ix  7.2 Participant narratives: What do they tell us? .............................................................. 229 7.2.1 Narrative construction ............................................................................................. 229 7.2.2 Discourses of ageing in the narratives .................................................................... 239 Chapter 8: Summing Up and Looking Forward .....................................................................248 8.1 Findings related to AL ................................................................................................ 250 8.1.1 (Meaningful) choice ................................................................................................ 251 8.1.2 Connection .............................................................................................................. 256 8.1.3 Some remaining observations about AL in British Columbia ................................ 261 8.2 Findings related to Narrative ...................................................................................... 266 8.3 Recommendations and future research ....................................................................... 278 8.3.1 Facilitating resident choice ..................................................................................... 279 8.3.2 Greater facilitation of connection ........................................................................... 281 8.3.3 Areas for future research ......................................................................................... 286 8.4 Final thoughts: Settling in versus just settling ............................................................ 287 References ...................................................................................................................................289 Appendices ..................................................................................................................................322 Appendix A Recruitment Poster ............................................................................................. 322 Appendix B Consent form ...................................................................................................... 323 Appendix C Interview guide ................................................................................................... 327 x  List of Tables  Table 4-1 Seniors housing and care directories ............................................................................ 98 Table 4-2 Promotional material private AL ................................................................................ 104 Table 4-3 Provincial regulatory legislation and policy documents ............................................ 118 Table 4-4 Vancouver Coastal Health Authority documents ....................................................... 127 Table 4-5 Subsidized AL facility handbooks.............................................................................. 135 Table 8-1 Recommendations.......................................................................................................281  xi  List of Figures Figure 7-1 Care and service plans ............................................................................................... 206 Figure 7-2 Food and dining......................................................................................................... 215 Figure 7-3 Social and recreational opportunities ........................................................................ 222  xii  List of Abbreviations AL – Assisted living  ADL – Activities of daily living IADL – Instrumental activities of daily living QOL – Quality of life   xiii  Acknowledgements  Although most of this dissertation was written up alone in one room or another, I always knew there was a network of support and well-wishers urging me along. In this space I would like to acknowledge those who literally made this project possible.   First – I so appreciate the time, wisdom, and enthusiasm of my participants. It was a privilege to hear your stories.   Second, I would like to thank my supervisor, Dr. Deborah O’Connor, for her encouragement and mentorship, especially during the times when I could not see the forest for the trees. I would also like to thank my committee members, Dr. Joanie Sims-Gould, and Dr. Jennifer Baumbusch for their solid support and feedback. I owe a special thank you to my third committee member, Dr. Clive Baldwin, for providing transcription resources as well as valuable methodological guidance.   Third, I would like to express my deep gratitude to my army of friends for their never-ending cheerleading, and to my family for the necessary emotional and tactical support in juggling parenthood and academia.   Finally, I must thank my PhD cohort and friends. There is no one who can understand this process as you can; laughing and commiserating with you kept me going, many times over.   xiv  Dedication To Brian, who was the first person to say, “Go for it!” (And who kept saying it when the going got tough).   To Beatrix and Jasper, two very important chapters in my life.  To my mom, who never doubted that I could (or should). To my dad, who would have read every word.   1  Chapter 1: Introduction  1.1 Point of entry  I worked, for a time, as a social worker on an acute care ward for older adults. In this setting, patients and their families often had to grapple with the difficult reality that the older adult could no longer remain in their home, even with support.  For individuals with the most complex medical needs who were to transition to long term residential care1, the hospital staff and dedicated transition team were available to assess, counsel, and place the individual. For those moving to assisted living, however, I often felt at a loss as to what to say or do. Assisted living (AL) was the purview of community case workers, and as I had only just started working in health care I did not know much about the system ‘out there,’ off the ward. My involvement in these cases was mostly related to recovery and the practicalities of returning home. In terms of AL resources, all I had to offer was a sympathetic ear and a small publication of property listings across the province. The message I took in was that moving to AL was somehow better, or at least less drastic a change, than moving to a long term residential care facility. Yet, I could see that the weight of the pending relocation was felt just as deeply by older adults and families.    Eventually I moved to a position as a social worker in a long term residential care facility, where I worked on the other side of the relocation process to receive and settle new residents. There were ample issues and questions to study in this environment, some of which I researched during my Masters degree. Yet, when I began my doctoral studies I found myself returning to the topic of older adults and AL.  I had witnessed what it was like for individuals to                                                  1 For a definition of long term residential care, see sections 1.2.  2  enter into the highly organized environment of long term care, but I wondered what the experience would be like in a supposedly more independent environment. How did older adults feel about moving to AL? What was it like to live there? How did their expectations about AL match the reality of relocating? I began with a literature search, which identified several trends and gaps in the existing research that helped to define my research focus and questions. In particular, it became clear that ‘assisted living’ is a term that has been applied to similar, yet varying, models that are meant to espouse a core philosophy. In the following sections I present a brief history of the AL model of care and define the way that it is structured in British Columbia.   1.2 What is assisted living?   ‘Assisted living’ refers to a level of housing plus some supportive and health care for older adults. The concept originated relatively recently in the United States, but has also been taken up other Western countries such as Canada, Australia, New Zealand, the Netherlands, and Sweden and the UK. However, understanding where it fits in the spectrum of care is challenging, because of the variations in terminology used internationally. Before discussing the evolution of AL in the United Sates and its spread to Canada, I will therefore briefly outline the different terms used in the two countries that are used to refer to similar types and levels of care.   In Canada, both ‘continuing care’ and ‘long term care’ are used to describe the entire spectrum of care for older adults, but ‘long term care’ and ‘long term residential care’ are also used in the majority of provinces and territories (including British Columbia) to refer to a facility that provides the maximum level of institutional care, employing 24-hour skilled nursing for the most physically/cognitively frail older adults. Of note for this study, some maximum-level facilities in British Columbia refer to their services as ‘complex care’, and I adopt this language 3  at points when this is the terminology used by the specific facility I am referring to. ‘Residential care,’ in Canada, generally refers to any kind of custodial facility for older adults with supportive or care services, including AL and long term residential care homes.  In contrast, ‘long term care’ is used in the United States as an overall term to describe a range of elder care services from in-home support to institutional care. Facilities providing maximum support are referred to as nursing homes. Therefore, although ‘nursing home’ is not as widely used in Canada, I use it at points where I am citing American literature.  In the United States, ‘residential care’ and ‘residential care homes’ refer to various types of housing including assisted living, rest homes, and adult foster care, with the exclusion of nursing homes.   Keren Brown Wilson, one of the original AL advocates and operators in Oregon, has traced the development of AL from discrete beginnings on the East coast and West coast of the United States in the 1980s (Wilson, 2007). She asserts that “the early models of assisted living emerged in reaction to nursing facilities and a vision of a different way of bringing physical environments, care and service capacity, and philosophy together to offer a more desirable product to older people” (p.9). Key constructs in this early picture of AL remain ideological cornerstones of the model today. These include: 1) homelike environments that are adaptable to changing needs but also private and personalized; 2) the provision of services to enhance individual physical and emotional well-being; and 3) a particular orientation to values that preserve self worth, such as a focus on ability and supporting autonomy and decision-making (including the right to live with some degree of risk to self) (Wilson, 2007, p.11).  Being able to age in place was also a founding vision for AL, but differences in state regulations and funding structures resulted in two approaches to development.  For example, on the West coast, Oregon negotiated a government-subsidized “living center with assistance” to provide an alternate level 4  of care, including some medical and health related supports, for older adults who did not need to live in a full nursing home, while on the East coast, privately owned AL facilities also provided an alternative to nursing homes, but state restrictions limited the tenancy of residents with more complex medical or physical limitations (Wilson, 2007, p. 13). As a result, private facilities tended not to develop in-house services and instead helped families arrange for additional care, until lack of finances or additional resources necessitated a move to a nursing home (Wilson, 2007, p. 13). These two models of AL currently continue to co-exist in the United States.    The development that early advocates could not foresee, however, is that the initial variation in AL models has proliferated further, so that operators use the term ‘assisted living’ to refer to multiple models of care (Hernandez, 2006; Mollica, 2008; Stone & Reinhardt, 2007) with varying levels of  adherence to the original vision of the AL movement (Hernandez, 2006; Wilson, 2007).  Ageing in place for example, remains part of the rhetoric of AL in the United States (Chapin & Dobbs-Kemper; 2001; Hernandez, 2006), but instead of simply wrapping services around the person in situ, there are now stratified levels of AL for basic, moderate and high care needs, including some specialized homes that accept persons with dementia (Hernandez, 2006). So, even though there is a common discursive ideal of AL, it appears that a standard type or level of care does not strictly exist in AL in the United States. It also seems that the line between nursing homes and AL may be becoming blurred.    The AL model of housing plus support began to appear in Canada in the early 1990s (McGrail et al., 2012). While the terminology used to describe the levels in the spectrum of Canadian elder care services varies in different provinces and territories (Hollander & Walker, 1998; McGrail et al., 2012), most offer a level called AL, intermediate care, independent living with tenant services, or supportive housing. These labels refer to a congregate housing 5  arrangement with a level of support that is a middle step between a private home and long term residential care. As with the United States, there are both government-subsidized and privately funded versions of this level of care across the country.   Despite any differences between the historical vision and values of AL and the myriad of ways they have been taken up in international facilities, AL continues to occupy a unique conceptual place in the minds of older adults, somewhere between the ideal of remaining at home and the spectre of fully institutionalized care (Imamoğlu, 2007). Values typically associated with AL are independence, choice, self-direction, and autonomy, which position it as an attractive alternative to traditional residential care models. Although this result is perhaps partly because AL has only emerged in the last several decades and many people have not yet had direct experience with it, this positive image is arguably bolstered by the consumer discourse surrounding AL, which situates it “as one choice in a marketplace where older persons act as rational and informed shoppers, seeking the goods and services that best meet their personal preferences” (Carder & Hernandez, 2004, p. S58).  1.3 AL in British Columbia  I turn now to the growth and development of AL in British Columbia, the province in which this research is set. British Columbia has adopted the language of ‘assisted living’ and was the first province to regulate AL.2 To legally call a facility assisted living, operators must register and provide private, lockable suites, with or without cooking facilities, provide five “hospitality services” (meals, housekeeping, laundry, a 24 hour emergency response system and                                                  2 In BC, both older adults and younger adults with developmental disabilities may reside in housing labelled as AL; in this study I will be focusing strictly on the former. 6  opportunities for socialization and recreation) and at least one to two “personal assistance services” such as help with activities of daily living3, taking medications, or monitoring of nutrition (Office of the Assisted Living Registrar, 2009, p. 4-5). The core principles of these residences, as defined by British Columbia’s Assisted Living Registrar (2009) are meant to support the “choice, privacy, independence, individuality, dignity and respect” of older adults, as well as their right to live with a degree of risk to self (p.3). Individuals may live in AL as long as their physical care needs do not require 24-hour skilled nursing or exceed a certain amount of care hours per day. An important distinction from some American models is the limit to service levels in British Columbia: individuals who have cognitive impairment to the degree that they might put themselves or others at risk through their actions are not eligible to move to or remain in AL.  In addition, ageing in place is not a tenet of AL in this province, and approximately half of those who move to AL will eventually move on to long term residential care because of increased care needs (McGrail et al., 2012).   The growth of AL in British Columbia occurred as part of a provincial restructuring of home and community care services beginning in 2001. The outcome was a series of changes that reduced the hours of both non-medical home support and medical home care available to older adults in the community, saw the closure of 26 publically-funded long term residential care facilities in the province, and restricted entrance eligibility for the remaining long term residential care to only those with “complex” care needs (Cohen, Murphy, Nutland & Ostry, 2005, p. 5-6). Also in the process of restructuring, three tiers of intermediate-level residential care were removed (Cohen, Tate & Baumbusch, 2009), resulting in a service gap for older adults                                                  3 Dressing, grooming, eating, mobility, and  bathing 7  who needed more assistance than what home care/support could now provide, but not enough to qualify for long term residential care. AL was viewed as a model that would address that gap (Cohen et al., 2009; McGrail et al., 2012).   Critics of the restructuring pointed out several issues related to these changes. First, during the 2001 provincial election campaign, the (victorious) Liberal party promised to build 5,000 subsidized long term residential care beds. Over time, their targets were changed to include AL and supported housing units as comprising over half of the 5,000. The result was an actual reduction of 804 long term care residential care beds between 2001-2008 (Cohen et al.,2009, p.22). Second, at the same time as the cuts to long term residential care, the number of acute care beds in the province was reduced, which resulted in older adults waiting in hospital for long term residential care spaces and people in the community being unable to access acute care beds (Cohen et al., 2005). As I experienced in my time working in the acute care ward with older adults, individuals who were waiting for long term care beds were then pejoratively cast as ‘bed blockers’, when in fact they were the symptom of a problem rather than the cause.  Third, the provincial government justified the prioritizing of AL over long term residential care by suggesting they were listening to public preference over what model of care was more appealing.  Yet, because the cost of long term residential care in British Columbia is partially born by the provincial Ministry of Health, critics pointed out that AL saved the government money by shifting costs to the older adults. Although most meals, housekeeping and light personal care are covered in the monthly rate for the current government-subsidized AL (the rate of subsidy is based on income level), the rest of the costs of living remain the responsibility of the individual. So, “the shift to an assisted living model may be more about limiting government’s responsibility than about providing ‘a homelike atmosphere’” (Cohen et al., 2005, p. 22).  8   Perhaps at least partially as a result of these changes, research suggests that AL may not actually provide the level of care needed by many older adults who live there: where older adults used to have more gradients of care available via greater provision of home support/care and the levels of intermediate care offered in residential facilities (Cohen et al., 2009), they now appear to arrive in AL at an already high level of care and often must subsequently relocate (Araki, 2004). One study calculated that more than a quarter the people in AL move out of within one year (McGrail et al., 2012).   In spite of these critiques, AL is an increasingly important part of the system of care for older adults in British Columbia. As of 2014, there were 4,422 registered subsidized AL units in the province and 3,213 registered private pay units for a total of 7,635 units (Office of the Seniors Advocate, 2015). In light of the above discussion on the founding philosophy and goals of AL, the current variations in structure, and the controversy around the growth of AL in British Columbia, this model of housing plus support needs to be better understood in terms of its role in health and social care for older adults. The goal of this research is to begin to critically examine the intersection of the philosophies, policies and personal experiences of AL in the context of British Columbia.   1.4 Overview of the chapters   The format of this dissertation follows my research stages of conceptualization, operationalization, investigation, analysis and reflection. Chapter Two provides a conceptual framework for the research in terms of the central theories, discourses, and literature that informed my approach. Understanding some of the assumptions and discourses around ageing, scholarly work on transitions, and the relevant literature on AL was an important grounding from 9  which to begin my project. The chapter concludes with a statement on the purpose of the research. Chapter Three outlines the methodological approach that structured the project, including research design and analysis. I also address the challenges faced in relation to carrying out the study and my responses to them.  Chapters Four through Seven present the research findings. In Chapter Four I provide an analysis of relevant policy and information documents about AL in British Columbia in order to understand the conceptual and political discourses surrounding it. Chapters Five and Six offer an extended engagement with the relocation narratives of two participants, Rose and Ian. Following this, Chapter Seven synthesizes the major cross-case findings from all the participants alongside the documents and discursive themes discussed in Chapter Four. It also discusses some of the potential influences on the participants’ choices in structuring their narratives and highlights the way that participants reference ageing. Finally, Chapter Eight discusses the study’s findings in relation to current literature and AL policies, provides recommendations and implications arising from the data, and suggests areas for future research.   1.5 A note on language  In keeping with the emphasis on language and discourse in this paper, it is important to comment on the spelling and terminology used throughout this paper. First, American literature tends to use the spelling ‘aging’, whereas the UK and other Commonwealth countries tend toward ‘ageing.’ In this paper, both spellings will be used according to the original spelling in any quoted material and according to my own preference for using ‘ageing’ in all other cases.   Second, in line with the recent trends in gerontological literature, I will be referring to my participants and to persons of this age demographic as older adults. As Putnam (2015, p. 229) 10  asserts, the term older adult “seems to imply less reduction in individual physical or mental status” than do the terms “elderly adult” or “senior.”  As with many terms for members of marginalized populations, there is an implied powerlessness or ‘othering’ inherent in the terms ‘elderly’ or ‘senior’. Adopting the language of older adult is an attempt to recognize that persons of high chronological age do not transform into a separate segment of the population, but remain full members of society.    11  Chapter 2: Conceptual Context    My interest in exploring older adults’ experiences of moving to, and living in, AL began through my own lack of knowledge about what distinguished it from long term residential care and how relocation to it might be different as a result. In order to move to a broader understanding of this phenomenon, I turned to theoretical and research literature related to my specific research interests. As Maxwell (2005) explains, how one makes use of existing scholarship and how one narrows a research focus is related to the researcher’s chosen paradigm. Paradigms are “a set of very general philosophical assumptions about the nature of the world (ontology) and how we can understand it (epistemology), assumptions that tend to be shared by researchers working in a specific field or tradition” (p. 36). I therefore begin this chapter with an overview of my guiding paradigms – critical theory and social constructionism. Following this, I present a discussion on the Western discourses of ageing that currently provide a backdrop to our expectations and responses to older adulthood. Finally, I bring in scholarship around transition and life in AL, including a discussion of the current state of research and knowledge in this area. My goal is to demonstrate the rationale for the study and set the framework for the methodological and analytical approaches taken in the course of studying older adults’ transitions to AL.   2.1 Guiding paradigms  My approach to this project was informed by two paradigms that share important underpinning values, beliefs, and assumptions, but also have distinct areas of emphasis. Used together, they provide a more complete investigational lens and speak more aptly to my own 12  ontological and epistemological position. In this section I will outline the aspects of critical theory and social constructionism that informed my research.  2.1.1 Critical theory   Critical theory initially emerged in the 1920s from the Institute for Social Research in Frankfurt, Germany. From its inception, it has been concerned with “how things have come to be the way they are and what they might be in the future...[and] the wider truth or validity of what is currently the case” (How, 2003, p. 3). In other words, existing social structures and relationships have been shaped over time but they are not the only possible ones; through careful reasoning and examination we may find those that are more just or appropriate. So rather than critiquing for its own sake, critical theorists challenge the historical, political, ideological, and economic circumstances that have generated our normative social ideals and oppressive social structures, with the goal of opening up the possibilities for an improved society (How, 2003; Kincheloe & McLaren, 2005). Over time, multiple critical theories have evolved, but a unifying feature among them continues to be the “substitution of power for truth as the primary focus of analysis” (Tallack, 1995, p. 3). For social workers and other researchers interested in issues of power and equity, critical theory offers a paradigm that recognizes the marginalization of different groups and offers a way of linking academia with political action and social change.  2.1.2 Social constructionism  Although social constructionism4  has variations across different disciplines (i.e. sociology, psychology, linguistics), there are several common interrelated ontological assumptions. First, constructionist social theory proposes that reality, truth, and knowledge about                                                  4 Although the terms ‘constructionist/constructionism’ and ‘constructivist/constructivism’ are closely related and sometimes used interchangeably, I have chosen to use the former terminology to avoid any association with educational psychology, where ‘constructivism’ is used in relation to learning theory. 13  our world are not simply existing ‘out there’, inertly waiting to be discovered. It holds that there are certain material constants, but how these constants are named, categorized and responded to is the product of human interpretation. For example, we can see that there is a mountain, but the arbitrary word for it, the legends around it, or significance of it have been constructed by humans. “The goings-on between people in the course of their everyday lives are seen as the practices by which our shared versions of knowledge are constructed” (Burr, 2003, p. 4). By extension, social systems, institutions and practices are not abstract entities exerting influence on human lives, but are comprised of “the actual activities of actual people” (Smith, 2005, p. 54) as they take place over time and space.    Second, social constructionism operates from a critical stance. It urges us to open up “taken-for-granted understandings of the world, including ourselves...and to challenge the view that conventional knowledge is based upon objective, unbiased observation of the world” (Burr, 2003, pp. 2-3). Thus, one of the major areas of focus within social constructionism is the deconstruction and interrogation of language, because it is one of the fundamental ways that social reality and culture are produced (Green, 1983; Habermas, 1983). Deconstruction is the idea that, whatever has been constructed can also be taken apart by exposing the assumptions inherent in a concept “and systems of opposition within it” (Burr, 2003; p. 201). A classic example of this is the binary division of gender and the normative ascriptions we have for ‘men’ and ‘women’. When one considers the great variation that exists within genders and the experiences of people who identify as neither, categorizing certain traits or roles as strictly belonging to either men or women is difficult. Gender can therefore be seen as a social construct that does not exist outside of human interpretation. Green (1993, p. 15) makes a similar argument in relation to ageing: 14  It follows from the principle that social reality is made in and of language that there is no such extralinguistic thing as aging or the aged (or any other social category). They are rendered realities achieved in linguistic practices of naming, describing, classifying, referencing, and the like, both in ordinary language and specialized discourse.   Third, social constructionism holds that “all ways of understanding are historically and culturally relative” (Burr, 2003, p. 4). The implication of this is that our conceptions of, and responses to, events, customs and practices, social groups, norms, and institutions have shifted over time and will shift again. Woven with our temporal understanding is our cultural interpretation of these phenomena. Part of the critical stance is therefore recognizing that what we accept as fact or truth about something is influenced by the partial nature of our current knowledge about it and by the biases particular to our culture or epoch. Age, for example, has been constructed differently across different cultures and different historical periods, as I discuss in the next section. Because of the multiplicity of standpoints and the shifting context of history, there is not one version of events or one truth about a phenomenon; rather there are multiple ways of knowing and multiple truths. Social constructionism therefore links with critical theory in its position that “knowledge and social action go together” (Burr, 2003, p. 5). By critically interrogating our assumptions about the causes of social problems or injustices, and by recognizing the multiple ways they manifest and are experienced, we can respond with more effective, equitable and creative solutions.   For many social constructionist researchers, these three aspects come together in a focus on discourse and power. Arguably, one of the most influential scholars in this area has been Foucault (Honderich, 1995). Discourse in a Foucaldian sense “refers to a system of possibility for knowledge; or, ways of talking and thinking” (Cheek & Rudge, 1994, p. 584). It is the 15  storyline we use in reference to a phenomenon; “a systematic, coherent set of images, metaphors and so on that construct an object in a particular way” (Burr, 2003, p. 202). But because different storylines can be told according to different social locations or vantage points, there are a multitude of discourses possible about any one thing. For example, is climate change an elaborate myth or a legitimate threat? What is the definition of a ‘family’?    The question, therefore, is how one story becomes dominant or seen as the ‘true’ version. A Foucauldian perspective proposes that dominant discourses arise from the interplay between historical conditions/contexts and the power of certain groups to influence: “One discourse, or discursive framework, gains prominence at any moment over other discourses by a product of social, political, historical and other structural influences operating on those discourses” (Cheek & Rudge, 1994, p. 584). For example, Foucault’s study of sexuality and medicine has demonstrated how the inherently neutral, disorganized entity of the body has been interpreted according to the values and interests of various historical epochs “to impose categories such as ‘good’ and ‘evil’, ‘natural’ and ‘unnatural’, ‘virtuous’ and ‘sinful’” on bodies and practices (Garner, 2007, p.405). Individual subjects are then defined and treated according to how they meet the criteria for ‘normal’ or desirable bodies and practices; deviance from this norm is marked using labels such as homosexual, disabled, criminal, insane, or sick.  This categorization is achieved through the power of those intellectuals and professionals we legitimize as experts – professors, teachers, scientists, doctors, lawyers and bureaucrats, for example – to ‘manufacture’ knowledge and truth by virtue of marginalizing or silencing competing knowledge claims and alternate discourses. To illustrate, in Canada acupuncture is not considered ‘real’ medicine according to the mainstream healthcare system. Despite its use in China for thousands of years, acupuncture in the West has had to undergo scientific testing to gain a modicum of legitimacy 16  here, and it remains only ‘complementary’ to mainstream Western medicine. “[T]here is a dynamic relationship between power and ‘truth’ where truth is a product of dominant discursive frameworks shaped and defined by power, whilst power is legitimated on the basis of expert ownership of such ‘truth’” (Cheek & Rudge, 1994, p. 585). Western medical professionals and scientists disseminate their truth about medical treatment and operate our medical system, ensuring a cyclical relationship between the generation of ‘truth’ and power.   A key part of analyzing dominant discourses is, therefore, the effect and means of power in their production (Foucault, 1982). Widely cited in critical social science literature, Foucault’s metaphorical application of Bentham’s Panopticon to modern social structure speaks to the role of surveillance in upholding dominant discourses. The panopticon is a hypothetical tower constructed so as to allow a supervisor in the centre of the tower to see into the cell of every inmate at all times, “to induce in the inmate a state of conscious and permanent visibility that assures automatic functioning of power” (Foucault, 1977, reprinted in Garner, 2007, p. 415). The supervisor may or may not be present, but the inmate cannot know this and therefore monitors her/his own actions to comply with the expected behaviour and avoid discipline. This metaphor demonstrates how the monitoring of self and others is both a means and an effect of the discursive power of ‘experts’. “It is an important mechanism, for it automatizes and disindividualizes power. Power has its principle not so much in a person as in…an arrangement whose internal mechanisms produce the relation in which individuals are caught up” (Foucault, 1977, reprinted in Garner, 2007, p. 415-416). The power to define ‘knowledge’ is dispersed into omnipresent, anonymous entities so that ‘truths’ about our social world appear natural and incontestable.  Importantly, Foucault (1982) also conceptualized resistance as a form of power, 17  which recognizes the potential of individuals to be active agents and to create alternative discourses.  In the next section, I will draw on social constructionism to critically examine the discourses that have constructed our Western concepts of age and ageing. Through what contexts and processes have they been constructed? What effect does this construction have on our social institutions and personal lives? What are the alternate discourses? Understanding what storylines older adults have to interpret and explain their experiences of ageing, or how these storylines have influenced our system of elder care, is an important backdrop to this study’s design and analysis.   2.2 Discourses of ageing  The current conception of ‘old age’ as a distinct phase of life with unique problems, needs and interests is a modern phenomenon (Gilleard, 2002; Hazan; 1994; Johnson, 2005b; Katz, 2009; Phillipson, 1998). The roots of such thinking can be traced back to the Enlightenment, which heralded a transition away from religious cosmological thinking. Until this point, humanity was seen as part of a divine universal order. With the advancement of scientific methods and equipment that enabled more of the earth and the heavens to be discovered than ever before, Western thinking began to reflect the notion that humanity could ‘step outside’ nature and “handle [it] from a point in the universe outside the earth” (Arendt, 1958/1998, p.262). Freed from the bounds of religious interpretation, scientists began to configure a new order of the world based on human perception, detached rationality, and observation. This order was applied successively to the physical world as well as human society, and helped to replace the cyclical conception of life with “one modelled on a rising and descending staircase” 18  (Johnson, 2005b, p. 565). The continued growth and dominance of the scientific paradigm and its focus on “calculation, division and hierarchy” (Katz, 2009, p.32) arguably recast age as something other than an accepted part of the life cycle. Later, the advent of industrialization and capitalism helped to increasingly define and shape the borders of ageing and the aged.  Today in mainstream Western society, ageing is typically approached in terms of a ‘problem’ to be solved or managed. According to critical and social constructionist theory however, any problems are not inherent in ageing itself; rather, they are the result of a particular way of conceptualizing and responding to age. Three main discourses currently form the basis of policies and programs for older adults: biomedical, economic, and successful ageing.  2.2.1 The biomedical discourse of ageing  “The biomedical model both colonizes notions of old age and reinforces ageist social prejudices to the extent that infirmity and decline stand for the process of aging itself and medicine its potential saviour” (Powell & Longino, 2001, p. 201). It is an inherently negative discourse focused on the physical aspects of ageing, which are framed in terms of pathology, burden, disease, and deficit.  Advances in research and treatment for medical conditions commonly associated with ageing are, of course, positive in many respects. They support older adults to maintain independence, preferred lifestyles and favourite activities. The difficulty with the biomedical discourse is that it often mutes alternative conceptualizations of age and ageing. Its dominance in Western society means that ageing is viewed primarily as a trajectory of decline until death, rather than an important life process, a subjective experience, or the signifier for a new social role.  The development of the biomedical discourse began in the first part of the twentieth century, when biological scientists began to apply their knowledge to the phenomenon of ageing. 19  Their work “melded basic research about aging with practical suggestions for the aged” (Hendricks & Achenbaum, 1999, p. 26) and marked the emergence of traditional gerontology and its focus on the ‘problems’ of age. “Indeed, the whole field was developed originally by physicians who were concerned about the impact of chronic diseases and the pathologies of later life” (Johnson, 2005a, p. xxiii). While gerontology later expanded to include social and cultural aspects of ageing, “most gerontological research in recent decades has focused on the functional problems of aged populations, seen in human terms as medical disability or barriers to independent living” (Bengston, Putney & Johnson, 2005, p. 4). Critics have pointed to the role of funding and research priorities set at institutional and governmental levels, which continue to prioritize biomedical goals and functional ‘solutions’ to the problems of ageing (Estes & Binney, 1989; Johnson, 2005a).   The resulting construction of ageing by ‘experts’ as a functional or medical problem has influenced both the conceptualization of ageing in general as well as what Estes and Binney (1989) call “the praxis of aging” – the “behaviors and policies growing out of thinking of aging as a medical problem” (p. 587). For example, services for older adults are most often located within the medical system and typically prioritize medical monitoring and physical maintenance over socio-emotional support or activity (Cohen et al., 2006; Diamond, 1992; Ronch, 2004). This means that housing or support services often have deficit-based criteria that require older adults to have poor physical health or functioning, and also that programs for non-medical needs like recreation or socializing are understaffed and underfunded. At a social level, the power of the biomedical discourse creates a ‘buy in’ from the lay public that “the problems of aging are primarily biological and physiological” rather than the outcome of social inequality or structural 20  barriers (Estes & Binney, 1989). This in turn legitimizes policies and programs for older adults that focus primarily on health and medical monitoring rather than social needs.   Another example of the influence of the biomedical discourse is how the everyday definition of ‘care’ has been separated from its relational and familial context and is instead equated with medical treatment and monitoring (Green, 1993). Research suggests that family members feel moral pressure to pursue complex medical treatments for relations in their 80s and 90s as expressions of care and love (Kaufman, Shim and Russ, 2004). This is not to assert that it is right or wrong to pursue such treatments for older adults, but to demonstrate that medical intervention has been elevated to the point where it is “normalized as necessary and appropriate. Medicine today is considered the right (and perhaps the only) tool for managing the problems of aging” (Kaufman, et al., 2004, p.731). As a result, older people and their families have learned “to interpret their problems and anxieties increasingly through the medium of doctors in general and drugs in particular” (Phillipson, 1998, p. 34).   The biomedical discourse also has an influence on individual expectations and experiences of ageing. In particular, the positioning of physicians and other healthcare professionals as experts in ‘care’ subordinates older adults and their own knowledge. For example, the specialized language of medicine means that, when making decisions for treatment within the medical system, older adults can face difficulty expressing their preferences and feelings in a way that doctors will understand and accept, because they “lack an adequate idiom” (Kunneman, 1997, p. 281). They must struggle to translate their point of view into the rational language of medicine in order to continue the conversation. As well, the privileging of expert knowledge also means that physicians and other health care professionals are positioned as gatekeepers to an array of services such as home support, day programs, respite care, specialized 21  transportation, etc. In order to access these services, older adults must submit to medical assessments, a practice which Powell and Biggs (2000) have linked to the Foucauldian concept of surveillance. For example, older adults are made aware that there are service eligibility requirements but these are not always explicit; potential service users must allow themselves to fall under the gaze of those in power in the hope of receiving (and continuing to receive) these services. Using decontextualized measures of function and health as determinants for access to services is useful in rationing limited resources, because it sidesteps issues of social inequality and in effect places responsibility for receiving services (or not) within the individual’s own body.  2.2.2 The economic discourse(s) of ageing   The biomedical model of ageing is linked to another dominant discourse in Canada and other Western welfare states, which frames older adults as economic liabilities. The ‘inevitable’ infirmity and poor health of old age, in combination with the retired status of older people and the population ageing associated with the baby boom generation have created a discourse                             described in various terms including ‘alarmist’, ‘voodoo’, or ‘apocalyptic’ demography (Gee, 2000; Katz, 2009; Rozanova, Herbert & McDaniel, 2006).  It is   ... the oversimplified idea that population aging has catastrophic consequences for a society. More specifically, it embraces the view that increasing numbers (or ‘hordes’) of older people will bankrupt a society, due to their incessant demands on the health care system and on public pensions. (Gee, 2000, p. 5)    Popular media contributes to the perception of the ageing population as an economic burden. Both Gee (2000) and Rozanova et al. (2006) reviewed Canadian newspapers and found that apocalyptic demography is a prevalent discursive theme in the stories about older Canadians. 22  This discourse is closely tied to the biomedical discourse of ageing: “Seniors, even if healthy at the moment, were portrayed as a time bomb that would sooner or later damage society due to the rising costs of the health care system” (Rozanova et al. 2006, p. 381). Such predictions rely heavily on dependency ratios, which Gee (2000; 2002) has criticized because they arbitrarily equate certain age groups with non-labour market status and define ‘dependence’ according to narrow economic criteria and a stereotypical construction of idle, unhealthy older adults. The dependency ratio is simply a measure of those who are considered to be out of the workforce (those under 20 and over 65), compared against those of working age. Those who are not in the workforce are assumed to be users of health care and social welfare benefits, rather than contributors. However, this measure does not capture the reality (and socioeconomic value) of many older adults who are retiring later (Carrière & Galarneau, 2011) or those who provide important unpaid labour such as childcare (Geurts, Van Tilberg, Poortman, & Dykstra, 2015; Gray, 2005) or community service (Wiles & Jayasinha, 2013).   Further, from political economy and moral economy perspectives, this overlooks the major role that the state has had in shaping the social identity of older adults and the expectations of retirement (Estes, 1999; Kohli, 1987). In feudal times, impoverished older adults received charity as part of a group defined as the ‘deserving poor’ under Elizabethan Poor Laws. In this period they were not identified as having unique considerations or status based on age, but on being able-bodied or not (Gilleard, 2002). Different models of social insurance and social pensions for older adults began developing in the latter part of the 19th century. Germany, for example, initiated a social insurance scheme in the 1880s that was financed by contributions made by workers during their employment.  Within the next decade, Iceland, Denmark, New Zealand, Australia and the UK had introduced non-contributory social pensions, and Sweden had 23  initiated both social insurance and social pensions by 1913 (Palacios & Knox‐Vydmanov, 2014). Payments were low, however, so many older workers continued working as long as possible or relied on family support as a supplement (Palacios & Knox‐Vydmanov, 2014; Phillipson, 1998).   In the post-world war period of the 1950s, industrialized nations began to develop an integrated, state-run system of income redistribution, including both contributory social insurance and non-contributory pensions. In part this was due to the recognition that state intervention was necessary to protect the stability of employment and the economy against crises like the Great Depression (Armitage, 1996). Older workers needed to be encouraged to leave the workforce and open up positions for younger workers; they therefore required a guaranteed minimum income. Using the example of Germany, Kohli (1987, p. 129) proposes the evolution of retirement and pensions was part of an effort to organize the lifecourse to meet the demands of the capitalist economy, specifically into periods of “preparation ‘activity’, and retirement...The emergence of retirement ...meant the emergence of old age as a distinct life phase, structurally set apart from active life and with a clear chronological boundary.” Over time, the restructuring became imbued with moral undertones of fairness and reciprocity, with the state being seen as providing protection against the risks that could interfere with paid work such as illness, disability and old age. This model became common in Western states, where retirement symbolized “a fair exchange for past work and services” (Phillipson, 1998, p. 120).  As arbitrary chronological age became associated with retirement age and lifespans continued to lengthen, retirement and older adulthood came to be seen as a distinct ‘third age’ of human development that offered older adults the opportunity for a new social identity and fulfillment beyond the workplace (Phillipson, 1998). Although public pension amounts have historically been set close to minimum income levels and have been eroding since the 1970s 24  (Phillipson, 1998), the idea of the third age has fostered a stereotypical image of retirees as spending their pensions on carefree, consumerist lifestyles. Self-improvement, activity, “sunbelt” and “snowbird” lifestyles, and even higher education have since become idealized retirement pursuits and have supported a lucrative seniors’ industry (Katz, 2009).   The economic discourse of older adults is homogenizing and paradoxical as a result. On the one hand, older adults have been constructed as a discrete social unit, seen as ‘deserving’ of pensions and social benefits by virtue of chronological age and presumed participation in the paid workforce. Yet the stereotype of older adults as being able to afford a ‘third age lifestyle’ at the same time as they are drawing public pension money seems to indicate that they are taking more than their share – apocalyptic demography asserts that there will not be enough in the government coffers to support the generations after the ‘grey wave’ of baby boomers has plundered them for health care and pension costs.   This discourse is damaging for several reasons. First, by referencing ageing solely in terms of financial costs, it fails to recognize the intergenerational social capital of older adults and perpetuates the association of age with dependence. While older adults are being recognized for past contributions, it still does not present a valuation of age in and of itself, which means that women who worked (and continue to work) in the home, those with disabilities, or those with tenuous connections to the workforce are not extended this social worth. Second, it can create a sense of failure or dissatisfaction for those who cannot afford the idealized image of retirement. In Canada, for example, the median income for individuals 65 and above is only  $26, 990 (Statistics Canada, 2017), meaning that a ‘third age lifestyle’ is out of reach for a significant number of older Canadians.  This links to a third issue, which is that, similar to biomedical discourse, the economic discourse individualizes the responsibility for how one 25  experiences ageing (Estes, 1999). There is no recognition of the cumulative effects of capitalist class stratification or social inequality that occur over a lifetime and which influence levels of health, savings, and private pension income at the time of retirement. Individuals with lifelong economic disadvantage typically enter retirement with low economic and social status; the process of retirement or the fact of being ‘old’ does not in itself create dependence (Walker, 1981). Similarly, the conceptual framework for the social determinants of health developed by the World Health Organization (2010) describes a complex set of political, structural, environmental and psychosocial and behavioural factors that interact to influence health, including the structure of the available health system itself. Differential access to health care based on geography or social policy; social and economic marginalization based on race, gender and ability that affects education, occupation and material wealth; political ideology influencing health care policy; and material factors like quality of food and housing act together across a lifespan to influence health even before individuals enter old age. Yet in using the state benefits to which they are entitled, older adults are singled out as unusual or problematic.  2.2.3 The discourse of successful ageing  The discursive constructions of ageing as medical and economic problems, as well as the ideals of the third age, come together in a third discourse of ‘successful’ ageing. Currently there is no clear consensus within the gerontology on the definition or scope of the term (Cosco, Prina, Perales, Stephan & Brayne, 2014; Jacobs, 2005; Pruchno, Wilson-Genderson, Rose & Cartwright, 2010).  However, literature suggests that it began gaining in popularity after Rowe and Kahn’s 1987 publication on the distinction between “usual” and “successful” aging, and their 1997 publication on “the three key components of successful ageing: the avoidance of disease and disability, the maintenance of cognitive and physical function, and social 26  engagement” (Martinson & Berridge, 2015, p. 59). These areas continue to be fundamental to the construct of successful ageing. Research in the following decades has attempted to find ways to measure successful ageing and identify both subjective and objective factors (Pruchno et al., 2010), as well as to address theoretical shortcomings such as lack of input from older adults or cultural variability (Martinson & Berridge, 2015).  The idea of an active, engaged, healthy old age is undoubtedly an improvement on the negative stereotypes of isolated, passive, depressed, unhealthy older adults that still dominate the public imagination (Abramson & Silverstein, 2006; Tornstam, 2007; Weicht, 2013). But there are several issues around the notion that one can age ‘successfully’. First, the associated features of what success looks like are arbitrary and illogical. From a social constructionist perspective, “old age is created conceptually, through picking out particular features and defining them as...constituting oldness” (Overall, 2006, p. 131). In line with the biomedical discourse of ageing, research with older adults has shown that the features most often associated with identifying as ‘old’ have to do with physical decline and dependence (Degnen, 2007; Clarke, 2000; Hurd, 1999; Nilsson, Sarvimaki & Ekman, 1999). Yet equation of ageing with disability is problematic. For example, it does not recognize the experience of individuals with life-long physical disabilities, who have already faced adaptations to identity and activity that are not necessarily linked to age (Cooper & Bigby, 2014). As well, it creates a logical fallacy: since some degree of decline is inevitable as one ages, the only way to be ‘successful’ at ageing appears to be “not to age at all” (Andrews, 1999, p. 305). As a result, the label of ‘old’ is pushed into a higher age bracket, where   the oldest old …(are expected to) conform to the traditional roles of old age and a new  phase of ‘young elderly’ are inserted into the lifecourse. In that way, instead of 27   deconstructing standardized age roles…traditional old age roles are shifted towards  higher age groups. (Jacobs, 2005, p. 2)   Second, the normative values placed on aging ‘properly’ are also problematic:  “terms such as successful aging are not neutral; they are laden with comparative, either-or, hierarchically ordered dimensions” (Holstein and Minkler, 2003, p. 791). So, although it seems to frame ageing in a more positive way, the binary terms of success verses failure actually “map onto... the decline-and-loss model of yesterday...These dichotomies are arguably two sides of the same judgmental coin” (Martison & Berridge, 2015, p. 67).   As such, successful ageing does not necessarily counter ageism or internalized ageism. A recent study by Calasanti (2016) explored whether the pervasive discourse of successful ageing resonated with middle-aged participants, whether they viewed it as attainable, and whether it had “lessened their fears about aging, decline, negative stereotypes and exclusion” for their future aged selves (p.1094). In instances where the participants felt they could not control the ageing process, they reported feeling stress, tension and fear. “Rather than supplanting the later-life disease and decline rhetoric, the successful aging paradigm simply became another discourse that existed in tandem with it. In this sense, ageism was not challenged so much as displaced, redefined, and perhaps intensified” (p.1099).    Ageism also appears intragenerationally, where ‘oldness’ is passed as a judgement on those who fail to age successfully. For example, during Degnen’s (2007) ethnography in a village in Britain, she found that her older adult participants monitored their peers and enacted social sanctions on those who displayed signs of ageing. One community member, Mrs. Atherton, was the subject of several conversations related to her disruptive behaviour, which was blamed specifically on observed characteristics that marked her as “old.” “Through this process 28  ...both between individuals and as a group, consensus is reaffirmed about Mrs. Atherton, who is stigmatised (sic) as a marginal figure, worthy of ostracisation (‘We just ignored her’) due to her unacceptably high levels of oldness” (p.75). In public meeting places generally, Dengen observed that community members paid “a great deal of attention” to how others appeared, “both physically and mentally” on different occasions. “Any perceived decline in others then becomes public property for the gossip circuit” and might then influence the “community code” around that individual (p.76). As Dengen discusses, her findings show how the Foucauldian concepts of surveillance, discipline, and governmentality operate on individual and social levels and serve to uphold normative bodily ideals.   The above examples also demonstrate a third critique of the discourse of successful ageing, which is that it strongly promotes individualized management of the ageing process. Research with older adults reflects this rhetoric; in one of her studies with older women Hurd (1999) found that, “without exception, [those identifying as] ‘not old’ profess a defiant refusal to slow down, a firm belief in the power of activity, and a conviction that their own lifestyle choices are what separate them from the ‘old’ (p. 430). Rudman (2015) studied the narratives of older adults preparing for and living in retirement and noted an intersection of positive ageing discourses with neoliberal values such as personal responsibility. Persons seen to be not ageing ‘well’ (including themselves) were judged as failing to take care of their bodies properly. In their study on the portrayal of ageing in the Globe and Mail newspaper, Rozanova et al. (2006) found that “successful aging was, indeed, the major discursive theme in the stories of older adults”, and that “overall, it was subtly suggested that older adults might have agency in determining the quality of their lives, through personal choices made earlier and in the present” (p. 379). Similar to the media coverage of older adults and their (over)use of health care and public pension 29  money, the researchers in this study observed that discussion of structural factors such as poverty, lack of community resources, or access to health care that affect the ageing experience was missing from the articles. In the absence of such a discussion, the implicit conclusion is that those who ‘fail’ to meet the standards of successful ageing (health, vitality, and youthfulness) have only themselves to blame. Subsequent studies of the Globe and Mail reaffirmed the messages of “successful aging is a personal choice” and “individual responsibility for unsuccessful aging” (Rozanova, 2010).  Interestingly, when Rozanova and colleagues studied the media depictions of nursing home residents in the United States, they found that “retaining purchasing power”, both in terms of purchasing care and in terms of having spending money, was a form of autonomy that supported a notion of successful ageing even in the fourth age of physical frailty (Rozanova, Miller & Wetle, 2014). This finding again points to the discourse of individual (economic) responsibility for one’s ageing trajectory.   At a policy level, the language and rhetoric of successful ageing have been incorporated into governmental approaches to ageing in Canada and other industrialized welfare states (Katz, 2009; Lassen & Moreira, 2014; Special Senate Committee on Aging 2007, 2008; Struthers, 2013). Arguably, this is at least partly because successful/active ageing is useful in shifting the financial and social responsibility for the aged onto older adults themselves (Katz, 2009).  Typically, models of successful ageing promoted by governments draw from health promotion strategies on “prevention and individually modifiable…behaviours” (Harris, 2008, p. 44) for the purposes of delaying or mitigating the ‘problems’ of ageing.  As an example, the official provincial website for older adults in British Columbia has a dedicated ‘Active Living’ page where it promotes health-based advice, internet links, and policy reports (http://www2.gov.bc.ca/gov/content/family-social-supports/seniors/health-safety/active-aging). 30  While much of the advice offered is applicable across the lifespan (exercise, healthy eating and social activity), the rhetoric of active ageing recasts them here as strategies specifically helpful to older adults. A statement on why the province supports this approach makes a clear link to other problem-based ageing discourses:  “Active, healthy aging helps reduce the pressure on health care and social services.”  Like the biomedical and economic discourses of ageing, ‘successful ageing’ is also a product of a particular era. Katz (2009) suggests that the current postmodern values of “timelessness…speed, impermanence and immortality” mesh well with “the neoliberal dream of the end of state-supported dependency” (p. 18) because each ascribe to increased individual choice and a decreased significance of traditional social categories such as age. Further, it ties in to the modern notion of a third age, where the ‘young old’ enjoy retirement by pursuing leisure activities and focusing on individualistic priorities. Economically, successful ageing is a useful discourse because it justifies reduced spending on seniors’ benefits at the same time as it drives a seniors’ niche market (Katz, 2009). We are also at a historical point where the baby boom generation, who spurred the initial development of youth marketing and youth culture (Friedan, 1993), is entering old age. Conceivably, these individuals will accept and perpetuate the youthful doctrine of successful ageing because they have been surrounded by youthful ideals throughout their lives. The idea of successful ageing is also congruent with the American dream of “the unlimited right to individual self realization” (Hazan, 1994, p. 48) and the liberal values of autonomy and independence (Nedelsky, 1989). Finally, the discourse of successful ageing may be particularly appealing in this secular era where old age is simply a symbolic marker of a transition towards death without any particular cultural status or function (Hazan, 1994). Lacking positive alternatives, older adults may struggle to maintain a middle-aged identity. 31   To summarize, the biomedical, economic and successful ageing discourses construct ageing as a problem to be managed. Using Foucault’s concept of ‘problemetization’ Katz (2009) states: “problemetizing practices discipline everyday life by transforming ordinary and sometimes arbitrary aspects of human existence – such as adjustment to retirement – into universal dilemmas that call for administrative and professional interventions buoyed by a politics of ‘thought’” (p. 124). The discursive connection of passivity, decline and dependence to old age serves to justify the work of gerontologists, social workers, case managers, geriatricians, care homes and professional carers who form the “oldhood industry” (McKnight, 1995, p. 31). While it is undeniable that people experience changes in their bodies and lifestyles as they age, there are alternate ways of discussing and conceiving the experience of ageing that can accommodate this reality while challenging the portrayal of ageing as simply problematic.  2.2.4 An alternative discourse of ageing   In the past, one of the criticisms of mainstream gerontology was that it participated “in the economic and political construction of the issues and ‘problems’ that are associated with old age” (Lassen &Moreira, 2014, p.33. But a growing body of research and literature that draws on critical and constructionist theory challenges the overly negative and empirical aspects of this traditional approach. In particular, it seeks to introduce multiple voices and perspectives into our understanding of ageing, especially those of marginalized or oppressed populations (Clarke, 2001; Overall, 2006; Segal, 2007) and to recognize structural and discursive influences that differently shape individual and collective expectations for, and experiences of, later life. Specifically, it critiques the inadequacy of objective, scientific language to express individual, embodied experiences (Kunneman, 1997) and asserts that ageing is individually interpreted against a backdrop of cultural and social discourses, institutions, practices, and assumptions 32  (Hazan, 1994; Rudman; 2015).  Further, it promotes a contextual knowledge of ageing that is shaped by social location and experience across the life span (Gubrium, 1993) and does not seek to impose unifying, macro-level theory onto its variegated form. A common goal of this alternate approach is to recognize the diversity of the ageing experience and open a conceptual space where older people themselves can influence the discourse of ageing and the collective identity of older adults (Katz, 2009; Zimmerman & Grebe, 2014).   Much of the work in this area is multitheoretical and resists categorization into a specific, bounded discourse because it does not aspire to monolithic ‘truth’ about ageing. However, there are several common themes that together challenge the assumptions of the dominant construction of ageing. First, an alternative discourse of ageing asserts that whatever ‘old age’ is, beyond a certain number of lived chronological years, is culturally and socially defined (including what number of years ‘makes’ a person old). As such, it cannot be viewed as a homogeneous or universal experience. In particular, the concept of intersectionality, initially developed by Crenshaw (1989), speaks to the idea that individuals who belong to multiple oppressed social groups, such as those based on age, class, dis/ability, gender, ethnicity and race, do not experience discrimination along separate axes of their identity. Rather, these axes intersect in unique and diverse combinations in different contexts, so that individuals can experience compound oppressions at the same time. Importantly, oppressions do not simply overlap, but interact to create an oppression that is something more and different than each type separately.  Ageing is, therefore, influenced differentially according to social location such as gender and class (Calasanti & King, 2005), ability (Clarke & Bennett 2013; Overall, 2006) and sexual orientation (Copper, 2015). In addition, changes in historical, social, cultural, political and economic contexts shift the power relationships between different social groups, further 33  individualizing experiences of oppression (McCall, 2005). This is a relevant point when considering ageing across generations.   Feminist literature offers some of the most developed theory and research with respect to the importance of social location in ageing. This is partly because feminists are beginning to explore their own experiences of ageing (Cruikshank, 2008; Friedan, 1993; hooks, 2002; Ray, 2004; Segal, 2007), and partly because the concepts of social identity, oppression, and the body are traditional territories for feminist investigation. Feminist theorists and researchers assert that gender expectations, particularly standards of attractiveness, strongly influence how women view themselves as they age (Clarke, 2001; Clarke 2011; Clarke & Griffin, 2008; Hurd, 1999). While ageism occurs for both men and women, “women are seen to be ‘old’ much sooner” (Calasanti, 2005, p. 10) because of the evaluation of a woman’s social worth is much more strongly linked to a youthful, sexualized appearance than it is for men. The demographics of ageing are also gendered. The social role of women as caregivers and wives influences their experience of ageing, especially in relation to the likelihood of outliving husbands and the resulting changes in their social and personal identities (Hurd, 1999). As well, women are more likely to experience poverty in old age, because of their tenuous connection to the labour market, statistically lower wages, and resulting difficulty accessing government or private pension plans (Blake, Dean, Kilgano, West & Westlund, 2004).  As Cruikshank (2008) argues, lifelong social identities such as gender, or race or sexual orientation are more salient than imposed categorization by age, so it is important that policies and theories de-emphasize ‘age’ as the unifying category and attempt to reflect the multiplicities of social location.   Second, an alternative discourse of ageing reclaims the body as a complex territory of personal meaning and expression. Traditionally, socially-focused gerontologists have “[handed] 34  over the study of the aging body to the physiologists and clinicians” (Powell & Longino, 2001, p. 201), which has implicitly supported the dominance of the biomedical discourse of ageing. Critical feminist and constructionist scholars, however, have taken up the study of bodies and embodiment (Clarke, 2011; Clarke & Korotchenko, 2011; Kontos, 2004; Kontos & Martin 2013; Twigg & Buse, 2013), positing that bodies are “simultaneously material and constructed” (Calasanti, 2005, p.9, emphasis in original). The concept of embodiment offers a bridge between objective, physical characteristics of age and the subjective experiences of individuals. It also decentres ‘expert’ knowledge by foregrounding individual, experiential knowledge. The ageing body is reconceived as a dynamic site of interpretation, control and resistance; the ageing individual is repositioned as an active agent who mediates dominant discourses with individual, contextual knowledge of ageing.   The mediating role of the ageing self has been demonstrated in research. For example, Field-Springer’s (2012) narrative research with women who had experienced, or were experiencing menopause demonstrates the complex layers of life experiences and dominant discourses that participants drew on when sharing their experiences of ageing. In some cases ageing narratives were rejected, as in the case of one participant who expressed her “disgust” at the advertising industry for only using slim, young models. In other cases, ageing narratives were incorporated as part of a reidentification of self as an older person, such as the participant who was out with younger co-workers and for the first time realized she was having difficulty climbing stairs. In other research, older adults have been shown to make a conceptual distinction between feeling and being old (Clarke, 2001; Cremin, 1992; Hurd, 1999; Nilsson et al., 2000; Rudman 2015). As noted in the section on successful ageing, feeling old is typically associated with a decline in health or functional ability rather than strict chronological age. Older adults 35  monitor themselves for these objective markers of age, but when they occur there is a reluctance to accept the label of ‘old’ for oneself. Instead, some older adults (especially women) foster a Cartesian split between inner and outer selves (Andrews, 1999; Twigg, 2004) in order to “distance themselves from the stereotypes concerning age as well as the physical realities of growing older” (Clarke, 2001, p. 458; also see Clarke, 2011; Hurd, 1999). Although this tactic may be interpreted as a negative reaction to perceived ageing, it does demonstrate the self’s interpretive role in rejecting that which does not ‘fit’ with personal experience, as well as a tacit perception that the dominant discourse of ‘age’ is not entirely accurate.  This assertion is further supported by research showing that ‘feeling old’ is often used by individuals to describe a temporary state (Cremin, 1992; Clarke, 2001) rather than an irreversible linear progression of decline as promoted by the biomedical discourse of ageing. Similarly, Grenier’s work around the concept of frailty revealed that older women made a distinction between ‘being’ and ‘feeling’ frail, where being frail was more about “an imposition of a classification that is medical or functional in nature” and feeling frail was related to “social, personal and emotional experiences (e.g. weakness, vulnerability)” (2006, p. 304). Yet even though participants in this study might have accepted the label of ‘frail’ as a means to access services, they also resisted the marginalized social positioning that comes with the label by rejecting frailty as a personal identity, focusing on their political right to services, and by claiming the label as an act of subversion when it would work to achieve their demands (Grenier & Hanley, 2007). Research also highlights other ways that individuals actively interpret and respond to aging. In some studies older adults used reflexivity, mental strength and individual values to interpret the challenges of ageing as catalysts for existential or spiritual growth (Dalby, 2006; Moore, Metcalf and Schow, 2006); in other cases they adopted a stance of “senior coolness” to counter dominant 36  narratives of dependence or helplessness (Zimmerman & Grebe, 2014). An alternative discourse of ageing therefore directs attention to the role of the embodied self in responding and reacting to ageing in personally meaningful ways. It creates a space for older adults to provide their own interpretation of ageing that may resist the discourse of decline and dependence.   Third, an alternative discourse of ageing stresses interdependence rather than independence. Biomedical, apocalyptic demography, and successful ageing discourses share a common vilification of the ‘dependence’ of old age. As some scholars have noted, the concept of ‘dependency’ has variations in meaning, but the connotations are “almost entirely negative” (Fine and Glendinning, 2005, p. 605). In Western liberal discourse, dependence is positioned as the binary opposite to the closely related concepts of autonomy and independence. Autonomy is equated with free will, self-determination, and non-interference from others (Agich, 2003; Nedelsky, 1989). The independent individual is valorized as “atomistic” (Nedelsky, 1989, p. 8) and makes rational decisions independently of external influences. Being seen as dependent therefore puts older adults in a stigmatized and powerless role, something which is reinforced by our system of elder care (Agich, 2003). Yet older adults who avoid help-seeking in an effort to remain independent can instead face isolation (Plath, 2008). Scholars coming from feminist, critical, and constructionist and perspectives have critiqued the dominant interpretation of independence and autonomy, pointing out that it overlooks the actual, discursive process of decision-making and the reality of the social world.   If we ask ourselves what actually enables people to be autonomous, the answer is not  isolation, but relationships…that provide support and guidance for the development  and experience of autonomy…We see that relatedness is not, as our tradition teaches, 37   the antithesis of autonomy, but a literal precondition of autonomy, and interdependence  a constant component of autonomy.   (Nedelsky 1989, p. 12)  There are two points to highlight in this quote. First, autonomy is not impeded or extinguished by being in relationship with others. We are rely on each other from birth for affection, security, and, as Arendt (1958/1998) asserts, to bring us into the social world as individuals by witnessing and naming our actions. Further, “some of our most essential characteristics, such as our capacity for language and the conceptual framework through which we see the world, are not made by us but given to us (or developed in us) through our interactions with others” (Nedelsky, 1989, p.8). Second, the notion of interdependence speaks to the continuous back-and-forth of independence and dependence within these relationships; people are never exclusively one or the other. ‘Dependence’ is therefore not an inherently negative term, nor is it the particular domain of old age. Further, one can experience aspects dependence while, at the same time, continuing to grow and develop in other ways (Tornstam, 2011).   The adoption of care approaches based in relational ethics (Bergum & Dosseter, 2005; Gadow, 2006; Gilligan 1987/1995), relational capacity (Hartrick, 1997) and ethics of care (Tronto, 1993; Barnes & Brannelly, 2008) has been proposed as a way of redressing the strict binary of dependence/independence and the accompanying power imbalance. In general, this type of approach   recognizes that we are all givers and  receivers of care at different times; it is not linked to  gender or ‘women’s work’; it acknowledges bodily, spiritual and material aspects, the  perspectives of caregivers and care receivers, the  existence of power and conflict within  care, and the moral dimension of care. (Barnes and Brannelly, 2008, p. 385) 38  While still marginalized in mainstream health care settings and services for older adults, such an approach does offer new possibilities for conceptualizing care in term of human rights rather than a biomedical burden. As an example, researchers have begun to develop social, cultural and even citizenship-based models of care for dementia (O’Connor et al., 2007; Bartlett & O’Connor, 2007), an area long dominated by the search for drugs to treat or cure.   Taken together, the concepts of social location, embodiment, and interdependence as embraced in an alternate discourse of ageing do not deny the physical fact of senescence or the challenges it presents to older adults. Rather, they broaden the perspective of ageing by asserting that it is an experience, not a problem, and that it involves a complex mingling of physical and social, political, cultural, structural, subjective and interpersonal aspects. Older adults are not a homogeneous social group unto themselves, but they do have particular needs and perspectives. Change and continuity “exist simultaneously” in older people and researchers “must find a way to locate and represent both” (Andrews, 1999, p. 313).   2.2.5 Section summary   To summarize, the biomedical, economic, successful ageing discourses discussed in this section demonstrate the critical and social constructionist position that the Western concept of old age does not exist outside of historical, political and economic context. The primacy of scientific and capitalist discourses has influenced the way ageing and old age have been interpreted and positioned; namely, as a problem that can be solved by medical or economic measures. Ageing has also been imbued with the rhetoric of personal responsibility and control, as the discourse of successful ageing tasks older adults with the impossible project of avoiding decline. The alternative discourse of ageing being developed by critical gerontologists in the literature has been useful in challenging these messages and offering a different lens that 39  recognizes subjective, embodied, heterogeneous ways of experiencing age, as well as the positive potential for this stage of life.   These different discourses of ageing provide important groundwork for this study about older adults’ relocation to AL. On one level, they help set the stage for research investigating how individuals experience the transition from life in their own, mostly individually-directed environments to the congregate environment of AL with its organizational authority: I needed to be familiar with the storylines participants might draw on in describing this experience, such as the biomedical discourse of the health care system in which AL is located, wider social expectations of ageing, and personal resistance. On another level, they focus attention on how different influences have shaped our system of care for older adults. The dominant concept of dependence, for example, underpins the current model of long term residential care and was part of the impetus to create a more independent model called AL. Making the connection between discourse and practice was a fundamental step towards critically investigating whether AL has lived up to its own founding philosophy of care.  2.3 Transition  Despite the debate among scholars and theorists about how to conceptualize old age, there is agreement on at least one point: ageing brings with it an expectation of change. Change in social roles, health, financial status, and even perspectives on life are only some of the possible changes that one may experience as part of ageing. Further, many of these changes are interrelated and precipitate larger personal transitions, particularly changes in health or ability that result in a move to formal residential care.  40   For example, Litwak and Longino’s (1987) often-cited model of migration patterns of the elderly describes three types of moves initiated after certain late life events and illustrates the link between health and living accommodations. The first is a comfort or amenities-based move following retirement, often to places such as vacation or retirement communities. The second type of move is made to be in closer proximity to children, whereby familial commitment provides a level of informal support that allows the older adult to continue to live in his or her home. It is typically related to an experience (or anticipation) of disability or difficulty with daily activities, either in self or spouse. It can also coincide with widowhood, where the spouse who provided either help with, or motivation for, household tasks is no longer present. The third type of move, to a more formalized care environment or residential care home (including an AL facility), occurs when the needs of the older adult outstrip the ability of familial network to manage care. Although this particular model of migration is only focused on kin support, it is also the case that relocation to formalized care can be influenced by the availability of community resources and whether they are too expensive or not available/sufficient. Other foundational theories similarly point to the imbalance between an older person and their environment that can result in relocation to formal residential care settings, such as Lawton and Nahemow’s (1973) idea of environmental press; or Wiseman’s (1980) concept of push-pull factors.   Importantly, these moves represent more than just a change of address – they can generate some of the most deeply felt indicators of ageing. In particular, relocation to a formalized care environment can be a major life event or “turning point” (Cappeliez, Beaupré, & Robitaille, 2008) for individuals. It generally involves the downsizing of possessions, changes in neighbourhoods or communities, disruption to one’s social support networks, and adjustment to 41  the structures and congregate life of a facility. The concept of transition is a useful way to frame this process because of its ability to incorporate temporal, contextual, structural and personal elements into understanding how individuals cope with the changes brought on by relocation. In this section I first explore the theoretical and conceptual aspects of transition before moving into a review of the research related to transition to AL.  2.3.1 Conceptualizing transition     Concepts of transition span the disciplines of psychology, psychiatry, anthropology, sociology, education, gerontology, nursing, geography, and migration studies. A simple definition from geriatric nursing defines transition as “a passage between two relatively stable periods of time” (Schumacher, Jones, & Meleis 1999, p. 2).  It is initiated by a break with usual circumstances, understandings, or habits that leads to a period of disorganization and, ultimately, the integration of the change into new and adjusted habits, self concept, or life contexts. A key feature of transition has to do with challenges to self identity that occur during the process (Meleis, 2010, p. 77). As such, “transition occurs over time and entails change and adaptation,…but not all change engages transition” (Kralik, Visentin and Visentin and van Loon, 2006, p.327).    Psychology and sociology have had a major influence in terms of framing transition as an integral part of human development and linking it to normative ideals of development occurring at particular ages. In gerontological research and practice, these developmental and age-and-stage based theories have been popular in terms of explaining positive/negative responses to life events among older adults. One of the most well-known examples is Erikson’s eight-stage model, which originally proposed that the eighth and last stage of life involved the struggle of ego integrity versus despair. In this stage, one looks back at one’s life and can either 42  find a sense of reconciliation and satisfaction or is filled with regret (Erikson, 1997). Informed by their own experiences of ageing, Erikson and his wife later developed an additional stage based on interviews with older adults. In the ninth stage, individuals deal again with the developmental tasks and issues of earlier stages, because increasing challenges to their physical function and autonomy result in new conflicts that must be resolved. For example, the primary task of childhood – trust vs. mistrust, is revisited in a new way when individuals are faced with depending on others for help and care (Erikson, 1997).  Other age-based theories have linked developmental change to transitional late-life events such as retirement, loss of a spouse, the onset of illness or disability, and the move to formal residential care settings (for example Fisher, 1993).  The notion of transition as used in developmental and age-based theories is positive in that it presents even difficult life events as opportunities for personal growth in late life.   However, while transition plays an important part in these theories as the means through which one develops, it is not the actual focus – the goal is to move from one stage to another. As such, transition tends to be conceptualized as a fixed, linear process. An alternate position views it as being comprised of fluid and intersecting experiences across the lifespan that may not always result in a person moving on to a new stage or role (Grenier, 2012). Kralik et al. (2006) have suggested that transition is an “intricate and convoluted process with forward and backward movement”, including the possibility to become “stuck” at a given stage (p. 325).  Grenier (2012) has provided several other critiques on how transition has been conceptualized in developmental and age-and-stage theories. First, these theories speak to broad trends in ageing and do not generally recognize the individual heterogeneity of people’s lived experiences or the intersecting effects of social location on expectation and opportunity. Different cultural expectations of age-based roles may render these ideas of transition, or what 43  growth is meant to occur from them, irrelevant. Individuals may also simply reject the conventions of developmental theory, such as the processes of marriage and raising children, yet be extremely satisfied with the trajectory of their lives. Others may have more preoccupying concerns that override normative developmental stages, such as chronic illness, homelessness, or experiences of abuse or trauma. Second, there is less emphasis on the efforts individuals make to maintain continuity in their lives than there is on the perpetual process of change. Older adults do not abandon the habits and identities of a lifetime just by moving into a stage of life that happens to be characterized by things such as relocation or changing physical/mental states. Third, developmental and age-and-stage theories tend to view transition in terms of discrete events that happen to individuals. Similar to the feminist and critical focus on interdependence, an expanded view of transitions recognizes that they are “linked experiences that occur in relationships with the self, family [and] society” (Grenier, 2012, p. 128).  A health crisis results in transition for the older adult experiencing it, but also the spouse and/or children who may have to change aspects of their own lives in response.   In reviewing the literature, I found two theoretical frameworks of transition that both responded to the above criticisms and could also be applied to older adults relocating to AL. Both of these frameworks have been developed over several decades through research and professional practice with adults. They share an emphasis on the dynamic and multilayered components of transition itself, rather than considering it as just a means to a larger developmental goal. As well, they provide a framework to explore individual experiences of transition rather than collective trends.   First, Schlossberg’s model for counselling adults in transition (1981; 1984) was initiated by evidence from her qualitative interviews that adults experience change across the life course 44  in variable and unpredictable ways. Her resulting framework synthesized human development theory, life event and transition perspectives, and individual variation theories. As such, the model is not solely focused on older adults, but can address experiences of late life such as retirement, grandparenting, and existential concerns; it has also been revised in recognition of current political contexts and diverse social identities and life experiences (Anderson, Goodman & Schlossberg, 2012). The benefit of this flexibility is that it avoids stereotyping older adults as having uniform characteristics or priorities.  Schlossberg’s model draws on aspects of human development theory such as shifts in identity over the lifespan, the continuous project of creating intimacy and relationships, the need for a sense of autonomy, productivity and competence, and desire to belong. But using concepts from ecological theory, the model also considers how the characteristics of the pre- and post-transition environment will act as assets or liabilities in the transition process. This includes the environment of personal and institutional support as well as the physical environment. In addition, transitions are anticipated or unanticipated, occur in specific contexts, and have differing degrees of impact. Transitions can have a positive or negative effect, and there are multiple influencing factors that shape how a person will adapt. For example, an individual’s perception of a transition is affected by aspects such as resulting role changes, precipitating events, the timing of the transition in a person’s life, control in the process, and any concurrent stresses. Interestingly, Schlossberg also considers “non-events” as influential as well, in the sense that an expected event which did not occur can still trigger a period of disruption. Finally, this model recognizes that individual characteristics will affect the process of transition. These include personal and demographic characteristics (socioeconomic status, age, ethnicity, gender, stage of life, and state of health); psychological resources like personality, outlook and personal 45  values; and individual coping responses such as creation of meaning, information-seeking and plan-making, proactive or inhibited action, and stress responses (Schlossberg, 1984, p. 108).   A second theoretical framework, developed by Meleis and Schumacher and colleagues (Meleis, 2010; Meleis, Sawyer, Im, Messias, & Schumacher, 2000; Schumacher & Melies, 1994), resulted from the need for a model of transition in nursing, where so much of the profession’s work takes place with individuals experiencing change and its accompanying uncertainty. It is relevant in exploring older adults’ relocation to AL because the pathway to AL is often through the healthcare system or related to changes in health, and also because the model has been applied to working with older adults (Meleis, 2010; Rossen & Knafl, 2003; Schumacher, Meleis & Jones, 1999). This framework involves several interrelated components, beginning with an acknowledgement that there are different types and patterns of transition, such as developmental, situational, health or illness-related, and organizational (environmental). These transitions can occur simultaneously or sequentially with related or unrelated effects. Importantly, this conceptualization recognizes that the transition of one person can have effects on others such as family members.    A second component incorporates the various factors and influences surrounding the transition such as awareness and engagement of an individual in the process, the perceived importance the changes have for the individual, the timing and duration of transition, and social/personal norms that influence how they are interpreted. The model acknowledges that some transitions such as integration into a new culture can take years and never truly be ‘finished’. Transitions can also have critical developments and turning points within them, which are an integral part of the overall process. For example, a person might be newly relocated to AL, 46  but then experience hospitalization which would interrupt the process of settling in or redirect how it proceeds.   The third component of this theory is the idea that there are facilitators and inhibitors to transition. These can be personal in nature, such as the meaning ascribed to events, cultural beliefs, the degree of preparation and knowledge a person has prior to the transition, and socioeconomic status. At a larger level, community and social conditions can act as facilitators or inhibitors in terms of the degree of stigma or social support associated with a transition. Moving to AL, according to this theory, might hold fewer stigmas than living in long term residential care where the dominant discourse positions residents as ‘frail’ or ‘dependent’.   The last component of the theory is what the authors describe as “patterns of response”.  Feeling connected, interacting with caring others, making comparisons between the old and the new, and developing self confidence in the new context are thought to be indicators that a person is actively in the process of transition. As an outcome of transition, individuals often display or express a mastery of new skills and a reintegrated identity. The goal of this multifaceted theory is to provide a framework with which to understand and evaluate particular components of transition and to initiate appropriately targeted interventions.    Combined, Schlossberg’s and Meleis et al.’s frameworks speak to the importance of objective and subjective factors in the process of transition, as well as the complex array of influences that provide each individual with a unique experience of similar events. They reflect the reality that transitions are not always ‘complete’ or linear. In this way, there is less emphasis on an objective marker of ‘success’ in transition – the end point is instead related to an individual’s own sense of reintegration after a period of disruption. As well, the models account for multiple, interrelated transitions, which reflect the reality of how life events often manifest, 47  especially in terms of health related changes that result in a change of residence, or the ripple effects on families when a member is moving to AL.  Importantly, they recognize that, while many changes of older adulthood involve loss, they can also bring opportunity.  Finally, from a constructionist perspective, the frameworks contain elements that incorporate the influence of wider social discourses and institutions on individual expectations of ageing and on our age-related polices.   My purpose in exploring the theories and conceptualizations of transition was to prepare for reading the substantive research on moving to AL and to be aware of the ways that my participants might speak about their relocation and process of settling in. What I noticed when reviewing the literature around moving to, and living in, formal residential care settings was that, although various individual components of transition suggested by the above frameworks are reflected in the research, there are few open-ended inquiries into the process of transition as a whole. Instead, research tends to highlight some discrete areas that the frameworks have identified as influential, such as the personal and structural context of relocation, organizational features in the residential care facility that support or inhibit resident satisfaction, or the role of interpersonal factors such as relationships. Arguably each of these areas is worthy of investigation, but it remains important to hear holistic accounts of transition during relocation because of the complex and individual nature of the phenomenon. Keeping this critique in mind, I turn now to a discussion of the research around older adults and transition to AL.  2.3.2 Transition to AL in the literature  Preliminary literature searches revealed that research specifically on the experience of relocating to AL is a relatively small body of literature; the body of Canadian research on the topic is smaller yet. I therefore broadened my search, using both Medline (Ovid) and Academic 48  Search Complete data bases and the terms ‘older adults or seniors or elderly’ and ‘assisted living or assisted living facilities’ and ‘transition or relocation or move.’ This resulted in just a handful of studies related to the actual transition process; substituting the terms related to transition for terms such as ‘experience or perceptions or attitudes or views’ or omitting them altogether produced results that spoke more broadly to aspects of life and living in AL. Alternately, I removed search terms related to AL and but kept the terms for transition or moving and was able to identify articles about relocation to long term residential care that were informative.   There are several observations to be made about the literature generally, before moving to a discussion of the search results below.  First, the majority of research on AL is American, which is arguably due to its role as a progenitor for the model. This has implications in terms of generating research that is not always applicable to British Columbia, such as the current focus in American literature on dementia care in AL, ageing in place, or changes to AL funding in the wake of health insurance reforms. Second, searching this literature is very challenging because of the multiple terms used to describe international models of housing for older adults. In addition to search results that referenced long term residential care or nursing homes, other articles referred to ‘retirement communities’, ‘congregate living communities’, ‘continuing care retirement communities’, and ‘extra care housing’ that had to be examined to ascertain whether they were describing something similar to AL or were otherwise applicable. Some studies were more explicit about investigating AL alongside other types of residential care and I chose to include them where relevant. Even the studies set specifically in AL exhibit great variation in research sites – they range from small, room and board type-houses to large, apartment-style residences. Finally, I subscribed to journal alerts from the major journals on ageing, gerontology, occupational therapy and social work throughout my doctorate and also conducted additional 49  literature reviews at various points in the research and writing process; the body of literature around transition to AL continues to be small. For example, since 2011 I sourced 22 new articles on a range of aspects of life in AL, with only two articles specifically referencing transition or relocation to AL. This may have to do with the trends in American AL literature noted above, or it may signify that academic interest in the project of AL is beginning to wane after several decades.   The following section is organized according to the themes that were reflected in the literature – precipitating and contextual factors of relocation, personal effects of relocation, and influential features of life in AL and long term residential care –offering critique and identification of the gaps remaining.  2.3.2.1 Precipitating and contextual factors of relocation  Although older adults report that they would prefer to remain at home rather than live in AL or residential care settings (Leibing, Guberman & Wiles, 2016; Wagner, Shubair & Michalos, 2010), this is not always possible. As such, a subset of the transition literature discusses the influences and pathways into AL and other types of residential care facilities. The studies comprise a mix of qualitative, quantitative and mixed methods, along with one systematic review (Stone & Reinhardt, 2007).   The literature reflects several common factors related to the context of relocation. Chief among these appears to be a change in health or function as a precipitating factor. Research suggests that episodes of hospitalization or decline in health or functional ability in daily tasks precipitate transitions to higher levels of care, including residential facilities (Cheek et al., 2006; Jungers, 2010; Seargeant, Ekerdt & Chapin, 2010). As well, the probability of moving to receive a higher level of care, such as to long term residential care, increases with age (Peek, Zsembik & 50  Coward, 1997; Statistics Canada, 2011; Wilmoth, 1998). One Canadian study in this area also indicated the link between a decline in health and transition to AL or long term residential care (Rockwood et al., 2014), with moderate dementia and difficulty carrying out IADLs accounting for the transitions from community to AL. Importantly, the research was conducted in Nova Scotia where AL is solely a private industry, so strict comparison with British Columbia may not be possible. Several studies also point to the combined effects of increased health care needs alongside limitations to personal or professional resources that could otherwise support individuals to remain at home (i.e. ability to modify one’s home, ask children for help, or pay for extra services) as influential factors in relocation to long term residential care (Jorgensen et al. 2009; Wagner et al. 2010). Other studies have found that sometimes it is the declining health of the caregiver that precipitates the move of an older adult to a long term care facility (Cheek et al., 2006; Heliker & Scholler-Jaquish, 2006; Kemp, 2008; Rockwood et al., 2014), which speaks to the interconnectedness of transitions.   Second, financial resources appear to be an important factor in where and when an older person moves. In the US, there are relatively few subsidized AL beds for low income individuals (Kemp, 2008; Polivka, 2010; Stone & Reinhardt, 2007). This provides a “structured advantage” for older adults who can afford to pick the timing and location of their move (Burge & Street 2009). In one qualitative American study (Ball, Perkins, Hollingsworth, Whittington & King, 2009), the researchers found that higher socioeconomic class allowed both Black and White older adults to be more proactive, not only in choosing to move before reaching a crisis point or overburdening family members, but also in moving to an AL residence that met their personal preferences. Given that Canada has a more well-developed system of publically subsidized AL, 51  it raises questions as to whether structured advantage occurs in this country as well. However, I found no Canadian studies that addressed this topic.    Third, research shows that family dynamics and involvement are also part of the contextual and precipitating factors around relocation. For example, some studies have found that older adults opt to move to AL in order to avoid becoming a burden on family members (Cheek et al., 2006; Jungers, 2010), but this can stem either from a proactive, independent decision (Ball et al. 2009) or from a desire to “appease” worried family members (Tracy & DeYoung, 2004).  In other cases, older adults spoke of being relocated to long term care facilities against their wishes, particularly after a time of crisis when they could not participate in the decision made by family members (Ball et al., 2009; Young, 1998, Johnson & Bibbo, 2014). Some individuals move to AL to access care for a spouse, rather than themselves (Kemp, 2008; Mulry; 2012). Even in cases where decision-making around moving to AL is made in concert with family members, conflicts can arise over the logistical and emotional aspects of relocation such as the timing of the move, the fit of the available services, or the reality of how the older adult is coping at home (Koening, Lee, Macmillan, Fields & Spano, 2014).   Finally, several studies are unique in their identification of larger structural issues that influence whether or not older adults relocate, particularly the availability of community resources. Young’s (1998) grounded theory study of an older adult congregate housing community found that the decision to move was made when the “demands of the former environment exceeded the resources of the individual” and included, among other factors, a lack of public transportation after giving up driving (p. 155). Scheidt and Norris-Baker (1999) made the important observation that the environment itself may change to the point where there is a loss of place attachment or a lack of resources, as in the case of gentrification and other 52  neighbourhood changes. In the case of small towns, it may be due to the loss or absence of services that support older adults to remain in their homes. One qualitative Australian study found that when available services did not match the needs of the individual in terms of geographic location, hours of operation, or available transportation, individuals were more likely to transition to “residential aged care”, in some cases prematurely (Cheek et al., 2006).   It is important that researchers keep developing an understanding of the context around older adults’ relocation to AL, especially in light of the limited number of studies investigating AL as a discrete type of housing rather than in combination with other models or levels of care. The multiple influences for relocation reflected in the existing literature suggest: a) that while health is a factor, presence/absence of environmental support and resources are also significant; and b) that it is not always up to the individual to choose when and where they move. The latter point in particular may have implications for how the person adjusts to the event; it also challenges the founding philosophy of AL.  Yet there are few studies that explicitly contrast this lack of choice in when/where to move with the popular discourse of AL as a positive, third age destination (see Carder and Hernandez, 2004 as a partial example).   2.3.2.2 Effects of relocation   A second theme in the literature speaks to the effects of relocation to residential care settings for older adults. Often, these studies have employed quantitative measures directed at specific, predetermined outcomes, most often around new residents’ health or depression rather than social or emotional aspects of the move for individuals (Tracy & DeYoung, 2004).  It does appear that depressive symptoms can be common in individuals recently relocated to long term residential care homes (Achterberg, Pot, Kerskstra & Ribbe, 2006; Scocco, Rapattoni & Fantoni, 2006). There is even a nursing diagnosis which refers to the combined symptoms of “anxiety, 53  confusion, fear, helplessness, hopelessness, indecisiveness, loneliness, suicidal thoughts and suspicion” among new residents as relocation stress syndrome (Morse, 2000; Walker, Curry & Hogstel, 2007, p. 2).  Yet a qualitative investigation by Walker et al. (2007) among both long term care and AL residents questions the usefulness of applying it for two reasons: first, it is not always clear whether these are symptoms of pre-existing and undiagnosed conditions exacerbated by relocation; and second, most participants felt that any difficulty related to their relocation experiences was on par with other life transitions and, as such, was not outside their ability to cope. Critical gerontologists might also point out that a focus on depression and negative symptoms pathologizes older adults for their arguably normal reactions during a time of major transition, or in the face of simultaneous and difficult personal experiences that can precede relocation, such as the loss of a spouse (i.e. Conlon & Aldrege, 2013). Such an interpretation speaks to the dominance of the biomedical discourse in interpreting and treating the ‘problems’ of older adults.  Moreover, a focus on the presence/absence of symptoms does not examine how structural inequalities such as unequal access to health care or home support, the overly medical environment of residential care, or the loss of an older adults’ voice in the decision-making process may contribute to feelings of depression.    In an attempt to present a broader picture of the experience of relocation, there have been a small number of studies using qualitative methods. Most of these studies  have concentrated on long term residential care homes (for example, Falk, Wijk, Persson & Falk, 2012; Heliker & Scholler-Jaquish, 2006; Johnson & Bibbo, 2014; Lee, Simpson, Froggatt, 2013; Lee, Woo & Mackenzie, 2002a; Sussman & Dupuis, 2014), but there are some that explore the transition of older adults to AL facilities specifically (Dobbs, 2004; Jungers, 2010; Tracy & DeYoung, 2004).  What these studies suggest is that the initial psychosocial and emotional responses are similar 54  between the two settings and that some form of emotional reaction is common in the first few weeks or months regardless of the context of relocation, including feelings of being “overwhelmed, emotional, disorganized…[and] homeless” as a result of the move (Brandburg, 2007, p. 54). Such a reaction is understandable when viewed in terms of the transition frameworks discussed above, in that relocating to both AL and long term residential care represents a rupture between an individual’s past and present, which requires some time to adjust. Home, for example, is symbolic of comfort, safety, privacy, independence, possessions, and continuity with the past for older adults (Johnson & Bibbo, 2014; Liebing, Guberman; Wiles, 2016; Sixsmith, 1990). As Chaudhury (2008) points out, our self identities can be deeply bound to physical environments because our memories are anchored to them in an embodied way. As such, the concept of home is built through layers of daily activity, even mundane tasks.  “If it is assumed that older people develop and maintain a sense of self through attachment to place, then relocation to a new place is a serious matter” (Eckert, Zimmerman & Morgan, 2001). Not unexpectedly, then, research has found that loss of the physical home is linked to other feelings of loss for both new AL and other long term residential care residents – loss of neighbourhood and friendships, loss of unique identity among so many residents, and unanticipated loss in types of independence such as choosing mealtimes or daily schedules (Heliker & Scholler-Jaquish, 2006; Tracy & DeYoung, 2004). But while they are understandable, these negative responses to relocation are also notable because they contradict the supposed preference of individuals for AL over ‘nursing homes’ and raise questions around what individuals expect from AL verses what they experience in it. Currently there are no studies examining how the philosophy and discourse of AL inform individuals’ relocation and transition. 55   Yet some older people do manage to find a way to move through the period of disruption after relocation. The literature offers different ideas of what a ‘successful’ transition entails, but based on qualitative interviews across long term care and AL it appears to involve aspects such as incorporating the move into one’s life story (Lee et al., 2013), actively changing one’s attitude toward acceptance and positive reframing (Johnson & Bibbo, 2014), feeling a sense of attachment to the new residence (Falk et al., 2012; Heliker & Scholler-Jaquish, 2006), and being able to exercise autonomy (Johnson & Bibbo, 2014; Jungers, 2010).    An important, but underemphasized, aspect of settling in appears to be the element of time, as historically there has been little focus on “the actual experiences involved as older people [make] their day to day adjustment after placement” (Lee, Woo & Mackenzie, 2002b, p.19). A limited number of studies address this gap in the literature, such as Lee et al.’s (2002a) grounded theory study of newly relocated older Hong Kong Chinese adults in long term residential care. The interviews began one week after participants’ admission and continued over a series of months. The data highlighted an order of priority for new residents, first of which was learning organizational rules and also ways to acceptably ‘bend’ them. Only after studying their new environment and the relationships within it could the participants begin to work on integrating their old and new lives. Similarly, Heliker & Scholler-Jaquish (2006) studied transition among newly-admitted long term residential care residents over a period of three months, and found that participants went through an early phase of “learning the ropes” before reorienting and “beginning new stories.” These studies begin to hint at the power of organizational structure and policy in shaping the experiences of those moving to AL, raising questions as to how effectively AL has, in fact, integrated some of its foundational values such as choice, autonomy, or independence.  56   However, while this focus on the temporal aspect of transition adds an additional nuance to our understanding of the phenomenon, it is also important to resist interpretations that transition can be understood according to normalized or linear stages as the above studies (Heliker & Scholler-Jaquish, 2006; Lee et al., 2002a) might suggest. Indeed, research supports the position of the transition frameworks reviewed here in that some individuals struggle after relocation and experience transition as an incomplete or convoluted process with stops and starts in different areas (Meleis et al., 2000; Schlossberg, 1984). For example, one British narrative study (Lee et al. 2013) found that instead of reflecting “time bound” stages of transition, residents’ narratives of moving to long term residential care were organized according to turning points or chapters in their personal stories. How settled a person felt was related to larger questions around how to integrate aspects of one’s previous life and values in the new setting, and how the move fit with one’s identity and expectations as an older person. Some participants could not make peace with the contexts surrounding their transition and, as a result, discursively constructed their residence as a continually unresolved problem. In an ethnographic study of six AL facilities in the United States (Eckert, Carder, Morgan, Frankowski, & Roth 2009) found that the process of feeling settled in could happen very quickly for some and take up to a year for others, especially in light of episodes of hospitalization and rehabilitation. These two studies point to the importance of exploring extended personal accounts that include biographical details, in order to capture the complexities of relocation that do not align with stage-based models.   Other researchers have also noticed the lack of extended accounts of transition. In particular, the motivation for one Canadian study on transition to long term residential care was directly linked to the paucity of research on the entire process of transition, “including residents’ 57  experiences with the actual move” (Sussman & Dupuis, 2014, p. 440). The grounded-theory study included a temporal exploration of relocation, as participants reflected on their experiences pre-move, during move-in, and in the initial days. As well, the study is unique for drawing explicit attention to the multiple layers of influences that were referenced in positive and negative stories of relocation. Specifically, conditions at “individual, interpersonal and/or systemic layers” that “nurtured a sense of control and a sense of respect for personhood” (p.451) contributed to a sense of comfort and belonging in the new residence. More studies that follow participants over time or ‘talk through’ participants’ relocation steps, especially in AL, could generate nuanced descriptions of the ways that older adults shift (or do not shift) their expectations, interpretations, or identities, over time as a result of the move. In addition, this approach could provide greater insight around the points during relocation where policies, discourses or other structural influences interact with individual transition experiences, since reaction to the institutional context appears to be a significant aspect of relocation. For example, Sussman and Dupuis highlighted how the requirement for participants to accept a placement in a very short period of time made it very difficult for them to process any of the transition before moving day was upon them. How this and other policies and practices affiliated with AL shape the transition process is currently unknown.   A final gap in this literature speaks to Grenier’s (2012) concept of finding continuity within transition. This idea is alluded to in many studies, but not often directly explored as being a part of adjusting after relocation. For example, studies may highlight demographic characteristics or previous occupations as part of the participant descriptions, but do not typically incorporate these biographical details in the analysis of how different participants settle in. Although not a study of relocation itself, Yamasaki and Sharf’s (2011) narrative study of older 58  people in AL illustrates how residents made linkages between their past and present experiences as a way of interpreting life in a congregate environment where they would prefer not to be. Combining this approach with a more sustained exploration of the process of transition to AL over time could be a useful way of extending our understanding of how older adults interpret and adjust to relocation to AL, including how it is the same or different from transitioning into to other types of residential facilities that do not explicitly claim the values associated with AL.  2.3.2.3 Influential features of life in AL   A more substantial body of literature exists in relation to specific aspects of life in AL and long term residential care, such as relationships, activities, environmental aspects, and structural considerations. Often these domains are approached in relation to, or nested within a larger investigation on satisfaction and quality of life (QOL) for older adults living in formal care environments (see for example Ball et al., 2000; Eckert et al., 2001; Kane, 2001; Mitchell & Kemp; 2000). The themes emerging out of that research demonstrate the importance of considering how characteristics of the physical, organizational, and social/affective environment interact with personal characteristics such as social location and personality to influence feelings of satisfaction after moving to AL (Ball et al. 2000; Cutchin, Owen & Chang 2003; Falk et al., 2012; Mitchell & Kemp 2000, Sikorska 1999). Qualitative research is well represented in this literature, which demonstrates an important incorporation of older adults’ own perspectives in furthering gerontological knowledge. What is often lacking in the studies set in AL, however, is an explicit link between the features of life identified as having positive or negative influence for residents and how they reflect/do not reflect the purported values or benefits of AL such as choice, autonomy, independence, or social connection. In this section I will consider some of the 59  most common findings about positive/negative features of life in AL in light of the model’s core philosophy and values.  Privacy, for example, appears to be one of the values that is well supported in AL. Several studies have indicated that one of the most positive aspects of AL appears to be the prevalence of private suites furnished with at least some personal belongings, which helps to maintain a sense of continuity and identity between residents and their former lives (Ball et al. 2000; Eales, Keating & Damsma, 2001). Moreover, research suggests that private rooms provide an important avenue of control for residents in helping to mitigate some of the territoriality that can occur in congregate living settings (Cutchin, 2003). Other studies have linked private rooms with enhancing social connections in terms of allowing privacy to make phone conversations (Ball et al. 2000) or providing intimate space for residents to socialize (Dupuis-Blanchard, Neufeld & Strang, 2009). Regardless of facility type, private rooms appear to be a beneficial amenity – in a study comparing independent living, AL and residential care homes, having a private room or not having to share with unrelated roommates were linked to lower rates of resident depression (Robinson et al., 2011).   Social connection has also been considered a benefit of living in AL, but the literature presents a more varied picture of the success of the AL environment in providing it. There tends to be three types of relational foci in the literature – peer relationships, relationships with staff, and external relationships. In terms of peer relationships, research indicates that, while new social bonds among peers are formed inside AL and other seniors housing/long term care settings, they are not necessarily close friendships (Cutchin, 2003; Dupuis-Blanchard et al., 2009). As well, issues of interpersonal difference can further inhibit resident relationships and connections, given that congregate living settings force a level of interaction between people 60  who might not otherwise associate (Yamasaki & Sharf, 2011). For example, some studies show evidence for discriminatory behaviour or language between residents based on physical frailty and cognitive impairment (Cutchin, 2003; Hubbard, Tester & Downs, 2003; Jaffe & Wellin, 2008). Another study found that women can feel unsafe in a mixed gender environment, particularly among male residents who make sexual advances (Cutchin 2003), while other research demonstrates that gay, lesbian, bisexual or transgendered residents can face open or underlying discrimination in residential care (Donaldson, Asta, Vacha-Haase, 2014; Walker et al., 2007). Two Canadian studies also suggest that the ethnocultural composition of the facility influences the social experiences of ethnic minority older adults who relocate to long term residential care or AL (Baumbusch, 2008; Koehn, Mahmood & Stott-Eveneshen, 2016), in the sense that residents may face isolation in the absence of others who share the same language or cultural worldview. From a critical perspective, these studies illustrate how dominant discourses and power structures from wider society can be replicated within AL, and how these might influence the subjective transition experience.   Literature on resident relationships with staff in AL indicates many care workers report a high level of commitment to residents and have positive relationships with them (Kemp et al. 2009; Kemp et al., 2010). Positive relationships with staff have also shown to be salient in helping AL residents come to terms with relocation (Ball et al., 2000; Jungers, 2010; Street et al., 2007). Further, a “cohesive environment” that fosters close relationships between staff, residents, and families was rated by participants in one study as contributing more to QOL than organizational features of the facility like schedules and policies (Mitchell & Kemp, 2000)., Yet, aspects of difference can negatively influence resident-staff relationships, particularly racism of white residents towards immigrant or ethnic minority staff (Kemp, Ball, Perkins, Hollingsworth 61  & Lepore, 2009; Kemp, Ball, Hollingsworth & Lepore, 2010), which is important when considering the context of  British Columbia where many residential care workers are from visible minority groups.  A third relational focus in the literature is the influence of external relationships on residents’ satisfaction in AL.  Findings indicate that this is a complex phenomenon. One study showed that while continued ties with family, particularly with children, appear to be very important to quality of life, participants also described being dissatisfied with the amount of contact they had with family members (Ball et al. 2000). Similarly, other research indicates that low frequency or duration of visits can be a source of dissatisfaction for newly relocated residents, in the sense that they may look to old relationships to maintain a sense of continuity in the face of change but find themselves “wanting more” than others give (Tompkins, Ihara, Cusick & Park, 2011). In fact, Burge & Street (2012) found that continued relationships with old friends did not improve perceptions of QOL after relocation; the authors suggest that these relationships may be “reminders of the loss of independence or nostalgia for an earlier social milieu, or the temporal frame may invoke comparison with healthier, community-dwelling elders” (p. 15). Yet, other studies suggests that external connections are valuable in cases where they act as a buffer to difficult relationships with staff, especially for those with lower income and less choice in facility (Burge & Street, 2010). Researchers have also begun to examine the role and frequency of residents’ access to the external community and how this influences adjustment to AL (Ball et al. 2000; Cutchin, 2003; Cutchin et al., 2003; Cutchin et al., 2005). This is important, because although AL residents are conceptualized as having more independence than older adults in long term residential care, there is some evidence that moving to AL is actually associated with a reduction in involvement in community activities (Cutchin et 62  al., 2005). Maintaining place attachment to community could provide a sense of continuity and identity for residents; in small towns this may partly be realized through prior community relationships between care staff and residents (Kemp et al., 2009). Taken together, the research on peer-to-peer, resident-to-staff and external relationships suggests that simply moving to an AL residence does not, in itself, foster social engagement. Research that identifies what residents themselves would like to see in terms of opportunities for social connection is therefore important, but not found in the literature.   Other research on the influential features of life in AL also hints at an implicit recognition of the tension between the founding philosophies of AL (such as choice, independence, and individuality) and the organizational practices of AL facilities. For example, although making the choice to move to AL or being actively involved in process is generally equated with higher satisfaction after transition (Burge & Street, 2010; Street & Burge, 2012), research demonstrates that AL facilities do not necessarily offer continued opportunities for choice within AL to support residents’ highly valued sense of independence and autonomy (Ball et al. 2000; Jungers, 2010; Koehn et al., 2014; Mitchell & Kemp, 2000; Sikorska 1999). This is notable, because although AL is often contrasted with long term residential care homes as being a more self-directed environment, one study on transition to AL found that “the loss of independence was one of the most prominent risk factors related to relocation”; experiences such as giving up a car or lack of control over one’s daily routine fostered a sense of “uselessness” or “incompetence” (Jungers, 2010, p. 419-420). Research also highlights several ways that facility regulations restrict choices at individual and structural levels. For example, AL residents speak of prohibitions on over-the-counter medications in their rooms and not being able to control maximum water temperature (Dobbs et al., 2008); having rigid meal schedules and menus (Ball 63  et al. 2000; Dobbs, 2004); facing both unofficial and official restrictions on visitors (Bennett et al. 2017); and limited opportunity to effect changes in policies or practices (Mitchell & Kemp, 2000). Activities organized by the facility can foster a sense of choice, but research indicates that simply offering more choices does not increase resident satisfaction (Sikorska, 1999).    As observed by Cutchin et al. (2005), the key appears to be offering “purposeful activity”, where “the purposes may vary by person, but the majority of activities do not appear to be about filling time or simply keeping busy” (p. 18). In contrast, some facilities offer “programming and other amenities based on a stereotype of generational preferences rather than individual preferences” (Dobbs et al. 2008, p. 523), which contributes to a sense of discontent or even infantilism (Dobbs et al. 2008; Jungers, 2010; Mulry, 2012). In other cases, organizational support for residents to facilitate their own activities is lacking; one Canadian study described how a participant’s repeated letters to the management of her AL facility, wherein she volunteered to beautify the neglected garden, were met with silence (Egan, Dubouloz, Leonard, Paquet, Carter, 2014). In general, what appears to make choices meaningful for residents is related to “a person’s values developed over a lifetime”, and inhibiting these choices can exacerbate feelings of depression or loneliness (Ball et al., 2000, p.320- 321).   Outside of day-to-day choice, other research highlights areas where the philosophy of AL contrasts with larger structural practices and priorities. As mentioned, ‘ageing in place’ is another philosophical tenet of AL in the US. In actuality, facilities make the final decisions on allowing residents to stay, and the varying models of AL mean that ageing in place may be possible in some facilities but not others. In the more restricted AL facilities, some residents to try to ‘pass’ as less dependent or continually negotiate exceptions in order to remain in AL (Cutchin 2003; Dobbs et al. 2008).  Others feel the strain of living somewhere for an 64  “undetermined” period of time until their care levels change, something Frank (2001, p. 11) has termed “prolonged residence” in contrast to true ageing in place. In Canada, AL is not structured for ageing in place so residents may not have that expectation. Residents might therefore face similar difficulty settling in, knowing that a change in their health could force a relocation to long term residential care at any time. However, there appears to be a gap in the literature around this topic. As well, researchers have articulated the tension between the right to live with a degree of managed risk, as espoused in the AL philosophy, and facility emphasis on safety and liability (Carder & Hernandez, 2004; Kane, 2001; Mollica, 2008). Again, Canadian literature is in this area is limited (see Koehn et al., 2016 as a partial exploration of this).  Studies that investigate the interplay of discourse and practice in Canadian AL are important because AL is becoming an important part of the spectrum of care for older adults across the country, but it has not yet faced the same degree of critical investigation and debate as has long term residential care. More research that includes a direct focus on the discursive construction of AL could illuminate areas of disjuncture between promise and practice.  2.4 Chapter summary and statement of research purpose   The three conceptual components I have discussed in this chapter have helped me ‘find my way into’ my research topic. First, my ontological positioning of critical theory and social constructionism encouraged me to question the way that ageing and housing in late life are currently conceptualized and structured. With these paradigms, I was able to approach the concept of AL as something constructed through discourse, policy, and the actions of real employees and residents.   Second, a focus on the dominant and alternative discourses of ageing helped to draw out the ageism inherent in a Western response to growing old, including our system of care for older 65  adults. A preoccupation with biomedical treatments, individualistic responsibility for successful ageing, and the social and economic dependence of older adults has meshed with neoliberal values to perpetuate a negative, role-less, and marginalized position for older adults. This is then reflected in our system of care, where older adults are housed in age-segregated environments away from community life. Alternative discourses, on the other hand, refocus our attention on the interdependent, embodied experiences of individuals and recognize the ways that older adults from multiple social locations navigate and resist negative stereotypes.   Third, an immersion in the theories of transition and the research on relocation to, and life in, AL provided me with information on what is known about this phenomenon and what aspects still require further development. Much of the research reviewed here appears to implicitly support the theories of transition that point to the influence of personal, temporal, environmental, and structural factors in how a person adjusts, including the possibility that some older adults might never completely settle into AL facility. Qualitative studies in AL and long term residential care have begun to build a common understanding of what early experiences of transition are like and how older adults describe their sense of being settled, but there are still some gaps, especially in terms of studies investigating AL as a discrete type of residential care. Further, it is important that Canadian knowledge be developed in order to draw out aspects of relocation and transition that reflect unique system structures, funding models, entry points, and service philosophies. In addition, more sustained, temporal descriptions experiences of moving and settling in would be useful in building a more nuanced understanding of transition over time.   On another level, the literature reviewed here speaks to the tensions between the founding philosophies of AL and the way that these are carried out in practice. The importance of private rooms and spaces, the ability and freedom to associate as one would prefer; the options available 66  for dining, recreation and care – these are related to core AL values of choice, independence, and autonomy. Yet there is a lack of literature that specifically examines residents’ perspectives of relocation alongside the unique philosophy and discourse of AL to explore how it has informed their experiences. Where studies that do touch on the subject, it is often difficult to interpret the results in a British Columbian context, given the multiple ways AL is operationalized.   It is necessary for researchers to continue to challenge and refine the philosophy and practice of AL. If it is simply perpetuating the regimented practices of long term residential care in a different guise, it is not fulfilling its intended purpose. Qualitative accounts of embodied, temporal, and spatial experiences in AL facilities can provide additional data with which to review the project of AL.  Soliciting the experiences of people living in this environment is key, because their position as service-users gives them unique insight into how AL policies are carried out from day to day.  The purpose of my research was therefore to explore older adults’ narratives of moving to AL, paying attention to the structural, discursive, and contextual elements of their stories. I was interested in hearing detailed accounts of what it is like to move to AL, and how older adults' life courses might be reflected in the ways they talk about, experience, and perceive their relocation. As well, I wanted to know whether dominant discourses, such as that of ageing or AL, were employed in telling these stories and whether older adults used alternate discourses to describe their transition.  My research questions were: 1) What are older adults’ experiences of moving to AL? 2) How do older adults speak about AL in these accounts?  3) How do older adults speak about ageing in these accounts?  67  Chapter 3: Research Design and Methodology   My interest in the detailed accounts of older adults’ relocation to AL, as well as my positioning within the social constructionist paradigm, fit well with using a qualitative, critical, narrative approach for this study. I begin this chapter by briefly highlighting the key features of each approach before outlining my research design, execution, and stages of analysis. I will then discuss issues of credibility, validity and limitations.  The last section of the chapter introduces the participants and provides a brief description of their AL facilities.  3.1 Qualitative, critical and narrative methods  The lens of qualitative research is attuned to “how the social world is interpreted, understood, experienced, produced or constituted” (Mason, 2002, p. 3).While the specifics of research design can shift according to where a researcher positions herself or himself across the qualitative spectrum, there is an understanding that some research questions are best explored using its flexible, inductive and description-based methods. The emphasis on in-depth interviewing to elicit rich, contextual accounts of people’s experiences distinguishes qualitative research as a suitable approach in exploratory research as well as in research that seeks to understand complex social phenomena (Singleton & Straights, 2010).   In a complementary way, critical qualitative research directs the researcher to inquire “not only about what is constructed, but… how it is constructed” (Patton, 2002, p. 102, emphasis added). To this end, discourses, power dynamics and structural influences are included in the researcher’s data and analysis. As well, critical inquiry involves being self-aware as a researcher and recognizing the role of ideology and values in what we consider to be “facts” about a phenomenon (Kincheloe & McLaren, 2005). Drawing on the historical focus of critical theory as 68  discussed in Chapter 2, there is also a fundamental idea in critical research that social inquiry should include an element of “emancipatory interest” (McCarthy, 1978, p. 76). The term “critical” has therefore been applied as an umbrella term for, or a stance within, research that generally aims to expose hidden power and assumptions and that seeks to redress current social or political inequities.   Finally, narrative inquiry is essentially research that centres on stories and their study (Wells, 2011). It stems from the assertion that we use stories to organize our experiences, to represent ourselves to the world, and to interpret the social world around ourselves (Baldwin, 2008; Bruner, 1991; Gubrium & Holstein, 2009; Plummer, 1995; Sarbin, 1986).  Storytelling appears to be an innate human activity; it appears very early in childhood and “happenings in our own lives are eventually converted into more or less coherent autobiographies centred around a Self acting more or less purposefully in a social world” (Bruner, 1991, p. 18). There is also evidence to suggest that, even in cases of cognitive impairment where certain verbal aspects of storytelling are restricted, individuals are still motivated to perform stories in a relational and embodied way (Hydén, 2013a; 2013b). Since people are agents in a socially constructed world, the stories we tell about ourselves and others incorporate and reflect the influences of social location, discourse, power, and resistance at play in wider society. For this reason, narrative inquiry is particularly suited to my research questions because it “honors people’s stories as data that can stand on their own as pure description of experience…or analyzed for connections between the psychological, sociological, cultural, political, and dramatic dimensions of human experience” (Patton, 2002, pp.115-116). I was also attracted to narrative inquiry because of its ability to keep participants’ stories intact and contextualized. While comparing the themes of 69  different narratives can occur as one part of the analysis, individual narratives can also be explored as discrete units (Reissman, 1993; Wells, 2011).   Further, narrative methods are well established in several areas related to this study: social work, gerontology, and health care. Gathering narratives of clients’ experiences is a cornerstone of social work practice, and case studies are commonly used for didactic purposes with students and teams. Narrative therapy is also used to reframe client experiences and help them move forward. However, there appears to be less narrative research published in social work than in other traditions (Riessman & Quinney, 2005), which is something I hope this study can help address.    In health care literature, use of personal narrative and life review has been promoted as a way of improving life in residential care for older adults. Studies have explored how narrative can be used to help residents find continuity of meaning in their lives despite living in institutional settings, and also how it can facilitate more responsive care based on that which residents identify as meaningful (Heliker, 1997; Moore, Metcalf & Schow, 2006).  These types of investigations are valuable because older people’s experiences and “interpretations of what it means to age, may illuminate some aspects of human life that are more important than the items that currently fill the social agenda” (Baars, 1997, p. 261). In this vein, the work of Gubrium (1975, 1993) and Gubrium and Holstein (1999) uses narrative and ethnographic data collected in residential facilities to draw connections between the experiences and insights of residents and dominant discourses, practices of power and resistance, embodiment, and constructions of identity and meaning. In more general health care research, gathering service-user narratives helped the National Health Service in Britain to solicit aspects of care that were the most salient for patients, rather than relying on satisfaction surveys that limited the types of response received 70  (Wilcock, Brown, Bateson, Carver & Machin, 2003). Aside from identifying themes or details that even the participants may not have realized were significant, the method redresses the power imbalance of the traditional method of interviewing by allowing the participant to direct their own account. Similarly, the work of Surr (2006) demonstrates how unstructured interviews can be used in conjunction with techniques of interpretive biography to create rich understanding of the lives of persons with dementia.  Narrative research has also been used in studies that explore the significance and experiences of ageing. One Finnish study (Vasara, 2015) examined older adults’ narratives about moving to different types of assisted housing; their stories demonstrated how individuals reinterpreted the dominant cultural narrative of ageing in place to find meaning in the relocation. Kaufman’s seminal work The Ageless Self (1989) used the life stories of older adults to contribute to new theoretical perspectives on how older adults “perceive meaning in being themselves in old age” (p.6). Indeed, the research of Nilsson et al. (2000) indicates qualitative and narrative research may fill a need for older adults; during the data collection on experiences of feeling old, participants sought information from the researchers on what the other participants had said about their experiences and whether their own experiences could be considered normal. Narrative inquiry is therefore amenable to the emancipatory coals of critical research because it opens up the space for older adults themselves to shape the available discourses of age.    3.2 Data generation  3.2.1 Participant recruitment  I began learning, both about AL and about the research process, from the beginning of my study. My original participation criteria were: individuals who were either scheduled to move 71  into AL imminently, or who had moved in within the last six months, and who were comfortable interviewing in English. My goal was three to five participants who would be interviewed up to four times each. Although I eventually did find four participants, the route to finding them was circuitous.   I had intended to set my research at one or two chosen AL residences in the Vancouver Coastal Health Authority, to allow for better contextual understanding of what participants’ might reference about living there and to see if there were differences of experience within the same environment. I approached two potential residences; both were publically subsidized AL facilities in the Vancouver Coastal Health Authority. I chose publicly subsidized residences as I felt this would best reflect the experience of people with a range of income levels and because of the Canadian tendency toward public health care.   One site was willing in principle, but they felt that asking people to participate as soon as they moved in was problematic. In their experience, many people were too frail upon moving in to participate (residents typically were in their nineties) and they preferred that I wait until after six months to conduct interviews. As well, they felt that providing recruitment material at the same time as moving in would be interpreted by individuals as having to participate as a condition of being accepted as a resident. Based on their observation around health at the time of moving in, I decided to extend my period of eligibility to those who had moved within 12 months. However, I did not want to categorically agree that I would wait until six months had passed before approaching residents. I wanted to capture as much of the transition as possible, so if a person felt able before then I wanted to be able to interview them. I therefore decided this AL site would not be a good fit. At the same time, the other site I had approached mentioned that although they were willing, they doubted I would be able to find enough participants there 72  because the waitlist was so long and no one was scheduled to move in. The residents who had been there less than six months were not fluent in English and were experiencing health troubles, so the administrator did not feel that they would be interested.   Already I had learned about the slow turnover for AL units, as well as a higher age bracket and lower quality of health than I was expecting. I also realized that it was not likely that I would be able to interview people who were about to move into AL, because the length of the waitlists meant that individuals would not know when they would get a placement and their move might therefore not fit within my data collection timeline. If their health was compromised, as the AL sites suggested it might be, they would be even more unlikely to want to participate amid the stress of moving. For these reasons, I decided to recruit in successively wider ways.   My first step was to contact two seniors’ centres in the vicinity of AL residences and ask to put up recruitment posters (Appendix A). My thought was that, since AL residents are considered independent, they may continue to go out in their neighbourhoods for socializing and programming. I also obtained approval to recruit through a private AL site with several publically subsidized units and that had welcomed research projects in the past. These steps also proved ineffective – although my flyers at the seniors’ centres were reportedly all taken, I received only two calls via one of seniors’ centres and the individuals were not suitable to participate. At this point, I expanded my recruitment to incorporate all eight publically subsidized AL facilities in the Vancouver Coastal Health Authority, and I gained ethics board approval to include word of mouth recruitment as well.   At this point I would like to comment on the issue of participant confidentiality as it relates to older adults and their status as a “vulnerable population” in research ethics.  The method of approaching residents that was approved by the Health Authority was for me to 73  provide a research poster to the Manager of AL, who then sent a letter of introduction and my poster to the administrative staff at each of the ALs. There appeared to be a concern that if I were to hold my own information sessions about my project within the ALs, residents might feel pressured to participate or they might recognize one another and feel that somehow their anonymity (if they eventually did decide to participate) would be compromised. It is true that the AL environment is intimate, much like a small town, and people can feel restricted or judged. My belief, however, is that residents are wise about their own needs, so they could decide to participate in an information meeting or the wider study as they wished. Also, AL residents are meant to be independent and their suites are treated as being rented, yet there was a level of protectionism and gatekeeping at play. If I had the chance to explain my study in person, to demonstrate my genuine respect and to answer any questions, perhaps it would have resulted in more participants. As it turned out, I was reliant on various administrators to both comprehend my larger purpose and to ‘sell’ my project to their residents.   Several of the AL facility mangers were supportive and approached the residents they felt were suitable. In particular, one AL residence with a history of welcoming researchers taped my posters to the door of every AL resident and, from what my one participant told me, made it plain that residents were entitled to speak their minds with no consequence from the residence. From this site, which I will call Forest Place, I obtained two participants. From word of mouth recruitment, I obtained another two participants, for a total of four. I will provide a brief description of them and their AL residences later in this chapter.  3.2.2 Documents  During the time that I was recruiting participants, I was also collecting publically available documents related to AL in British Columbia. The purpose of this was to provide a 74  contextual background that would help me develop interview questions and also clarify what AL looks like in this particular locale, given that the legislation and structure of AL vary so widely. Finally, I wanted to use the documents to create a discursive ‘story’ of AL; a backdrop of regulation and conceptualization against which the participant narratives could be explored. I collected a number of documents, including seniors’ care and housing marketing material, government legislation and publications, Health Authority publications, and handbooks from publicly subsidized AL sites. I present the summary and analysis of documents in Chapter 4. 3.2.3 Participant interviews  Participants were interviewed in a location of their choosing at least one time to record their relocation narratives, and up to four times for clarification and elaboration. Each interview was recorded using a digital audio recorder. I had planned to allow each potential participant time to reflect on their interest in participating between explaining the study and the signing of consent forms, but all participants declined this step and agreed to participate immediately. Therefore, all first interviews were preceded by a discussion around the purpose of the study, my ethical obligations as a researcher, the right to anonymity and withdrawal from the study, and finally, the signing of the consent form (Appendix B). I began each interview by asking participants to tell me the story of how they came to live in AL, beginning wherever they chose. I had several prompt questions prepared in case certain information was not covered (see Appendix C). One participant, located in a small town in the Fraser Valley, was only available for a single interview and declined further involvement because she felt she had said all she needed to say. I had spent the entire morning with her in her AL residence and had lunch with her in the dining room, however, so I did have contextual data as well. A second participant was interviewed one time in person, in her suite, for an hour. She also walked me through the 75  common areas of her AL residence afterward. A second interview was conducted two months later over the telephone for approximately half an hour, as she lived in a small city in the interior of the province. The third participant, who lived in Forest Place in Vancouver, gave an almost four hour account of her relocation narrative, as well as three follow up interviews that ranged from an hour to two hours. The interviews took just under a year to conduct, with the spacing as follows: two months between the first and second, two months between the second and third, and six months between the third and fourth. This participant always preferred to meet in a coffee shop, but we spent time talking about the physical environment of her AL residence. The fourth participant also lived at Forest Place, and we conducted all the interviews in his suite so I was able to observe the site myself. During our fourth and final interview we went on a walk-through of the common areas. His initial relocation interview took place over an hour and a half; subsequent interviews ranged from just over an hour to just under two hours. His first three interviews were spaced approximately one month apart; the fourth one was just 20 days after the third. When I tried to schedule a fifth interview, I found, sadly, that he had passed away.  All participants were mailed a copy of the transcript from their first relocation narrative interview and given a chance to review it before the second interview. My purpose in sharing the interviews was partly to perform member checks, but also allow the participants the opportunity to remove any information they did not wish to be shared. As well, since these were the participants’ own reflections and recollections, including biographical anecdotes, I felt they might wish to have a copy of their stories to keep. This approach reflects the position of critical qualitative researchers that attempts should be made to recognize and rebalance the power differential that can happen in the researcher-participant relationship (Karnieli-Miller, Strier & Pessach, 2009). It also stems from the epistemological position that there is no ‘pure’ or ‘true’ 76  version of a story, since we perform them based on the context and of their telling and the purpose we believe them to serve. Similar to comments made by Plummer (2001) or Riessman (1993), the goal of a second interview or other member checks was not to pin down the exact truth of the original relocation narrative, but to expand and deepen the account. If a participant wished to reformulate, remove, or even contradict a section, it would be their prerogative because it would support their identity as they wished it to be represented. As it turned out, no one had any objections to, or specific comments on, what was written, other than some jokes about how the conversational “ums” made them sound less articulate.  The reason for including walk-throughs as part of the interview process was inspired by the work of Phoenix and Sparkes (2009), who found that they could elicit different types of information from their participant in different settings. In the formal interview, they obtained ‘big’ stories featuring biographical narrative content centred on the specific topic of the research. When simply spending time with the participant, they were able to hear spontaneous ‘small’ stories that provided a glimpse into his inner world. In my project, I did not approach the walk- through as would an ethnographer; spending long periods of time observing the setting and individuals in it. Although I observed the features and atmosphere of the spaces as much as possible, I followed the pacing of the participants and was generally focused on their reactions and comments. I had a few prompt questions prepared (Appendix C) but used them varyingly because the context of each of the three tours was very different. I will provide some of this environmental data later in the chapter as I introduce each AL residence and participant.  3.2.4 Field notes and research memos  A third type of data generated in the study was from field notes and research memos. After each interview, I wrote a series of impressions, contextual information or ideas to pursue in 77  the next interview. I transcribed all of the first interviews myself and several of the follow up interviews, during which time I often stopped to write down additional memos about hunches or clarifications needed. For the interviews that were transcribed by others, I listened to the recordings while reading the transcripts in order to ensure accuracy and to check that the meaning I felt was conveyed by the participant or myself was reflected in punctuation or directive notes around intonation or body language. Again, I often stopped to record memos while undertaking this process. These memos were important in helping to generate questions for subsequent interviews and were also a way of building trustworthiness into the data generation. In particular, I followed a series of reflexive questions that Wells (201, p. 121) suggests the researcher employ as a matter of course during the research process that relate to issues such as: the researcher’s attitude towards the participant, the effects of emotional responses on the recording and analysis of data, location of power during the research process, how theoretical assumptions or methodologies might have affected data collection, analysis and interpretation; and considering what alternative explanations or interpretations are possible from the data collected.   3.3 Data analysis  Data analysis in this project was a multi-step, iterative process. The documents and transcripts were first analyzed separately. As mentioned, the document selection and analysis will be discussed in the following chapter. Early analysis of the interviews began with memos and field notes as described above; I used the gaps in my knowledge and my hunches to create questions for the follow up interviews. For the formal analysis of interview transcripts I used the qualitative software program Atlas.ti, which was helpful in allowing me to tag passages with 78  multiple codes and to create memos around entire sections. I analyzed each participant transcript in three ways. The first was a thematic content analysis, where I read for recurring themes and topics. These eventually developed into a list of codes that applied across all interviews. Some of these codes were related to aspects of the move to AL, such as how the decision was made to look for an AL residence, how that particular site was chosen, how family members were involved, how long the person was on the waitlist, and details of the moving day. Other codes related to organizational aspects of AL, such as policies, programs, services, and staff. The physical and social environment was another code family. I also made note of spontaneous sub-narratives embedded into the larger relocation narrative or interview. As well, I created codes around existential topics such as ageing, independence, comparing abilities, and values. My goal in creating these different types of codes was to tease out the ‘factiticites’ of the narratives – the personal, interpersonal, sociocultural and structural aspects of lived events (Denzin, 1989; Kenyon & Randall, 1999) – as well as to think about a “three-dimensional narrative inquiry space” comprised of the “personal and social (interaction); past, present and future (continuity); [and] the notion of place (situation)” (Clandinin & Connelly, 2000, p. 50).  In the second reading, I paid attention to the different voices in the narratives. In particular, I was looking for examples of where participants’ voices were active or passive, how they described their thought processes or internal dialogues, and how they represented others in the quotes or anecdotes they used. I was interested in hearing the shifts of power in the narratives and the discursive references to AL or aspects of ageing. Here, I drew on Bakhtin’s concepts of heteroglossia and polyphony (Vice, 1997, p. 113). Heteroglossia is similar to the idea of discourse and refers to different languages present in a society – professional, class, colloquial, formal, women's, men's, etc.  Polyphony describes the difference voices of different characters, 79  but Bakhtin also used it to describe cases of characters' self reflection and internal voices. By examining voices, I hoped to orient myself to how participants linked various discourses into their personal narratives and interpretations of experience.   In the third reading, I made memos around points of the participant narratives that resonated with me. I included this step partly to incorporate reflexivity in my research, a component of qualitative trustworthiness (Wells, 2011), and partly to expand the analysis on another level. Being aware of my own assumptions and responses was important in order to keep focused on what participants were saying about themselves and their own lives, instead of analyzing based on my own experiences. It was also a good way to keep track of how my response to any particular comments may have influenced the course of the interview. This was a different process than the field notes and transcription memos, because by the third reading I had a deeper engagement with the transcripts. It gave me a space to reflect in a ‘messy’ way, and then incorporate those observations relevant to the larger analysis with a more distanced and critical eye.    During the analysis of the data from individual participants, I began to see several cross-case themes emerge. However, I felt reluctant to fracture or constrict the narratives to in order to present theme-related discussions. The power of the narratives seemed to be in their ability to portray the vitality and personality of the older adults and the contextuality of their transitions to AL. I was also having difficulty recruiting a fifth participant. As I was still in the process of data collection, I decided to expand the number of interviews with the two Forest Place residents and draw on techniques from interpretive biographical analysis to build their cases. In particular, I incorporated interview questions and analysis around the participants’ reflections on relocation and on other transitions in their lives (Denzin, 1989).  80   In choosing my cases I used a combination of convenience and purposeful sampling. Pragmatically, the Forest Place participants were local, and one of my other participants had already expressed her feeling of being done with the study.  I was fortunate, however, that the Forest Place participants demonstrated good variation in their cases: they represented both male and female social locations, they came from different economic classes, they had very different paths of entry to AL, their narrative styles were quite different, and they had experienced different levels of success in settling in after relocating. Because of this variation, I felt confident that they would be interesting and illuminating cases. I also thought this approach would be consistent with accepted narrative conventions for exploratory studies. Narrative researchers have argued that, when consistent with the study goals and when interviewing and analysis is undertaken in depth, a small number of cases – at times even one – may be sufficient (Baker & Edwards, 2012). In addition to the thematic content analysis of the AL documents and the four sets of transcripts, and the discursive analyses that I discuss below, I felt that the inclusion of two in-depth case analyses would present an engaging way of illustrating key themes, contextual details, and temporal aspects.   To develop the case studies for Rose and Ian, I analyzed all four of their interviews for narrative elements and personal themes. I constructed abbreviated accounts of their relocation narratives using illustrative quotations punctuated with my own analysis and linkages to the aspects such as the context of telling the narrative, the context of the relocation in Rose and Ian’s lives, pertinent biographical details, important relationships, and personal values and identities. The aspect I found most challenging in doing so was how to present the data in a way that met the constraints of written accounts, despite the fact that the original narratives had taken hours to collect, were often out of sequence, and had been iteratively developed over the course of several 81  interviews.  Yet the process of collating the data around common themes and turning points proved very useful, because I was able to see contradictions, nuances of meaning, and larger implications of key topics across the interviews.   In partial response to these challenges, I decided to use poetic transcription to create poems that prefaced each chapter, in order to introduce Rose and Ian in their own words. Poetry is an effective vehicle to present long narratives, because it is able to compress accounts while retaining the emotions and context (Furman, 2006). To create the poems, I followed the rules developed by Glesne (1997): the words must be participant's; the phrases could be from anywhere in the transcript; the phrases must honour the participant's way of speaking; and I had permission to slightly change words for coherence and depict the essence of the theme.  Although poetic transcription is more a technique of representation than analysis, I found that in pulling the most evocative and resonant passages from the transcript I was also reinforcing the themes I had identified in the content analysis and memoing process.  A further benefit was that poetry invites empathetic positioning that is different than reading quotes surrounded by academic analysis. It allows the reader to think " ...with rather than about the participant’s experience. In the context of older persons, often words are spoken for them or on them, but here using poetic inquiry, [one is] able to speak with them" (Miller, Donoghue & Holland-Batt, 2015, p. 416, original emphasis). The relocation poems therefore allowed Rose and Ian a direct platform for interaction with the readers of this dissertation.   After completing the cases and the cross-case content analysis, I moved to a third level of analysis focused on the ways that discourses and discursive social structures were represented and used within the participant narratives. In particular, I was interested in how participants spoke about ageing and moving to/living in AL, and the ways that their discourses supported or 82  challenged the discourses from the AL literature and the dominant discourses of ageing. Taken together, the three types of analysis conducted on the data in this study – individual document and transcript analysis, cross case analysis, and discursive analysis – provided a multifaceted view of the process of moving to AL.   3.4 Validity and credibility   I have addressed aspects of validity, and credibility in previous sections, but I reiterate them here. In addition to the incorporation of reflexive activities into the research design and analysis, member checks, and supervisory/committee feedback during the process of data collection and analysis, I turned to literature on qualitative and narrative research methods for guidance. A key point from this literature is that how one measures the validity in a study is related to one’s epistemological position. Social constructionist and narrative researchers tend to be interested in subjective meaning-making over verification of ‘facts’ in participant accounts, because facts themselves are the products of interpretation, and our interpretations are influenced by available discourses (Riessman, 1993; Riessman, 2003). Member checks are useful in that the participants themselves can judge whether the account captures their experiences (Cresswell & Miller, 2000). Rather than employing concept of validity, some narrative researchers espouse trustworthiness – a concept that is linked to appropriate and coherent design as well as ethical and reflexive investigation (Wells, 2011). Creating trustworthiness is therefore an ongoing activity built into the research process. By clearly positioning myself theoretically, choosing epistemologically congruent research methods, employing transparent and ethical research practices, using reflexive and evolving analyses, and maintaining a clear understanding of the 83  study’s purpose, I have made efforts to incorporate standards of good-quality research into this study.    3.5 Introduction to the participants and AL sites  I this section I present short introductions to the four participants and some details about their AL residences. Other details are presented in the case studies chapters and the findings chapters as relevant.   Mabel was a 95-year old Caucasian woman born in Saskatchewan. She moved to the Kootenay region of British Columbia at 19. For a time she lived in Ontario on an army base where her first husband was stationed, but she moved back to the Kootenays when he went overseas. She worked as a switchboard operator and also trained as an early childhood educator but did not work after marriage. She had two daughters from this first marriage. After she was widowed, she married a man who was also widowed and became a stepmother to his three sons. She was also a grandmother. Prior to Mabel’s move to AL, she was living in an independent seniors housing complex in a city in the Fraser Valley. The AL is in a neighbouring rural town; one son lived very close and visited almost every day.   Mabel lived in a small AL residence of 32 suites, 10 of which were publically subsidized. At the time that she was looking to move, her cleaning lady recommended this particular AL where she sometimes performed as a singer. Although it had subsidized units, her family felt that her health was too poor to wait for a subsidized spot and they elected to rent a privately-paid suite, available immediately. The building had two levels; the upper level also had library and large patio. There was a bright, open common lounge and dining room on either side of an entry hallway, as well as a coffee and tea area. A private dining room off the common room was used 84  for holiday events but could also be booked by families for private functions. The doors had no entry or exit restrictions but Mabel said if she returned from her son’s after 10pm she punched in a key code to open the main door. The town centre was approximately 1.3km away.   Helen was a 91-year old Caucasian woman. A daughter of Russian immigrants, she grew up on a farm in Manitoba near Medicine Hat with her ten siblings.  Helen joined Air Force at the age of 21 during WWII. She was stationed in a personnel office in London, England until a year after the end of war when women’s unit was disbanded. Afterwards, she took a “commercial course” and performed various office jobs until she settled in Surrey with husband in 1940s, where they raised a daughter and a son. After her children were in school, she did typing work and eventually got a job as the school secretary. Helen and her husband moved to a gated community in Okanagan after retirement. Her son lived in Lower Mainland, her daughter and a niece lived in a neighbouring community in the Okanagan.   Helen’s AL residence was built in 2008 and offered both AL and residential care sections. I was able to walk right into the bustling lobby/reception/common area, but I did notice a resident sign in/sign out book while I was signing a guest book at the reception desk. When I went up to Helen’s suite, I came across a door marked “Secure Unit”, which is presumably why the main entrance could be left unlocked. There were 50 AL suites, some of which were occupied by couples. Helen paid privately; there were no publicly subsidized AL units. The multi-story residence is located on a main road close to a strip mall with post office and a drug store; Helen said she could walk there. There was a large common room with contemporary decor, a television and multiple seating areas, as well an open lounge for entertaining. The dining area was separate; Helen and I accessed it via stairs from her hallway on the second floor. The property also had a tuck shop, chapel and hair salon.  85   Rose, a 78 year-old Caucasian woman, immigrated to Canada from England as a newlywed in her 20s. Her husband left after a little over a decade of marriage and they divorced, leaving her a single mother with two sons and a daughter. She found a job as an after-school care provider and remained happily employed there until her retirement. She was a grandmother of four and a great-grandmother of one. Prior to her relocation, she lived in an independent seniors’ apartment complex for 11 years and was very involved in her local community centre.   Ian was an 81-year old Caucasian man, born and raised in Vancouver. He was widowed, with a son and daughter who lived locally as well as a son and a daughter who lived in England and the United States, respectively. He had fifteen grandchildren. In his career he was a lawyer.  Ian experienced a series of moves from home to hospital to AL to independent living before arriving in Forest Place.   Both Rose and Ian lived in Forest Place, a campus of care in a neighbourhood of Vancouver. Campus of care refers to a mix of independent living, assisted living and complex care/residential care units located at one site. There were 28 independent suites, 36 AL suites, and 112 complex care rooms. I describe the features of Forest Place in more detail at the end of Ian’s chapter, as our final interview included a walk-through portion.         86  Chapter 4: Document Analysis: What is the Conceptual Story of Assisted Living?  The first stage of my data collection was to collect various promotional and regulatory materials about Assisted Living. My motivation for this was partly to begin to understand the context of what my participants may have expected, read about, or experienced as part of their relocation (Bowen, 2009).  From a critical and social constructionist perspective, I also wanted to begin to unpack the dominant conceptual story of AL, based on the terminology, policies, ideologies, themes, and prominent messages found in the AL literature. This helped to create more relevant and informed interview questions, and also helped attune me to how the official, public story of AL might compare to the individual, contextualized stories of my participants.  As Grenier (2012) suggests:   “When local stories are set against larger interpretations of ageing and late life, the  comparison between the official storylines of public policy and those experienced in  everyday lives of older people provides glimpses into the coalescence or disjuncture  between the suggested and the experienced.” (p. 69)   4.1 Selection of documents  My main criteria in selecting documents were that they were publicly available and specific to, or relevant in, British Columbia. Within this, I sought documents that would be provided to individuals or their families by health care professionals and AL operators, or documents that were easily ‘discoverable’ by the individuals or families in the course of investigating AL. Arguably, some of the more technical documents I included, such as 87  legislation or AL operator manuals, would not be commonly accessed by older adults or their families. I felt it was important to include them, however. Partly this was because they have been made publicly accessible by virtue of their posting on government websites, and partly because they are an important component of the “communities of meaning” (Yanow, 2000) around the concept and purpose of AL. Indeed, much of the discourse used in the higher level policy documents has been reproduced in the language of handbooks and other publications targeted to older adult service users. While different groups (policy makers, AL operators, older adult residents) may interpret the core messages in these documents differently, there is a common set of terms and references within them that invite comparison.   There are several types of documents I did not analyze. For example, I chose not to conduct textual analyses of the government websites related to AL. Instead, I made note of the type of content covered on the three major government sites covering supportive housing for older adults (The Ministry of Health, The Province of British Columbia and BC Housing). I downloaded and reviewed any relevant publications posted and then returned to the websites to compare the publication information and website information. It was clear that most of the information on these sites is drawn from, and refers back to, the core legislation on assisted living (The Community Care and Assisted Living Act, 2002) and the policies of the Office of the Assisted Living Registrar, but is organized differently. The website information is typically organized to be read quickly and concisely and is sometimes repeated across pages according to search terms or related topics. It is written for older adults and families as well as assisted living operators and health care professionals, whereas the actual documents are typically targeted for one audience or another. Because of the repetition of information, and because it is often less 88  precise to cite information from websites as compared to traditional text, I chose to analyze the original, core documents or publications referenced there.    As well, I had initially intended to include an analysis of the actual assessment form used by case workers when determining eligibility for AL. I was able to obtain an ‘off the record’ copy of the assessment from a personal contact, but I felt I could not openly discuss or analyze it without having Health Authority permission. In part, this is because I would be violating my research ethics agreement with the Health Authority, and in part it was because my contact made it known that s/he was providing the document to me at professional risk. Therefore, I also requested a copy from the Health Authority. However, this request was met with a degree of hesitation. After conducting several participant interviews I decided to stop pursuing the assessment form because it seemed to be much less significant to the participants than I had anticipated. While they mentioned being assessed, none of the participants mentioned any of the details from the form or spoke about the initial assessment process in much depth. What seemed to make more of an impression with participants was the final interview just prior to move-in, where they met the staff and saw the building for the first time. From seeing the assessment forms in the course of my hospital social work, I knew that they are based on scores around physical and mental function, formal and informal caregiver support, and the degree of risk to the individual in the current environment so I was still able to ask pertinent questions and understand the general assessment process without specifically referencing the official form.   I also did not include internal staff, operations, or policy manuals for individual AL sites. Clearly these are very important in understanding the culture of assisted living and how administrative priorities can influence the day-to-day experiences of older adults in this setting. However, the focus of this study was to understand the experiences of the older adults 89  themselves. Because these documents are not available to the public, it would be very unlikely that participants would reference them in describing their experiences. As well, the Assisted Living Registrar and government documents cover many of the mandated procedures and policies that govern all AL sites. As I discuss below, I did include resident Handbooks from two ALsites that were able to give a picture of the values, expectations, and services that residents would experience. I felt that analyzing site-specific, internal AL documents would be better undertaken as a discrete future study, informed by the results of this project.  Ultimately, I included 18 documents and one website, sourced in several ways. From my experience in acute care with older adults, I knew of a publication given by hospital social workers to older adult patients and families that listed various private housing and home care companies (The Care Guide, 2012/2013), and I was able to obtain the most recent issue. Serendipitously, I found another national seniors housing and “retirement living” serial inserted into my Globe and Mail paper in the fall of 2012 (Comfort Life, 2012/2013). I was also directed to, or provided with, other documents through my contacts in a provincial Health Authority:  A brochure on AL, given out by case managers to older adult clients and families  The Ministry of Health and the Office of the Assisted Living Registrar publications for older adults, available online  The Assisted Living Registrar’s Registrant Handbook (2011) excerpts, available online  A set of materials that the Health Authority gives to individuals after being placed on an AL residence waitlist, comprised of: a general resident handbook covering all subsidized ALs in the Health Authority; a cover letter; and an Assisted Living Application and Terms for Services document 90    I also performed simple internet searches on “assisted living Vancouver”, and “assisted living BC”. This generated results from private and public AL residences in Vancouver as well as in the general lower mainland and coastal BC; the Vancouver Health Authority website and its publications on subsidized assisted living; and the provincial government websites where I was able to follow links to key AL policies and regulations. As well, I requested that information be sent to me from the first two privately operated AL residences in Vancouver displayed during my internet search on “assisted living Vancouver”.  Based on what Ian told me about the location and services of his first AL residence, I requested another package of information from a third, private AL that I thought might have been his. Because he could not recall the name of the property, I could not use the document as a source of data for his case. Nonetheless, it proved to be an interesting document as I will discuss below. Finally, I was able to include two resident handbooks from subsidized AL residences; one of the public AL handbooks was downloaded from the website and one was obtained through a participant at Forest Place.    4.2 Analysis  Since my goal was to construct a discursive story of AL and compare it to the stories told by participants, I elected to conduct a thematic content analysis that would include the context and function of the documents and the language used therein. I devised a set of questions that were drawn from literature on discourse and interpretive policy analysis (Gee, 1999/2005; Wood & Kroger, 2000; Yanow, 2000). The work of Grenier (2012) was helpful for its specific focus on the intersection of late life, transition, and ageing policy. Consistent with the critical and social constructionist approaches in this project, discourse and interpretive policy analysis direct the researcher’s attention to questions beyond the literal words on the page, towards broader 91  questions around the social messages, power structures, functions and assumptions of the texts. “Focusing on the messages that are articulated in public policy show how ideas about the lifecourse can become fixed into social practices that influence interpretations of ageing” (Grenier, 2012, p. 63). For example, the emphasis on health and function throughout many of the AL documents reflects the dominant perception of late life as a time of decline and infirmity. As I read the documents, I asked:  Who is this document written for?   What the function/purpose of the document?   How is the document structured or organized?   What is obvious or overtly stated/shown in the document?  What is not said/shown?  What are the assumptions in the document, about older adults or otherwise?   What language or metaphors are commonly used?  What are the dominant messages or themes in the document?  My goal in using these questions was to help me understand how AL has been discursively framed for Health Authorities and health care workers, older adults and families, and the general public. As Yanow (2000) explains, “frames direct attention toward some elements while simultaneously diverting attention from other elements. They highlight and contain at the same time they exclude” (p.11). Older adults may use these publicly available “frames of reference” to interpret and compare their own experiences with ageing (Grenier, 2012) and transition to AL.   92   In the following section I will present analytic summaries of the five different groups of documents:  1) Publicly distributed seniors’ housing and care directories;  2) Information packages from private AL residences; 3) Provincial regulatory legislation and policy documents;  4) The website and documents from Vancouver Coastal Health; and  5) Resident Handbooks from two publicly subsidized AL residences.  Afterward, I will discuss how the themes and discourses across these documents come together to form a broader conceptual story of AL in British Columbia.  4.2.1 Seniors housing and care directories   Description and format   These guides are free, publicly-distributed serials that are published annually. As mentioned, The Care Guide is a booklet provided by (at least) one metropolitan hospital in British Columbia, to older adult patients and families who are considering alternative housing or care arrangements after discharge. It is produced by a Toronto company, Care Planning Partners, who offer provincially-specific versions. I was not able to find an electronic issue for the year I analyzed, but the current version is very similar in terms of purpose, layout and property listings (http://www.thecareguide.com/guide/BritishColumbia/ ). The Comfort Life print directory is one of several resources produced by a Canadian media company, Our Kids Media, who markets private schools, summer camps and retirement communities (http://www.ourkidsmedia.com/).  It is a full-sized magazine format. Both the Care Guide and Comfort Life have online platforms that complement or extend the information in the guides. Comfort Life also produces an  93  e-newsletter that is sent several times a year. I was able to find a link to the entire online edition of the Comfort Life issue I analyzed, and I include the link here to be used as a reference to the pages and images I discuss (http://epub.comfortlife.ca/i/63074-10th-annual/66).  The directories are a combination of seniors’ housing listings per province/city and information articles. It is important to note that in the issues I analyzed, all the listings in Comfort Life and the listings of prominence in the Care Guide are from privately-operated properties that elected to advertise with the publications.  The publishers’ statements of this are located obscurely in the publications, however, which could give readers the impression that the properties listed are the only properties available. Both directories provide an operator-written description of the properties, contact information, and a small photo of each that emphasizes flattering aspects such as grand entrances, modern apartment-style design, gardens, recreational amenities, and smiling staff and residents.   There is a slight difference in the terminology and organization used in each guide. The Care Guide uses the phrase “full spectrum of choice” (p. 10-11) to describe the listings, implying that older adults will be able to pick from a variety of housing and service options to best meet their preferences and needs.  The properties are organized by care level (home care, independent living, assisted living, long term care and hospice). A short introductory article defines each level and briefly mentions the possibility of government subsidy “in some cases” (p. 10-11). The listings show specific services offered at each property, such as meals, laundry, housekeeping, “Alzheimer care”, specialized staff, incontinence management or medication management. At the end of each section, there is a very small-print list of contact information for additional properties that did not advertise, but were collected by publication staff. This list includes both private and public properties, but this distinction is not made for the reader. Notably, this list is 94  the only printed collation of public assisted living properties in British Columbia I was able to find. The other listings seem to be available online only, via the Ministry of Health’s Assisted Living Registry page, or on Health Authority websites.   Comfort Life uses the term “retirement communities” to describe the properties and simply includes the care levels offered as part of the listing details. Naming them as such makes a link to the idea of the third age, wherein individuals enjoy leisure and comfort as reward for their lifetime of paid employment. However, there is no discussion on what a retirement community is, or what the different terms (Independent Living, Assisted Living, Active Adult, Long-Term Care) mean in this context. This is an important point, given that the publication is national and provinces have a range of terminology for levels and types of care. The listings also include prices per month, where provided by the operators.  Target audience  The articles in both publications are written for older adults as well as their children. The editor’s foreward to the issue Comfort Life, for example (p.4), switches audiences from paragraph to paragraph; one is directing single older women to an article on financial planning and the next is addressing children about how to have “the talk” about relocation with parents, with the help of  articles in the issue. The Care Guide tends to use passively-phrased or simultaneous “seniors and their families” language to reach both audiences. Both publication covers feature middle-aged, Caucasian daughters with their able-bodied parents (a father on the Comfort Life cover and a mother on the Care Guide). While it does not reflect the multiethnic population of Canada, it does reflects the reality that daughters are often the family members who take on the care of their ageing parents.  95   Beyond this, the articles and advertisements speak to a particular socio-economic class. For example, there is an assumption of technological comfort and accessibility throughout the guides. The publications’ web addresses are a runner on every page, many property listings offer virtual tours, several advertisements and property listings have smart phone QR scan codes, and one prominent advertiser in the Care Guide is Zoomer Wireless, a mobile phone company that specializes in cell phone plans and adaptive cell phones for older adults (p.21). This in itself is not unusual, given the recent growth in internet and smart phone-driven marketing, but when it is combined with pages and pages of advertisements for upscale, private residences and private-pay homecare services, it can be seen as targeting older adults who are active consumers and who have more income available for such amenities. It also references the popular language of ‘zoomers’ (baby boomers with ‘zip’) and consumer lifestyles. A Comfort Life article on financial planning, with its language of “investment portfolios” and “risk tolerance” provides this quote: “There is no reason why a senior woman, regardless of her marital status, needs to retire into poverty” (Irwin, 2012, p. 47). Such as statement negates the financial precariousness faced by many women in Canada.  Unequal rates of pay, gendered patterns of job insecurity, years spent caring for family, and experiences of disability, immigration, and abuse can affect a woman’s access to the paid economy and financial independence.  Content analysis  The articles focus on themes of knowing when it is time to move, downsizing and preparing for moving, and choosing personally-suitable accommodation. The listings for properties then serve as the solution to the problem of relocation. As one two-page spread asserts: “Your home is just walls. If it’s not fitting your need, you need to find new walls” (Comfort Life, pp. 12-13). This comment minimizes the emotional connections people have to 96  their homes and neighbourhoods, and does not recognize the effort and resources it takes to make such a relocation.  The core set of articles in the Comfort Life publication are based on the themes of “the seven pillars of a fulfilling retirement”: social, environmental, spiritual, sexual, emotional, physical and intellectual (p. 7). Each pillar is addressed with testimonials from older adults living in the featured private-pay residences. The language of the articles draws heavily from active/successful ageing discourses, particularly the notion that individuals should take steps to prevent decline: “...idleness and social isolation are the enemies of healthy ageing” (Workman, 2012, p 10).  The Care Guide is arguably broader in its target audience due to its inclusion of a spectrum of both public and private care information, Health Authority contact numbers, and a list of national, public resources for older adults. Yet both publications demonstrate a conflation of neutral information with articles of promotional benefit to a private company. The Care Guide, for example, has several feature articles that ostensibly provide information about health issues, mobile phone providers for older adults, and how to decide when to move to seniors housing. Yet these ‘articles’ have actually been written by companies who stand to benefit from providing this information, such as home care service providers, a cell phone company, and housing operators. In the case of the Comfort Life article mentioned above, different housing operators are embedded into the happy narratives of older adults who have relocated, thereby providing additional advertising for the companies. Less critical readers might easily interpret these types of advertising articles as unbiased, researched information.   Visually, the images from the articles and advertisements complement the themes presented in the articles. In the Comfort Life publication, colourful photos of happy residents (exclusively Caucasian) socializing and laughing with spouses, peers, pets, children and 97  grandchildren suggest that assisted living could be just like being at home. Photos of older adults exercising, or the groomed grounds, cozy lounges, and grand entrances suggest that perhaps assisted living could even be a little bit better than home – more like a resort. As one quote states: “This place is like the Ritz. There’s always something going on” (Comfort Life, p. 27). One memorable photo (pp. 40-41) shows five well-dressed and smiling women around a table set with a white table cloth and full dinner service, being served sushi by a chef. They look delighted with this exotic and classy offering. The publication is called Comfort Life, and these images depict just that.   The images in the Care Guide are smaller, because of the booklet format of the publication, and fewer, because of the emphasis on property and service listings over articles. Yet they reflect the overall theme of the publication towards care, as its name suggests. Photos of older couples, or older adults with their children (again, exclusively Caucasian) are prominent. The posing suggests intimacy and caring: heads bent towards each other, bodies in embrace or with hands showing a caring touch. Advertisements for properties outside of the directory listings show images of dining luxury, modern and tasteful suites, and residents in happy groups.98  Table 4-1 Seniors housing and care directories    Assumptions   Readership is middle to upper class Caucasian or culturally Canadian   Private-pay properties are the standard    Older adults have the support of their families and other resources when relocating  Personal choice will determine where a person moves; shopping around for the right fit is possible (ex. checklist for touring  is included in the Care Guide)  Dominant discourses/messages/ themes  Preparation for decline; moving is inevitable so do it now, on one’s own terms  Health and safety are better met in AL /retirement community  Where one lives and ages is a choice   The third age as a time of pleasure, comfort, relaxation and reward  AL as combination of home and resort & ready-made community  Active/successful ageing  What is not said            Minimal explanation/acknowledgement of public system of care  Functional assessments are still a part of entrance in private residences – not all is up to choice and finances  Ageing in place is not strictly possible as there are limits to care levels in both private and public AL  99  4.2.2 Promotional material from three private AL operators Description and format  I received property information for each of these private AL providers promptly after completing the online request forms. Property A sent an email brochure. At the time I requested it, I did not know that the property was one of the few private AL residences that contracts with Vancouver Coastal Health to provide some subsidized units. Part of the research agreement I made with Vancouver Coastal Health was that I would not name AL properties; therefore I cannot include the brochure in the appendix.  Property B mailed a larger information package containing a folder with various leaflets and a handwritten card from the sales associate inviting me to contact her for a tour and lunch. Property C also mailed a similar folder of information about the property, along with a welcome letter and invitation for a tour. All three properties are located in Vancouver. Properties A and B and are operated by private Canadian companies with multiple retirement communities across the country. For reasons of copyright, I will not be including the images or text from these advertising packages.  Target audience  Property A avoids addressing any particular reader, so as to be applicable to older adults and their families. Property B is directly targeted towards older adults, with the cover of the folder incorporating the words, “My Life” into the title. For both properties, the images of residents are nearly all Caucasian. Staff, in the few images where they are depicted, are similarly Caucasian. In neither case do the images represent the multiethnic population of Vancouver. Property C is targeted to the “prospective resident”, with invitations for family and friends to be involved in the resident’s life and care at the property.  Images in this package depict some racial 100  variety, although the residents are Caucasian and the staff are visual minorities. All three of the packages reflect an upper-class target audience, as I discuss below.   Content analysis  The content of the packages from properties A, B and C share a particular emphasis on refinement and luxury. Property A, for example, has chosen the image of a smiling older woman and young woman (both Caucasian) raising teacups in a toast for the cover of the brochure. Inside, photos feature the scenic view from the property, a smiling older Caucasian couple being served by a young Caucasian woman in a restaurant-like dining room, and a happy, well groomed older Caucasian couple reading together. Reminiscent of the discourses of active ageing and the third age, the text largely focuses on describing the “boutique apartments” and “trendy” neighbourhood, with its “exclusive” art galleries, shopping, and proximity to other “vibrant” districts. The adjacent medical centre is included casually in this list of amenities. Mention of actual care services is secondary. Staff provide “the best of service and caring”, but the degree and type of caring is vague. The parent company is described in the last section as offering a “full spectrum” of housing types across their various properties, but it is not clear what care is offered at this property. The slogan on the cover is “So nice to come home to.”   The extensive information package from Property B emphasizes a total retirement “lifestyle”, not just the ‘housing plus support’ concept of AL. There is minimal mention of the word home; just one paragraph of the Building and Suite Features leaflet mentions “rental and condominium homes.” Instead, the package emphasizes services, amenities and choice (“If it’s your choice to make the most of your senior years, then [Property B] can help you make your choice a reality.”) The leaflet describing the owner operator vision explains that this company has a “commitment to cultivating and expanding the most positive aspects of aging and 101  maturity.” Portrait-style, black-and-white photos of 10 older adults (five women, three men and a heterosexual couple) are used on the cover of the main fold-out booklet in the package; one woman and one man are Asian and the rest are Caucasian. The booklet includes four pages of testimonials from attractive, able-bodied, young-old Caucasian individuals who may or may not be actual residents. A man, an “ex-food critic”, wears a leather jacket and speaks to the quality of the food. A woman, a “yoga instructor”, speaks to the health and wellness amenities that include personal trainers and a brain fitness program. Another woman, an “actress”, is quoted as saying that she feels “more engaged in life than ever.” She makes use of the in-house travel service and finds her time freed up by the housekeeping staff and personal concierge. Also included in the package is a floor plan showing amenities such as the pub, classroom, restaurant (not ‘dining room’), fitness centre, spa, internet cafe, creative arts centre and library. There is also a sample monthly calendar of events, which includes movie nights, walking club outings, shopping shuttles and day trips, knitting, relaxation classes, lectures, art classes, brain exercises, hiking, birthday teas, yoga, happy hour, a current events group, fitness and strength classes, and poker night. Other brochures discuss the amenities of the newly developed neighbourhood in which the property is located. There are no images of children or grandchildren in the package; rather, the emphasis is on individual preference and priority.   The concepts of self-directed active ageing and the third age of leisure and reward are therefore prominent in the material. As with Property A, the discussion of care, or care needs is secondary. The message seems to be that Property B will manage resident’s bodies and “design a lifestyle” so that they are not bothered by the inconveniences of ageing.  In one vignette, “Sarah” enjoys being free from the “hassles” of living on her own now that the property is “helping her” to “stay fully engaged in life.” In another vignette about a couple, Property B is described as “a 102  community where assisted living services [can] be discreetly provided - without compromising the quality of life they’ve come to enjoy” (emphasis added). Care services are listed and priced separately from rental and dining costs, ostensibly to demonstrate their approach of providing “custom-designed” services, “instead of providing...a standard plan.” Here, a “standard plan” seems to be code for public assisted living, thus encouraging prospective residents to think about the added cost as ensuring better service and more choice than public system. Yet with rental prices starting at $3,700 a month, paying $340 to $1,050 extra per month for care services is arguably well out of reach for many older adults.    Property C has a similar emphasis on luxury and “elegance”, but with a much more prominent focus on ‘care’ rather than independence or choice. The slogan on the front cover reads “Providing the finest in seniors’ care for over 45 years.” The cover of the main pamphlet inside proclaims, “All the Comforts of Home.  Luxury Personal and Intermediate Care for Seniors.” Perhaps because of this focus on care and because of the apparently higher care needs of residents, the amenities highlighted in the package do not reference the neighbourhood or the cultivation of a “lifestyle”. Instead the information is focused on in-house services and amenities, such as the professional services available (massage, dentistry, physiotherapy, podiatry, and aesthetics), and the type of food and care services. Also included in the package is what appears to be a resident handbook. In it are explicit directions on entry procedures, what personal effects to bring, a list of recommended clothing, instructions for adaptive aids and furnishings, a daily meal schedule, and a list of staff and services. In this way, it more closely resembles a standard residential care type handbook than the luxurious, independent lifestyle guide from Property B.  The sample monthly calendar of activities also suggests more standard facility offerings, such as a walking club, music therapy, musical entertainment, crafts, happy hour, exercise classes, bingo, 103  tea, bus “adventures” and church services. Interestingly, the packet also includes a copy of the Residents’ Bill of Rights (developed in 2009 by the provincial government to cover all types of residential care facilities for older adults; http://www2.gov.bc.ca/assets/gov/health/accessing-health-care/finding-assisted-living-residential-care-facilities/adultcare_bill_of_rights.pdf).  The emphasis on care is also demonstrated in several of the leaflets. For example, “Resident and Client Testimonials” leaflet is made up of letters from three family members expressing their gratitude to Property C and commending the “patient, understanding, compassionate” care from staff. The “Care and Food Services” leaflet uses examples to demonstrate the high quality in these areas. For example, the leaflet states: “We maintain a staff to resident ratio, which exceeds licensing requirements, ranking us among the highest quality of care in our industry.” Regarding meals, the leaflet states: “Residents are offered the highest quality of food and service excellence. Let us take care of your nutritional needs and make dining a pleasurable experience.”   But I found Property C to be an anomaly, and I struggled to include it in this analysis at all. The leaflet on care levels and rates shows that the operators are still using the term “intermediate care” levels I, II and III, as was the case in British Columbia until 2002. In addition, they offer “extended care”, which is another name for complex care or long term residential care. When I worked in the hospital system, intermediate care III was considered to have been functionally the same as extended care, yet Property C has distinguished a specific level called extended care. AL, in the current definition and regulation, is considered to be one discrete level of care with a maximum of daily assistance hours and prescribed services. Intermediate care, at some of its levels, may line up with AL in terms of resident independence and care hours, but it is not strictly comparable. Importantly, intermediate care in private 104  facilities was not regulated, so there were differences in the naming of levels across facilities. Presumably because Property C offers higher levels of care, they also advertise 24-hour nursing care – also not standard AL policy under current regulation.  If this property is, indeed, where my participant Ian went when he was discharged from hospital, I can understand his confusion around terminology for different levels and models of care (I will discuss this more in the findings chapters). For these reasons, I do not include it in the summary of private AL properties listed in Table 4.2 below. Table 4-2 Promotional material private AL Assumptions:   Upper-middle to upper class residents; finances not an obstacle  Caucasian or culturally Canadian   Amenities and lifestyle are the prime attractors for moving; care needs are secondary  Care needs will be unchanging   Family are not/do not need to be involved  Dominant discourses/messages/ themes  Independence  Personal choice, personalized/self-directed care  Older adults as consumers; AL staff there to serve   Third age retirement lifestyle-  a time of leisure, reward, pleasure   Active ageing  Private, discreet, dignified care  What is not said            Assessment of care levels is still necessary for entry; maximum care levels may apply even in multi-level communities   Residents can expect to pay more as their care needs change  Rules/regulations for tenancy and communal living still apply 105  4.2.3 Provincial regulatory legislation and policy documents Description and format  This group of documents together form the core legal and policy framework around the provision and regulation of AL in British Columbia, particularly the Community Care and Assisted Living Act (2002). While the Act also covers legislation and policies for long-term residential care, child or youth residential programs, and residential mental health and addictions treatment facilities, I will focus here on the sections dealing with AL for older adults. The Community Care and Assisted Living Act sets out the legal definitions of AL and its services, establishes the requirements of registration to operate an AL, and distinguishes between AL and other types of care facilities. Yet the Act has been criticized by both the provincial Ombudsman (2012) and the British Columbia Law Institute (2013) in two key areas. First, AL residences do not fall under the auspices of the Residential Tenancy Act, which mediates landlord/tenant relationships. This leaves AL residents with little recourse when faced with rental increases or other rental-type disputes. As well, the distinction of “supportive” versus “prescribed” levels of service set out in the Act is vague, meaning that the distinction of care services in AL versus that provided in long term residential care can be difficult to strictly apply or enforce. However, the Act remains the fundamental text from which flow all other AL policies across the province, Health Authorities, and individual AL residences.   Another important function of the Act is to create, and give legal authority to, the Office of the Assisted Living Registrar (OALR) who can register, inspect and revoke registration of AL facilities in the province. The OALR has, in turn, published four publicly available documents: the Registrant Handbook (2011); A Case Manager’s Guide to Section 26(3) of the Community 106  Care and Assisted Living Act (2007); Information about Assisted Living for Seniors (n.d.), and two versions of a pamphlet on making a complaint for AL residents (n.d.).   Finally, there is a Home and Community Care Policy Manual (2012- 2016) available on the British Columbia Ministry of Health’s Home and Community Care web page, which is nested under the general Health and Safety topic web page. This document covers the full spectrum of care from home health services to long-term residential care, but my analysis focused on the sections applicable to AL. This manual interprets the requirements of the Act as they are to be enacted and upheld within the Ministry of Health and across provincial Health Authorities. The purpose is to ensure that services are accessed and delivered in similar ways across the province. Specifically, the Manual directs Health Authorities to “provide information to the public about home and community care services, how to access the services and how to make a complaint” (1.A). Different sections have been updated between 2012 and 2016.    For reference purposes, I include the web links to these documents as I discuss them below. Target audience   Although most of these documents are written in a technical and bureaucratic style, they are posted on government web pages meant to be accessed by the public. The web pages themselves are more casual in language and often summarize key points for the reader. Therefore, while the original target audience of the legislation or the policy/practice manuals would not be older adults, they are now being offered to this population as a source of information on AL. The other documents written by the OALR have been specifically written for older adults and use the language of “you” and “your” when addressing the reader.   107  Content analysis 1) Community Care and Assisted Living Act (http://www.bclaws.ca/civix/document/id/complete/statreg/02075_01).  The Community Care and Assisted Living Act (1.1) defines an assisted living residence as:   a premises or part of a premises, other than a community care facility,  (a) in which housing, hospitality services and at least one but not more than 2 prescribed  services are provided by or through the operator to 3 or more adults who are not related  by blood or marriage to the operator of the premises, or  (b) designated by the Lieutenant Governor in Council to be an assisted living residence    Hospitality services are further defined as “meal services, housekeeping services, laundry services, social and recreational opportunities and a 24 hour emergency response system” (1.1) Prescribed services are not specifically defined here, however, this list is available in several OALR documents (discussed below).   The AL section of the Act deals only with the legal requirement to register a property wishing to use the title of AL, and the power and jurisdiction of the OALR to register, inspect, suspend and cancel licenses of AL operators. A key directive provided in the Act is the requirement that “a registrant [operator] must not house in assisted living residence persons who are unable to make decisions on their own behalf” (Section 26.2). In reading the Act, the main distinction between persons who qualify for AL over long-term residential care seems to be the need for not more than two prescribed services and the absence of advanced dementia. Essentially, the Act defines what type of property can be called an AL residence and the legal parameters of service.  108  2) The Assisted Living Registrar’s Registrant Handbook   http://www2.gov.bc.ca/assets/gov/health/accessing-health-care/finding-assisted-living-residential-care-facilities/assisted-living-residences/seniors-assisted-living/seniors-registrant-handbook.pdf  The Registrant Handbook (2011) provides a much more thorough description of the expected policies and procedures that AL operators must follow to obtain and maintain registration. Its purpose is clearly stated as setting out the operators’ obligations according to the Community Care and Assisted Living Act, provincial health and safety standards, and OALR policies and procedures (Section 1.1).     The Registrant Handbook opens with a statement on the philosophy and core principles of AL, which operators are “expected to embrace”:   The core principles of assisted living - choice, privacy, independence, individuality,  dignity and respect – derive from a recognition that adults, even when they need support  and assistance in daily life, retain the ability and right to manage their own lives.  (Section 2.1)  The limit to this right of self-determination, however, appears to be risk of harm to self or others. As such, assisted living operators have a duty to keep a “watchful eye” on residents, which is explained as being somewhat higher in responsibility than in independent or supportive living but not as high as in long-term residential care facilities (Section 2.2). This language of risk and safety is then woven through the rest of the document. The section on the entry and exit of residents, for example, repeatedly mentions that the operator is “not to house people who are unable to make decisions on their own behalf”, unless there is a resident spouse who will agree to take responsibility for that individual (Section 5.2). Indeed, there is such an emphasis on 109  decision-making ability that there are five appendices devoted to different aspects of assessing it and determining who is or is not eligible for AL. In addition to setting out the parameters by which a competent spouse may live in AL with a spouse deemed unable to make decisions, the appendices outline the most pertinent legislative approaches to substitute decision-making. They also offer flow charts to help operators screen for who is eligible to enter AL, how residents should be monitored, and what steps to take with health care professionals and case managers should a change in decision-making occur.  Further, the OALR also created a separate document for case managers on how to interpret and carry out the legislation around decision-making capacity and residency in AL (A Case Manager’s Guide to Section 26(3) of the Community Care and Assisted Living Act, 2007), which is essentially a repetition of the Handbook sections on decision-making plus some specific actions that case managers should take (http://www.llbc.leg.bc.ca/public/pubdocs/bcdocs2011_2/486232/case-manager-guide.pdf).   An interesting finding from the Registrant Handbook is that an operator cannot force a person to undergo an assessment of capacity, but if they feel there are concerns over risk and capacity and the person does not comply with a request to have an assessment done, the operator “should trigger the exit process by giving notice to the resident to end the tenancy” (Section 5.3, p.8). Operators therefore have the ultimate choice over who may live in their facilities.   Residents may also be asked to leave if they are exceeding the physical care levels provided by the facility, but there is much less clarity in the Registrant Handbook on how that is decided. Part of this decision involves determining whether a resident’s needs for services are exceeding the legal service provision levels allowed by the OALR. The section on Personal Assistance Services attempts to differentiate between a “support” level and a “prescribed” level of care, using medication management as an example. If a resident’s care needs increase to more 110  than two personal assistance services, they would be legally ineligible to remain at an AL facility. However, the AL operator may choose to offer some of the other personal assistance services at a less intense support level. The six personal assistance services allowable by law are:   (a) regular assistance with activities of daily living, including eating, mobility, dressing,  grooming, bathing or personal hygiene;  (b) central storage of medication, distribution of medication, administering medication or  monitoring the taking of medication;  (c) maintenance or management of the cash resources or other property of a resident or   person in care;  (d) monitoring of food intake or of adherence to therapeutic diets;  (e) structured behaviour management and intervention;  (f) psychosocial rehabilitative therapy or intensive physical rehabilitative therapy.   (Registrant Handbook, section 6.2)  An important point around prescribed and support services is that it is the operator, not the resident, who chooses the two prescribed services and any other support services to offer. I was surprised to learn that even though residents are not allowed to use more than two services at a prescribed level, operators do not actually have to offer all of the possible prescribed services to their residents. The Registrant Handbook states: “When you registered, you determined the one or two personal assistance services that you would offer at the prescribed level in your assisted living residence” (Registrant Handbook, Section 6.2). As the British Columbia Law Institute notes (2013, p.8), most operators have chosen to provide the first two services – help 111  with ADLs and medication management – meaning that choosing an AL based on best personal fit or tailoring services once there may not be strictly possible.   The section on Personal Assistances services is one of the shortest sections of the Handbook; it consists of only two pages. And yet, one of the directives in the chapter is that operators “must develop and maintain personal services plans that reflect each resident’s needs, risks and service requests” (Registrant Handbook, section 6.2). Service plans are referred to throughout the Handbook, giving the impression that they are a cornerstone of service delivery and reference for residents and staff alike, but there are no templates or examples of what a service plan might look like. The Handbook makes reference to additional sections within the document called “tabs” or “policy tabs” where staff can find examples such as “Personal Assistance Guidelines.” It is possible that a template for a service plan is included in one of these sections, but these tabs appear to be inaccessible from the public, online version. I was interested to ask my participants what they knew about their service plans and what role these plans played in their experiences of relocation.   The remaining sections of the Registrant Handbook speak to the prominence of health, safety, and risk in the legislation and administration of AL facilities in British Columbia. Sections cover medication management and administration policies; serious incident reporting; meal and dietary obligations from a health and safety perspective; food handling and safety; complaint resolutions in the case of health and safety concerns; and procedures for the prevention and control of infectious diseases. The emphasis is on the accountability of the AL operator for maintaining health and safety and the standardization of procedures for the purpose of regulation.  This is important to understand, because The OLAR is able only to inspect for 112  health and safety; it cannot resolve tenancy or quality of service issues. Yet the provincial Residential Tenancy Office does not have any specific policies or practices for AL residences, and quality of service issues are up to the individual operator to resolve, leaving residents in a jurisdictional gap (British Columbia Office of the Ombudsman, 2012, pp.180, 187).  3) OALR documents for older adults and families   The final two documents from the OALR are meant directly for older adults and families, although it is not clear how they are distributed or made available to residents. The purpose, services, and limitations of AL are very much drawn from the higher level policy documents and legislation but are written in plain language. The first document is Information about Assisted Living for Seniors (2009; http://www.health.gov.bc.ca/library/publications/year/2009/ Info_Assisted_Living_Brochure.pdf)  It covers the different funding structures of private and public AL; the philosophy and core principles of AL; a description of hospitality and personal assistance services; a description of the possible staffing models in AL; move in/move out requirements; residents’ rights and expectations of residents; a description of the role of the OALR and the types of complaint it will and will not respond to; a list of health and safety standards for AL facilities, and a reference to the OALR’s directory of AL residences in the province. Mental capacity is again highlighted as a requirement for residency, along with the caveat that personal choice is respected as long as it does not pose a risk to self or others. Reference is made to documents from AL operators that residents must sign and adhere to – an occupancy/residency agreement and a services plan.  113   The second document has a short and long version: Assisted Living Registry: Making a complaint, (n.d.; http://www2.gov.bc.ca/assets/gov/health/accessing-health-care/finding-assisted-living-residential-care-facilities/assisted-living-residences/alr-making-a-complaint.pdf) and Complaint investigation for residents of assisted living for seniors (n.d.; http://www.health.gov.bc.ca/library/publications/year/2009/Complaint_Investigation_Brochure.pdf ). They describe how residents can make a complaint to the OALR, and repeat the information from the Information about Assisted Living for Seniors document. By isolating the information about what types of complaints the office does and does not handle, it attempts to clarify and simplify the process for interested parties at the same time as it emphasizes the jurisdictional limitations of the OALR.   Visually, all three documents have large print and feature photos of older adults of varying abilities, age groups, and ethno-cultural groups engaged in different activities. Based on the clothing, hair styles and environmental cues, the residents depicted appear to be of more moderate income level than those featured in the private AL promotional material. Presumably this is to demonstrate that the OALR responds to the needs of all seniors across the province.  While the tone of the documents is respectful and informative, the underlying message is that AL is a service with expectations and limitations for both providers and service users. This is a very different message than that of retirement communities that are selling a lifestyle to older adult consumers.  4) Ministry of Health Home and Community Care Policy Manual (http://www2.gov.bc.ca/gov/content/health/accessing-health-care/home-community-care/accountability/policy-and-standards/home-and-community-care-policy-manual). 114  Content analysis   Although this document is publicly available by following links posted on the SeniorsBC page of the Ministry of Health website listed above, the intended audience is administrators of Health Authorities who must carry out the policies as specified in the Manual. Throughout the document, service users are referred to as “clients”, which reflects more of a contract model of services than a medical model. Although the Health Authorities are providing medical care, this language may have been chosen to best capture the broad range of service users, such as persons with disabilities who manage their own portfolio of care providers or individuals who receive home care services but who are not ‘patients’ or ‘residents’ under the stewardship of the Health Authority.  The impression given by using this language, however, is that individuals have the opportunity to choose service providers when there are, in reality, few low cost alternatives to home, AL or residential care outside of the Health Authorities’ subsidized services.    Chapters relevant to AL describe: who the approved service providers are; general eligibility requirements of residents (citizenship and provincial residency, age, and health condition); how a person is referred and assessed; standards around complaint processes; expectations for Health Authorities to “measure and monitor improvements in quality of care and health outcomes” (3.A); the expectation that AL operators will negotiate residency agreements and create care plans for each resident; and a description of the specific policies for housing plus care model, which encompasses AL.   The Home and Community Care Policy Manual reproduces the focus of the Community Care and Assistance Act and the OALR publications on maximum service levels, mental capacity, and risk to self or others as grounds for refusing or terminating service. The care plan is again woven throughout different sections as providing a reference point for an individual’s level 115  of function and as a tool to ensure that services are being delivered appropriately. But there are also several other sections that provide policies for day-to-day administration, outline further restrictions on service or address special circumstances. For example, three additional requirements that a potential resident needs to meet before admission to AL are: the need for both hospitality and personal care services; the requirement for an individual to be at “significant risk” should he or she remain in the current living environment; and the need to agree to pay the assessed rate for services and additional charges (5.B.1, p. 1).   There is special mention of the policies around couples in AL and what to do in cases where the relationship is terminated, or in cases where spouses die or have disparate care levels. For example, residents who have been living in AL with their spouse but do not require the care services are asked to leave within six months of the partner’s death or transfer. Another topic is the regulation of absences from the AL residence. Residents may be absent multiple times in a year due to hospitalization or other specialized services, but they may not be absent for personal reasons for more than 30 days annually. This policy speaks to the expectation of infirmity in residents, the acceptance of a medical model of ageing, and the restriction on personal habits and pursuits in order to maximize the use of the limited and costly commodity of health care.       Finally, the Manual sets the AL monthly rental rates, allowable charges, included benefits, and chargeable items that are not included in rental rates. Health Authorities are to calculate a monthly rate by multiplying 70% of an individual’s income or a couple’s joint income “and then dividing by 12, subject to the minimum and maximum rate” (7.B.2 page 2).  The minimum monthly payments are calculated based on the maximum amount of Old Age Security and Guaranteed Income Security that an individual or couple can receive. As of 2016, an individual’s minimum monthly payment for AL was therefore set at $921.40; a couple’s 116  minimum payment was set at $1485.40 (7.B.2 page 2).  In Canada as of January 2016, the maximum monthly Old Age Security payment for an individual was $570.52 (https://www.canada.ca/en/employment-social-development/news/2015/12/canada-pension-plan-and-old-age-security-benefit-amounts-effective-january-1 2016.html?= undefined &wbdisable =true) and the maximum Guaranteed Income Security was $871.86 (https://www.canada.ca/en/ services/benefits/publicpensions/cpp/old-age-security/payments/tab1-1.html). For an individual receiving the maximum government security payments and paying the minimum AL rate, this would leave just $520.98 per month for other expenses. Regarding the maximum monthly AL rates, the Manual states only that it is “based on a combination of the market rent for the housing and hospitality services for the geographic area where the client is receiving assisted living services and the actual cost of the personal care services for the client” (7.B.2 page 2).    Operators are also allowed to charge a damage deposit of a half month’s rent, as well as a surcharge for hydro. Other allowable charges include items such as cable or telephone connection and monthly fees, transportation, personal grooming services such as hairdressing or foot care, personal laundry service, parking, pet deposit, and guest dining or suite rental. One potential difficulty is that there are no maximum rates listed for the allowable charges, meaning that if an AL operator contracted with a particular service provider, such as a telephone company, who then raised their rates, residents could be faced with an unexpected cost. In the case of the included benefits, there appears to be no way to opt out of services that are perhaps not needed, such as meal service or activity costs for residents who prefer to take care of such things on their own. For low income residents whose monthly income may be funnelled largely toward rent and prescription medications, any additional charges could result in having to choose 117  what to go without in given month. Arguably this is not the kind of ‘choice’ intended by the foundational values of AL.         118  Table 4-3 Provincial regulatory legislation and policy documents Assumptions   AL residences will operate in good faith according to the legislation.   Older adults and families will be educated on the existence and purpose of the OALR (but by whom is not clear)  Moving to AL will not interfere with individuals’ pre-existing routines and social /recreational pursuits    Individuals to manage own health and well-being as much as possible  Individuals will be able to afford extra charges for activities and services after paying for the monthly rental fee Dominant discourses/ messages/  themes  Legal framework for AL, jurisdiction of OALR   Obligations and responsibilities of AL operators and the OALR  Boundaries of service in AL   Focus on health, safety and risk   “Watchful eye”, gatekeeping, surveillance by AL operators and case managers   Setting minimal mental and physical function levels of residents  “Care” refers to care of the body    AL is not meant for ageing in place; not a permanent home What is not said            Residents have the right to complain or make reports, but the OALR and the Ministry of Health have the power to decide to inspect, make reports, fine, revoke/reinstate ALRs   There are no obligations to regularly inspect facilities   AL residents fall outside the protection of the Residential Tenancy Act  Social well-being as a factor in health is not directly discussed; things like environment and programming are given minimal mention.   AL values mentioned briefly in some documents, but not focused on in depth or operationalized  “Choice”: how much and over what is not entirely up to the resident  119  4.2.4 Vancouver Coastal Health Authority documents Description and format   The documents I analyzed from the Vancouver Health Authority I approached for my study included their website pages on AL, a brochure on AL given out by case managers to interested older adults and families, and a set of documents sent to older adults who have been accepted to a waitlist for a publicly subsidized AL facility. This set included two letters and a general AL handbook that outlines the access to and provision of AL across the Health Authority.  I included the Health Authority website in my analysis because it appears to be a main source of information on AL eligibility, access, and individual properties in Vancouver. If a person was not already connected to community support services or a case manager, I felt it would be a common place to begin for someone researching supportive housing options for themselves or for a family member.  Target audience   As expected, these documents are targeted towards service users, prospective service users, and their families. The use of “you” language in some documents demonstrates that the information is meant for older adult themselves. In others, the use of a question and answer format is used to convey details in a more casual and easy to follow style for the lay reader. For example, several chapter headings in the Vancouver Coastal Health Subsidized Assisted Living Handbook are questions, and the answers are in bullet points or short statements (i.e. What is Assisted Living?; Is Assisted Living right for me?; What assistance is available to me?)  Content analysis  1) Vancouver Coastal Health Authority website  http://www.vch.ca/your-care/home-community-care/care-options/assisted-living 120   In order to access the AL web page on the Vancouver Coastal Health Authority website, one must navigate to it either by using the search field or through a series of tabs (i.e.Your Health, then Seniors, then Assisted Living). Although the page has been redesigned in the last year to be more clean and simple, and has clearly marked options to increase font size, one would need to be comfortable with internet searches to be able to pinpoint the correct links and subject headings to quickly sift through the large amount of data on the website and find information on AL.   The main AL page makes a direct statement that AL “may be an option” for “independent people who need a little extra help with meals and personal care...particularly if you are living alone or feeling isolated.” The page is further divided into sections on the types of accommodation, hospitality and personal care services, general eligibility requirements, and how to locate private AL facilities that are not accessed through the Health Authority. Information on cost for services and more specific information on eligibility are provided via links back to the general Home and Community Care Services page. There is also a link to the Health Authority’s Subsidized Assisted Living Handbook and an invitation to provide feedback on care to the Office of the Assisted Living Registrar at the provided web page or phone number.   The final feature of this page is a list of links to AL sites grouped by geographic location. Clicking on Vancouver, for example, one can view a list of properties, their contact information, and a map of locations. However, it is stressed that “These sites cannot be accessed by calling the facility directly.” Instead, one must visit the Accessing Services page and choose one of several main intake numbers according to one’s city of residence. In this way, the Health Authority asserts its control as a gatekeeper to the resource of AL. There is more evidence of gatekeeping when attempting to view information on individual properties. Upon clicking the 121  links for individual AL sites, one is taken to an intermediate page that again summarizes what assisted living is and repeats the message that “Clients cannot access Assisted Living by contacting the providers directly. [They must] be assessed by a case manager at a VCH Community Health Centre for eligibility.” Only after reading the text to find an additional link is one taken to the individual site’s page. On this page are details such as building amenities, a brief description of the suite, services included, costs, philosophy of care, pet and smoking policies, neighbourhood and community amenities, and any language/cultural/religious affiliations. Eight of the ten subsidized AL facilities in Vancouver listed have their own external web pages. When I first began my research these were not accessible from the Health Authority website, but in the most recent version of the site these links have been included.   In summary, the website does have a reasonable amount of general information on the individual AL sites, but the organization of it encourages individuals to rely on the Health Authority for information and access from the outset. 2) Vancouver Coastal Health AL brochure   This brochure is unique in that it recognizes AL as a housing plus support option for older adults as well as “people with physical disabilities”. This speaks to the broad legislation of the Community Care and Assisted Living Act (2002), where AL can also be provided for younger adults. Visually, however, the brochure only depicts images of older adults- being served in a dining room, playing a keyboard in a personal suite, gardening, and participating in a seated exercise class. Presumably, this reflects the predominant use of AL by older adults. The staff and residents are a mix of ethnicities and genders, which does reflect a heterogeneous reality. This brochure and the subsidized AL handbook below are the only documents I found that mention income level. One page of the brochure states that AL is “affordable for all people, regardless of 122  income” and the other specifies that AL is “for seniors with low income”. While this may reflect the reality of residents in AL and the rationale behind subsidized rates, this is not a specification mentioned in any of the higher level policy or legislation documents. Information on eligibility and physical/mental care levels, services included in AL, and access via case managers is succinctly presented in bullet points. Instructions to call one of the community health centres for more information set a clear boundary for those who might be inclined to investigate individual properties on their own. This is in contrast to the invitation of private ALs to book personal tours and even enjoy a meal.  3) Vancouver Coastal Health Subsidized Assisted Living Handbook http://www.vch.ca/Documents/Assisted-Living-Handbook-February-2016.pdf  This handbook expands on the practical details of AL that incoming residents would want to know such as eligibility, cost, who to call for initial inquiries and how the application process works, who AL is suitable for, and names of AL facilities in the Vancouver Coastal Health Authority. There is also a list of other contact numbers for seniors’ services in the province, including the OALR. The language is less blunt and technical than the Registrant Handbook or Home and Community Care Policy Manual that were meant primarily for staff and administrators. For example, a comment in the side bar of the page on moving out carefully explains that:  Occasionally, the health of an Assisted Living tenant improves so much, they consider  moving to a more independent setting. By the same token, sometimes their health needs  change and they need 24-hour professional care that is provided at complex care  sites.  (p.16) 123   Despite this gentle tone, the emphasis on limits to service remains. For example, in the frequently asked questions section, the issue of escalating care needs is posed in two separate hypothetical questions whose responses involve the possibility of moving to long term residential care.   Several other key policies are embedded in various sections throughout the handbook:   that AL does not fall under the jurisdiction of the Residential Tenancy Act  that changes to one’s income will affect one’s monthly rate  that case managers are the ones to organize a tour of  “ a suitable” AL facility  that final approval of the individual as a resident does not occur until after a person has been added to the waitlist and after another interview with the AL operator and AL case manager (not one’s own case manager)  that turning down a suite when it is offered results in being removed from the waitlist entirely  that if a person “choose[s] not to participate” in the meals and social programming, he or she may be asked to move out   that a resident is not permitted to privately purchase extra care related services  that a resident is not permitted to attend any previous day programs  As mentioned, the first point is a serious legal gap that has been specifically mentioned by the Ombudsman in her recent report of seniors care in BC (2012), and also by the British Columbia Law Institute (2013). The points about tours and waitlists indicate that it is not simply a matter of individual choice to move into one’s preferred AL facility, and that there is some degree of uncertainty in the process until final approval is granted.  The last three points suggest 124  that, although AL residents are encouraged to be maximally independent and maintain individual routines and relationships, the AL facility is expected to replace several areas previously under the individual’s control. Yet, given the lack of attention paid to social programming in the higher level policy documents, It raises the question of whether the social programming in AL facilities is as extensive or well-developed as it could be.   Throughout the handbook, there is an interesting and ongoing juxtaposition of organizational structure with messages that uphold the notion of AL as an environment of choice. One page in particular describes the decision to relocate as “a personal decision, and you must feel comfortable with your choice” (p.7). It states that, “ultimately, Assisted Living is all about choice and maintaining your independence” (p.7). The sidebar comments, however suggest that potential residents ask themselves whether they are “able to live in a congregate setting where you will have your meals with other tenants and be expected to participate in social activities”,  and whether they will “abide by the ‘house rules’” (p.7). Elsewhere in the handbook, there is a checklist of questions to ask on a tour (pp.12-13), suggesting that the older adult has a degree of control over where they choose to live. On closer inspection, the proposed questions are less about finding personal fit than they are about collecting information about the rules and organization of the AL (ex. parking policies, laundry room usage, the policy on tenant insurance, where the activity sheet is posted).   Finally, there is a page on how to make AL “work” for the individual (p.17). Advice includes being tolerant of new experiences and individuals; getting involved with “your new community” and the activities there; maintaining relationships with family and friends; and expressing personal preferences to staff. This section also contains several references to AL as a possible home: taking time to settle in to a “new home”; bringing cherished objects to make the 125  suite “feel like home” (p. 17). While this advice is reasonable, it also suggests that residents themselves are largely responsible for how they adjust to the pre-existing structures of AL. The final piece of advice in the section is to “be tolerant and enjoy the new experiences” (p.17). 4) Health Authority letters to waitlisted applicants   These two letters form a key part of the package mailed to individuals in the process of relocating to an AL facility the Vancouver Coastal Health Authority. The first is a Client Application Letter indicating that an individual has been placed on a waiting list and for what site, but that they are not yet approved to move in. There are a series of next steps outlined:   The individual’s case manager will contact the individual when his or her name gets near the top of the list. If a person has been waiting for a long period of time, or if his or her care needs have changed, the person may be required to undergo a reassessment.  In the case of no change, the person is “invited” for an interview with the Site Manager of the AL and the Health Authority case manager responsible for that AL.   The individual will be contacted within seven days with the outcome of the interview  The individual then has 48 hours to decide whether or not to accept the offer  If the individual accepts the offer, the individual and the AL Site Manager decide on a move-in date  If the individual declines the offer, his or her name is removed from the list and any new applications will have a new waitlist date  The letter then indicates what else has been included in this package and directs the individual to contact his or her case manager with further questions.  126   What this letter does not explain is that the waitlist times can vary from several months to a year or more. If an individual is not sure that they will be accepted, he or she may not begin to prepare for the move until after the final interview. At that point, downsizing possessions and making moving arrangements for just weeks ahead could become stressful, with or without assistance from friends and family. The letter gives the impression that, once on the waitlist, the person is swept into the machinery and processes of AL and must adjust accordingly.   The second letter is actually a contract of resident/tenant expectations and terms for service: “There will ...be expectations of you that we want you to understand before you move in.” From my contact at the Health Authority, I understand that this document is not actually signed until the time of the final interview at the AL site, but it is sent out ahead of time to “set individuals’ expectations.” The letter reiterates once again that a person is not approved to move to an AL until after this final interview. It explains that the Health Authority and the OALR have policies and procedures in place that must be followed. The terms of service incorporate these requirements, but in plain language. It also mentions the ability of an individual to make a complaint to the Registrar.   Despite the assurance at the top of the letter that the Health Authority wants the move to be a positive experience, my impression after reading all the terms of service was a sense of restriction, contractual obligation, and surveillance. The high level of formality caused me to wonder what effect this might have had on my participants’ existing attitude toward the move. From a practical, organizational standpoint, there is value in covering contentious points and limits to service upfront, in order to minimize conflict when asking residents to move out or comply with policies. However, one can imagine that it does not help foster a sense of positive anticipation of the move, or the idea that the AL will be a “new home.” 127  Table 4-4 Vancouver Coastal Health Authority documents Assumptions   AL is able to provide adequate social, recreational and care needs in house   High income older adults will pursue private AL   There are multiple suitable AL facilities in an individual’s geographic area and the individual’s preference will be a main factor in picking one  Dominant discourses/messages/  themes  Gatekeeping through case managers and assessments for admission   Tentative language that AL “may” be appropriate, or that an individual “may” have to move out sets authority of AL and health care staff as final decision-makers  AL is for accessing housing and personal care   Establishing limits to service – mental capacity, physical care levels  Monitoring, surveillance. compliance    Choice and independence, within organizational constraints  Fitting oneself into the structures of AL  What is not said            Details about social and recreational programming   Minimal positioning of AL as home  An integrated discussion of AL values within the information   What will the benefits of moving be for the individual? What might they look forward to?       128  4.2.5 Site-specific subsidized AL facility handbooks  Description, format and target audience  These two documents are examples of what public/subsidized operators give to their new residents upon moving in. They are in booklet format with tables of contents, and the AL address and main phone numbers displayed prominently. Both are printed in black and white, with no pictures except in the one handbook where there is a photo of the front entrance and photos of the persons who have made welcome addresses in the booklet. I found the first handbook, which I will simply call the Tenant Handbook, on the operator’s main website. This is unusual, as none of the other AL sites in the Health Authority have made the decision to publicly post their resident/tenant handbooks .The second handbook I will call the Forest Place Handbook, because I obtained it from one of my participants. I will make further reference to it later, as it forms an important part of that participant’s move-in narrative. In this section, however, I will simply provide an initial content analysis. The terminology used for older adult service users is ‘tenant’ in the Tenant Handbook, and both ‘resident’ and ‘tenant’ in the Forest Place Handbook.  Content Analysis   The main distinction of the resident handbooks is that, while they mention many of the policies that are mandated by the Ministry of Health, OALR, and Health Authority, they are also meant to provide site-specific details about organizational routines, services, amenities, and expectations. Another key distinction is the clear statement of the ALs’ vision, mission, values, and care philosophies and the effort to integrate them throughout the handbooks. While higher level policy documents make mention of the underlying tenets of AL, their focus is on practical and regulatory details rather than the values of   “choice, privacy, independence, individuality, dignity and respect” (OALR, n.d.).  The Forest Place Handbook, however, foregrounds these 129  guiding principles and expands upon them in the address to residents on the first page.  Interestingly, this is the only document to refer to ageing and not just older adults. The language is respectful and recognizes the inherent worth of “elders.” The opening statement reads:  Forest Place recognizes that aging is a normal human experience and the gradual  fulfillment of the lifecycle...It is our belief that elders are not different or special people,  but are individuals with his/her own uniqueness, who request only that we respect them  as persons with intelligence, sense of worth, and dignity.  Further, the closing statement makes reference to the concept of home, where Forest Place is seen as “a beginning, not an end, as a home, not an institution.” Two further addresses to the new resident, one from a board member and one from the Executive Director, make references to Forest Place as the individual’s “new home” where the individual is the “newest member of [the] family.” This conscious positioning of Forest Place as a home is not common in the other AL literature I reviewed, with the exception of private AL Properties A and C. Property B emphasizes lifestyle, and the regulatory and policy documents are focused on the functional legalities and operational responsibilities of AL as a provider of housing plus support. The Assisted Living Application and Terms for Services letter from the Vancouver Coastal Health Authority uses the word home, but more as a mechanism for introducing the letter: “Moving to a new home can be both exciting and stressful. It is important that you have as much information as you need to make an informed choice prior to moving “(p.1).  The accompanying Client Application letter frames AL in a completely opposite way – as simply a “program” for which applicants are now waitlisted. As mentioned, the Vancouver Coastal Health’s Subsidized Assisted Living Handbook uses the word home, but with the similar purpose of framing the experience of moving and settling in: “the time it takes to move to your new home will vary” 130  (p.17).On the other hand, referring to Forest Place as a home and linking it to family within the first few pages of the resident handbook sends an important message to new residents that Forest Place can be a place to settle and look forward.   Returning to the values incorporated in the individual AL handbooks, the Tenant Handbook also includes its mission, vision, and values, but these are based on principles of Christian faith and the Eden Philosophy (a culture change movement originating in long term residential care). Language throughout the document is respectful and encourages residents to collaborate with care providers and ask for assistance. There is some representation of the residence as a community of caring: “At [this AL residence] tenants and staff work together to create a caring, compassionate and dynamic community where people are meaningfully engaged, life is celebrated, and individual contributions are encouraged.” While not invoking idea of the whole AL as a home, it seems to strike a balance between individuals living in their own apartments who also come together to create a shared community of activity and relationships.   Sections common to both handbooks include information on procedures during fires, evacuations and outbreaks of illness; smoking policies; building maintenance; pet policies; the 24-hour emergency response system; car parking; cable connections and payment; access to the building; and visitor policies. Regarding visitors, both handbooks state that there are no restrictions on visitors, but that after 10 pm noise is requested to be minimal. The Tenant Handbook includes a brief additional paragraph explaining that visitors who stay in suite may only do so for 14 days out of 12 months; additional time must be approved by staff. Both handbooks give information on accessing personal laundry services and on housekeeping services. Interestingly, the AL site that produced the Tenant Handbook allows residents to purchase additional, private housekeeping services. This appears to be in violation of the 131  provincial AL regulations, but there may be specific parameters that are not stated here, such as staying within a range of service hours or service types.   There are other small differences in the language around how services are carried out. Where the Tenant Handbook says it will “make an effort” to schedule housekeeping services at a time preferred by the tenant, it does not guarantee it. The Forest Place Handbook uses much more flexible language, even stating that a tenant’s “personal preference and routines will be respected and honored” and tenants will be “assisted with cleaning as required” (emphasis added). Personal service plans are mentioned briefly in each handbook, with both ALs offering only medication monitoring or help with ADLs at a prescribed level. Again, the Forest Place Handbook takes care to weave in language that references the AL values such as “individualized” attention and upholding “dignity and self-esteem” during assistance.   Meals and dining expectations are also covered in the handbooks. The Forest Place Handbook assures the reader that “a pleasant dining experience for two meals a day [lunch and supper]” will be provided in the dining room. The “meal program” is meant to “encourage independence through offering tenants choices”, and the “Hydration and Nutrition Programs” encourage proper nutrition and “proper fluid intake.” This description is quite different from the emphasis on the cuisine and restaurant-like atmosphere mentioned in the private AL brochures. Interestingly, the Forest Place Handbook states:  “We regret that we are unable to accommodate special restricted diets however the menu offers a variety of selections.” This is despite the Ministry of Health and the OALR’s assurances to the contrary.  Finally, the Forest Place Handbook mentions that the “dining experience allows the residents the opportunity for rich social interactions.”  132   The Tenant Handbook’s description of meal service is much more succinct and simply relays lunch, dinner and snack times and locations. Both ALs welcome residents’ guests to meals, providing the resident advises the staff and purchases meal tickets in advance. Both handbooks also mention “tray service”, which is a temporary in-room meal service for ill residents.   Social and recreational opportunities are mandated hospitality services for every registered AL in the province. The Tenant Handbook covers this very briefly, however. It mentions that there are “therapeutic and recreational activities as well as health and wellness workshops”, and that individuals are “encouraged to attend programs and get to know your neighbours.” Tenants are urged to volunteer and to provide input into activity programming via the Tenant council and Activity Coordinator. On the main floor, residents are encouraged to “enjoy the facilities” of a lounge with a stationary bike, TV and piano, a library that can be reserved for parties, a small kitchen, personal care “spa”, and a patio with a garden. On each upper floor, there is a common living room, dining room and balcony. The onus appears to be on the new resident to participate and to make social connections, with the exception of one passage about moving in:   Moving day is an exciting, but often stressful time. We try to make the experience as  pleasant as possible and can introduce you to other tenants who may participate in your  tour of the building and help make you feel welcome.  The Forest Place Handbook provides a more expansive description of the types of activities offered – social, educational, spiritual and recreational – but the language is otherwise vague. The resident is assured, however, that there is a “full calendar of activities” available at various times and for holidays. The rest of the section describes recreation areas that residents 133  may use in their own time, such as a recreation room, games room, art room, library and communal kitchen. There is also an in-house, non-denominational chapel.   The final handbook sections common to both AL facilities are those relating to Resident/Tenant councils and avenues for complaint. Resident/tenant councils are promoted as a way for residents to be informed and empowered members of their AL community and to voice concerns. Dates, times, and locations for each facility’s council meetings are included in the handbooks. The handbooks also mention periodic consumer satisfaction surveys as a way to improve services. Should a tenant have a complaint that cannot be, or is not being, addressed at the council meetings, both handbooks describe a process of resolution that involves taking the complaint to successive levels of staff until the issue is resolved. The contact information for the OALR is also provided in both handbooks. The Tenant Handbook further describes what type of complaint the Registrar will respond to and directs the residents to the OALR’s complaint resolution brochure that is to be found in their welcome packages.   Other sections of the handbooks are unique to their respective facilities. The Tenant Handbook includes a description of the conditions under which a resident may no longer be eligible to remain in AL. The Forest Place Handbook does not because it is a campus of care, meaning that residents would most likely move to a complex care floor instead of being relocated entirely. The Tenant Handbook also includes a section on signing in and out and the missing person procedures that result from unexplained absences. Residents are free to stay out overnight, but they are requested to inform staff so that medications or meals can be planned accordingly. Forest Place appears not to have this aspect of surveillance, but the handbook does assert that it is the responsibility of every resident not to escort other residents off -property. Presumably this relates to the presence of complex care residents who may be at risk for 134  wandering. One interesting section of the Forest Place Handbook specifically addresses alcohol consumption and the fact that it is “left to the discretion of each resident/tenant.” This position is congruent with the Handbook’s opening statement on the right of older adults to self -direction and their “responsibility for their own actions.” Finally, Forest Place includes an 18-point list of “Elders’ Rights and Responsibilities.” The purpose of this section appears to be an application of the values and philosophy of the facility, but also a way of setting expectations for harmonious congregate life. The tenets are similar to, but not replicated from, the Resident’s Bill of Rights passed by the provincial government in 2009 and included as part of the inserts from Property C’s package.   From participant interviews and from the information given to me by my Health Authority contacts, it seems that resident handbooks for individual AL sites are given to older adults only after they have moved in. This is likely due to the admission process where a person cannot know before the final interview whether they are actually going to the chosen AL, but I cannot help but think that having a specific handbook for the AL ahead of time would be a very useful addition to the mailed package. Potential residents might have a better sense of the AL environment and could more accurately tailor their questions for the final interview.         135  Table 4-5 Subsidized AL facility handbooks Assumptions   The mission, vision, values and philosophy of the AL will translate into good staff practices and organizational culture  Residents have avenues to voice concerns (Tenant/Resident Councils; OALR) and will feel comfortable doing so; ALs are receptive and responsive to critique  While meal options will not be decided by residents, meals will offer quality and variety  Residents will find activities to participate in within the AL  Residents will find a place for themselves in the life of the AL Dominant discourses/messages/  themes  Speaking to the individual resident    More language around organizational values and resident rights such as self-direction, respect, dignity, individuality, and independence   Entering into communal life; settling in, adjusting oneself to fit the environment and routines  Relinquishing some autonomy to gain security   AL as offering “family” or “community” (at least conceptually)   Staff  are collaborators in care and service  What is not said            Limited mention of neighbourhood amenities, except as related to medical care and prescriptions   Vague description of social and recreational programming      136  4.2.6 Discussion and summary   Returning to the notion of frames (Yanow, 2000), the documents overall seem to present two different but related conceptual constructions of AL, which I will refer to as the ideological frame and the service delivery frame. The ideological frame is primarily promoted in the directories, advertisements, private AL promotional packages, and aspects of the individual AL Handbooks. This frame emphasizes the commonly held values of AL such as choice, independence, self-direction, privacy, dignity and respect. ‘Choice’ here relates to a consumer model of service, where a person not only makes choices in terms of where to live, but also has choices within the AL environment. ‘Care’, in this frame, is a relational interaction that is presented as dignified, respectful, discrete (private), and flexible. Residents are therefore portrayed as having power to direct their lives and care plans, in collaboration with the staff of the AL facility.  Assessment, gatekeeping, and terms of service are deemphasized, which reinforces the notion that one may choose when and where one moves, and can live in continuity with life-long pursuits and preferences.    In the ideological frame, the environment is referenced both in terms of its physical design and amenities, but also in terms of its affective qualities. Affect is a term describing “how the world is known rendered meaningful through the body’s sensorial capacities prior to cognitive reflection...Simply put, in terms of an experience, affect is a vague but intense ‘atmosphere’...registered...in an instant” (Andrews, Evans & Wiles, 2013, p. 1351). By describing AL residences as home-like, luxurious, warm, welcoming, vibrant, or being a close-knit community, AL is ideologically linked to positive affective associations.  In the case of privately-operated AL residences, the promise of a carefree, stimulating and self-indulgent lifestyle echoes the notion of retirement as a third age. The connection of AL with physical care 137  is downplayed as a reason for relocation.  The subsidized AL handbooks do incorporate a discussion of care and care plans, but weave the language of affective values into the writing.  Although the OALR includes an official statement on the values of AL in their Information about Assisted Living for Seniors (2009) publication, their Registrant Handbook (2011) is actually more focused on the practical and organizational aspects of AL. This is typical of the second frame, the service delivery frame. Here, AL values may be referenced in relation to specific policies, such as maintaining residents’ privacy with lockable suites, but they are not a central discourse. The documents in this group are comprised of The Community Care and Assisted Living Act, the OALR and Ministry of Health publications, and the Vancouver Coastal Health Authority website, handbook and letters. The subsidized AL handbooks are also part of this group, because of their need to cover the practical details of living in an organized environment. In the service delivery frame, AL is consistently described in terms of its core structure and purpose:  housing plus support, the provision of two support and five hospitality services, suites with lockable doors, functional requirements to move in/move out, and the key role of the personal care plan and ongoing assessment.   ‘Choice’ in this frame is more about whether an individual is competent to make ‘good’ choices, and less about what the AL residence offers. Amenities and recreational opportunities, for example, are cursorily discussed; meals are referenced mostly in functional terms such as nutrition, attendance, and dining times. The emphasis on function, risk, and safety also suggests that there are certain limits to choice in AL. The terms of service, for example, require prospective residents to submit themselves to the expert gaze of AL and other health care staff, who determine who may enter and who may remain.  The concept of ‘care’ is then shifted from a relational or emotional interaction between people to service items on a contract that both justify 138  the right to be in AL and serve as a marker of decline. Where the ideological frame downplays the role of organizational rules or structures the daily lives of residents, the service delivery frame is very focused on explaining regulations and service limits. Power here rests with the AL operator, but the residents may be consulted in a structured fashion through required care plans or participation in resident/tenant councils.   When viewing the ideological frame and the service delivery frame together, the conceptual story of AL that emerges reinforces the critical literature on AL, which suggests that there is some tension between the values of AL and the functional operation of AL residences. Documents like the subsidized AL handbooks, however, show that at the level of the individual AL sites there is an attempt to integrate both these frames into the day to day operations and environment. After reviewing the available documents, I was curious to know how the ideological and service delivery frames would be incorporated in the narratives of newly relocated older adults. How would their expectations and experiences of AL have been shaped by what they read or knew about it before moving? Did they also experience a tension between the values and the organization of AL? What would their stories illuminate that had not been included in either frame?    139  Chapter 5: Rose: Doing Something and Feeling Useful    I certainly didn't want to leave where I was.  Most of my life then was the community centre.  Suddenly, my health took a turn. My lifestyle changed completely.  I couldn't go on  worrying about the children worrying about me.  So that was that.  There was only a choice of two.  Couldn't put your name on both, Couldn't go and see it until you'd applied. Ridiculous!  I waited almost a year;  Then a phone call- "You're in."  And suddenly realized -  Putting a bed in a different building is one thing  but what about the rest of it?  What about friends you've had for 13 years? I chose not to think about leaving. Because that, in the end, was the answer.  The mountain has always been my dream. I was so amazed at the accommodation. Eighth floor, with the most perfect view of the mountains. The walks -   They'll just be a different type of beauty. You've got your water.  You've got your trees. But now you've a mountain as well. So, alright.   I have to say, I shouldn't have been dreading walking down.  All you've got is a piece of paper: Welcome to Forest Place. Your table number is 25. I went to one table,  Said, could you help me?  "You can't sit here. You're not allowed." So my first impression was  I can't wait to go back up to my room. I don't need to be part of this. 140  Everything in the booklet:  the expectations, the principles, the values.  They're words, that's it. They're words. There's things I just can't do. I can't eat the food. The activities are all one level.  The atmosphere is not right. Walk in and close my apartment door,  Then I'm fine. It doesn't make it right. It doesn't make it home.    I was frustrated.   Then I went to England.  When I came back, suddenly there was a lot of work to do.  I really look forward to those committee meetings. What I've gained is feeling I've still got things I can do. I feel as though I’m back in the community centre working;  Doing things that I feel need doing, Helping when I can, more and more. It's no good complaining if I don't offer a solution.     5.1 Introduction   I first talked to Rose over the telephone. I had anticipated the need to explain the study more to her and to reassure her about confidentiality before gaining her verbal consent, but Rose had already made up her mind and had contacted me to set up our interview. I was struck by her warm tone and upbeat energy. She elected to meet in one of her favourite coffee shops close to 141  her AL residence, Forest Place.5  When I entered the coffee shop, she waved to me straight away and even reached up for a hug. She had chosen a particular spot to sit, out of the sunlight, because she had rheumatoid arthritis and could not tolerate heat. At times it was difficult for me to follow her narrative, because our seats were located next to a stereo speaker and Rose had a low, soft voice. However, my field notes and transcription software, alongside her animated storytelling, were valuable in helping me transcribe the almost four hour interview with very few points of lost data. Going over the consent form, Rose indicated that she was very comfortable talking about her experiences at Forest Place (“They know I’m going to say what I feel”), and mentioned that she had even received a letter from the residence that gave her “full permission” to say whatever she wanted to say.   Rose’s motivation for participating was directly linked to her own moving in experiences and her desire to bring about the improvements that she feels would have made her transition more positive. She agreed to take part in the study around the same time as she had agreed to take on a project initiated by Forest Place to recruit AL residents to improve the resident Handbook.  During our first telephone conversation, Rose specifically said that she wanted to tell her story so that “no one else would have to go through what I went through.”  At the time of our first interview, Rose had been at Forest Place for just five months. I began by asking her to tell me the story of her move to AL and she gave her account in great detail, from beginning to end. At points the narrative was suspended to introduce sub-narratives, clarify points, or answer questions, but Rose always picked up the thread and moved the story                                                  5 As per the consent agreement, participants were free to choose the location of their interviews. Rose always chose a coffee shop near Forest Place. We did spend a great deal of time discussing the physical environment and her use of common areas via interview questions. I was able to see a suite and the common areas of Forest Place through my interviews and tour with Ian, and I incorporate that data into his chapter.  142  along. We met three more time over the course of a year, always in a coffee shop close to Forest Place. These interviews were always an hour or more and focused on clarifying details of Rose’s narrative, exploring recurring themes, and receiving updates on Rose’s life in Forest Place. Even though her life was the subject of the interviews, Rose had a remarkable ability to make me feel as though she cared about me and my life in return. Going over the interviews, I began to see that Rose held a multidimensional concept of caring that was integral to the decisions Rose has made in her lifetime and to her sense of authentic self.  In the first sense, Rose simply derived pleasure from caring about people. Without prompting, she was able to articulate that she has a natural orientation toward caring and connection as part of her personality. Although she said that she “never needed to have very, very close friends” because she had that type of relational intimacy within her family, she nevertheless enjoyed “knowing and caring about a lot of people.” The relationships she was able to forge in her first year of living at Forest Place and in her new community had a direct influence on how comfortable she felt there. In the second sense, caring was a core value that Rose upheld in daily life. Partly, this was reflected in Rose’s belief that “if you’re going to do something, you do it correctly or you don’t do it at all.” Doing less than one’s best, for oneself and for others, implied a lack of care. By extension, Rose had a particular concern with how daily routines, comportment of staff, and the organization of the physical space of Forest Place did or did not demonstrate care for the residents and staff. This relates to the third dimension of care in Rose’s narrative, in that Rose embodied her value of caring through her acts of service. As we read in the poem, most of Rose’s life before her move to Forest Place was being involved in the local community centre – not so much as a participant, but as a key volunteer. She demonstrated care for her community members by developing and delivering programs that 143  nurtured and supported participants. Until Rose found a way to replicate this type of purposeful activity within Forest Place, she was discontent with her life there.   A second major theme within Rose’s narrative was doing. This theme partly encompasses her drive to perform acts of service, but also reflects the importance Rose placed on proactive problem-solving, managing her arthritis, pursuing social and recreational activities and maintaining her independence. Even in our interviews Rose often became very animated, acting out characters and voices and providing her reflective commentary on the situations she was describing.   Below I will introduce Rose and present a summary of her relocation narrative.  Within these sections I will highlight how the themes of caring and doing are woven into Rose’s story.   5.2 About Rose  Rose was a petite, 78 year-old Caucasian woman with short, silver hair and a ready laugh. She was born in England and grew up in a close-knit family of two sisters, a brother, and parents whom she described as “very loving people, and very considerate.” Her maternal grandparents also lived out their lives in a little cottage built for them on the family property by Rose’s father. Rose credits her parents for instilling in her the value of caring for others, particularly her father. Several anecdotes demonstrate her father to have been very “forward-thinking”, compassionate, and altruistic for the time. For example, Rose’s father was a builder in their village. After the end of World War II, he employed several men who had been prisoners of war.  So he had two men who had been prisoners of war, who were scared of every human being.  So frightened, it was unbelievable.  And then another one, he came back, and was completely shell shocked... [My father] just managed them so beautifully.  And in the 144  end, you know, we couldn’t believe it...Within five years they were talking, and they would go and knock on the door and say to Grammy, ‘Is the kettle on?’... And to think of them saying that before... it was amazing. (original emphasis)  Rose’s father also took the step of approaching the village vicar “the minute the war was over” to set up an exchange of German and British youth through the Church. Rose remembered her father expressing that “you can’t hate a whole country” and that “the only way it’s going to stop, is if the generations stop it.” Rose said, “He just got hold of that vicar and said, ‘Now, look. You’ve got to start somewhere. I think the Church can arrange a friendship trip, and my three girls will be going.’“ Rose’s family therefore modelled caring as a value and as a social responsibility.   Rose and her siblings were also encouraged to travel and explore the world, and Rose had already spent time in Canada visiting her brother before she and her husband emigrated here early in their marriage. When her oldest son was 15, her husband left and Rose raised her children (two sons and a daughter) as a single mother. Although it was a very hard time for her, she still had the capacity for empathy:   I think I was more sad thinking about the things that he would never see. The boys graduating. Getting married...[T]he more we got on with our lives,  every now and then I found myself thinking, “You have no idea what you’re missing,” you know? And I found  that very sad.  Rose says she simply dealt with it by “[getting] on with things.” She took a job as a before- and after-school care provider; she spoke of this job very fondly. The hours were very long, but she “loved it.” She recalled that “all those mothers were my friends” and they were “as important to me as the children.” One of her most treasured possessions before she moved to 145  Forest Place had been a framed print given to her by the parents – clearly there was a mutual sense of caring established during her years of work there.   Yet the most important focus in Rose’s life appears to have been her family, both near and far. From early in the first interview, Rose freely incorporated their anecdotes and voices into the overall context of her narrative. Her sons and daughter still lived in the metropolitan area along with several grandchildren. Both before and after her move to Forest Place, her children made a point to visit her as often as they could. They worked and travelled a great deal, but kept in touch with phone or video calls and email. She had regular contact with her grandchildren, even the ones living in England and Eastern Canada. And despite living in different countries, Rose’s parents (now deceased), her siblings, and their children visited between England and Canada several times a year over the last 20 years. Her younger sister maintained the family property in their village, and, in the past, Rose would return at intervals to visit and give that sister respite from caring for her own children and Rose’s mother and father. Since moving to Forest Place, Rose has been to England to visit her siblings twice. After the first trip, Rose laughed when she told me about how they all took turns in the wheelchair she rented when they needed a rest. The impression given was of a family that was emotionally and physically supportive, if not always geographically close.  As indicated, an ongoing part of Rose’s life was actively managing her rheumatoid arthritis. She was familiar with the trajectory, because her father also had the disease and actually died from the cumulative side effects of his medication. Rose described it as a “travelling arthritis” that could affect different parts of her body from day to day, or even from hour to hour – “I can be talking to you now and by the time I leave, I might not be able to walk.” Yet, she had creatively dealt with the inconvenience of this disease: 146   Nine times out of ten, there’s a way. And in actual fact, sometimes it becomes quite an interesting challenge! One of the kids had brought me a bottle of wine, going back several years. And it had a screw-top. [I] couldn’t open it. And then I remembered nut- crackers. So I got my nutcracker! So you see? It does [become] sort of a game in the end.  Over the year that we met, Rose’s arthritis progressed several times and eventually resulted in an additional diagnosis of osteoarthritis. There were days that she “couldn’t control the pain at all”, or where she couldn’t lift her arms or move one or both of her feet. She had trouble sleeping at night because of the pain and because reclining made the symptoms worse. Through it all, Rose persevered with what she felt to be the most helpful course of action for her - yoga, exercise, and a nutritious diet. I found it very revealing that, when her arthritis progressed during the first year at Forest Place, she also took the initiative to ask her doctor to fill out the forms for medical marijuana use. She was not bound by convention or opinion (she actually did not even consult her children); she chose to investigate every available avenue. This determination in problem-solving proved successful for Rose, who found that the marijuana did relieve the pain enough for her to be able to sleep more soundly.   Another remedy Rose found helpful in coping with her arthritis was volunteering, at least until the point that she was unable to predict what her symptoms would allow her to do in a day. Volunteering “motivated” Rose to get up and get moving, which helped reduce stiffness and pain. But it was also an important outlet for her caring nature and her need to feel she was contributing. Part of what she gained was camaraderie with other staff: “Most of the time...we were working damn hard, and enjoying every moment of it.” But she also gained satisfaction from the act of service itself: “At the [community] centre, it was the sheer enjoyment of the pleasure the other older people got, out of seeing rooms decorated with flowers on the tables 147  and...being taken out on trips.” The sense of belonging she felt there extended to the wider community. She says she was never able to walk around her neighbourhood without someone she knew from her time at the centre walking up to make a coffee date, or “simply giving me a kiss.” This reflection demonstrates the esteem with which she was held in her community and the social benefit Rose reaped from her hours spent volunteering.   5.3 Moving In  Rose was quite content, therefore, living in her Independent Living apartment in a suburb of Vancouver, volunteering and being involved with her family. Yet approximately 18 months before she moved to Forest Place, she had a particularly aggressive arthritis flare-up with unusual symptoms. This prompted her children to try and see her more often, on top of their busy schedules.  “I said this is ridiculous, all it’s actually is doing is making things worse to me.  I worry [about them]. When I worry, then the immune system isn’t coping. I’m going back to England... I’m taking a break from everyone “(original emphasis). She spent several months in England being cared for by her younger sister on the family property while the family doctor tried to stabilize her condition for the flight home.    When she eventually came back, she said that her symptoms were not much better and that her children were so “horrified” when they saw her that her daughter “immediately called in a case worker.” Another of Rose’s sisters, who had been living in South Africa, came to stay with her for the next several months. During this time, Rose and her family applied to an AL residence in Vancouver, the city where her children lived. I asked her why she chose the one she did, and she replied that the priority was to be as close as possible to her children.  148   So whenever they came to see me, it meant at the end of a work day – and sometimes that could be eight, nine o’clock at night - driving across three bridges to see me, driving back. They’d done it for twelve years. It got to the point where...I almost didn’t want them to come.   I asked if she did any research before making her choice, and she replied matter-of-factly that there wasn’t much point, because there were only two in the neighbourhood closest to her family. As we can see from the poem, Rose still bristled at the fact that she was not able, as far as she knew, to visit either place before choosing to go on one waitlist -  “You don’t know until you walk into the place...I’m not talking about the furnishing inside. You know, in your heart, if you listen to yourself” (original emphasis). But Rose’s family did what they could initially to help her narrow down her choices; she describes how her daughter and son-in-law drove around and ruled out potential properties based on what they knew Rose needed and preferred. Rose’s particular worry with Forest Place, after driving by with her family one day, was that she had accidentally chosen a ‘nursing home’. As mentioned, Forest Place was a campus of care, with independent living, assisted living, and complex care/long term residential care in different sections of one building. Her first impression upon seeing the main (complex care) entrance was, “What have I put myself into?” Without being able to tour the AL residence beforehand, she could not know that there was a separate apartment tower for the AL residents. Still, she tried to think optimistically after noticing the surrounding neighbourhood with its tree lined streets, beautiful scenery, shopping, and pedestrian friendly walking routes – “Nothing could be that bad with all these things around me, you know?”   Rose spent a year on the wait list for Forest Place, during which time her family arranged for a private home care company to come in and support her as needed. Rose says she had some 149  good days and found her functioning stabilized somewhat over time, but she did not allow herself to think about perhaps staying in her community because she knew the unpredictable trajectory of rheumatoid arthritis.   That year was pretty good for me, activity wise. Then [my name] came up and I knew immediately I mustn’t even stop and think about it. Don’t stop and think about it. Don’t think, that I’m doing this on my own, now I’m doing that on my own, I can wash my own hair...don’t think about any of it. You don’t know when it’s going to happen again.  Rose eventually heard from her case manager that she should expect a call from Forest Place for a final interview. Her account of the interview process again highlighted the value she placed on caring and on family. She was demonstrably pleased that her family came with her to the assessment and paper signing interviews; she smiled when she told me that the Director of Resident Services had to look for a larger room in which to hold the first meeting because she never had so many family members at an interview. Her first impression of the Director herself was favourable, largely because the woman greeted Rose by name, had taken the time to read that Rose was a certified yoga instructor, and asked Rose if she would teach her yoga one day. Rose said this effort to get to know a little bit about her “was one of the high points” of that interview. By showing that she cared, the Director gained Rose’s respect.   In contrast, Rose was put off by the case manager for Forest Place, about whom Rose said, “I got no feeling of warmth, disapproval, approval, attitude, couldn’t be bothered. There was nothing.” The case manager went over the official rules, regulations and policies of Forest Place and the Health Authority. Rose was unimpressed with this aspect of the process: “Everything she read through was in the booklet that I’d been given the year prior.”  The 150  paternalistic tone, as well as the case manager’s impersonal demeanor, caused Rose to “just tune out.”   The presence of Rose’s family, however, and the burgeoning rapport with the Director, enabled Rose to feel sure that there were ways of being flexible within the rules. For example, Rose’s daughter began to ask more detailed questions, such as what would happen if Rose wanted to go visit her sisters in England. Rose imitated the brusque tone of the case manager’s response: “You’re allowed to go for a week. Can’t leave for more than a week at a time.” At this point Rose’s daughter reassured her by mouthing, “Don’t worry.” Rose smiled in recalling this, and said it was like her daughter telling her, “We will sort it!” So while Rose was hearing the official ‘voice’ of AL, she was able to filter it through her knowledge that her family would look after her and through her impression of the Director as a caring person.   Rose had a much more favourable impression of the actual suite – after viewing it, she made up her mind almost immediately. She says, “I was so amazed at the accommodation. Now, I’m not saying everybody’s is like it. I don’t know. But mine is gorgeous.” The studio suite impressed her with its large windows, mountain view, ample closet space, large bathroom (shower only) with plenty of grab bars, neutral colours, full kitchen and laminate floor. Two features in particular were important for Rose. The first was a reasonable view. As someone who has experienced periods of being bedridden, Rose has an appreciation for   ...how you feel when you’re in a room and you know that you’re going to feel comfortable there....The other thing is, what do you look at when you can’t get out? And my biggest dread has always been to live somewhere where my living room or bedroom window faced um, an alley...  151  The way she described the view from her suite to me, it was as if she was painting it with words. She said that at the time she thought, “if I couldn’t move, except to the bathroom and back, and I have to sit and look at this, nothing can be that wrong. Knowing, that, the children would be there, you know” (original emphasis).  The second crucial feature was a window that opened so that she could maintain a cool temperature for her arthritis. She suspensefully described how she was unable to open the window at first, and how her acceptance of the suite hung entirely on this test. When the case manager eventually got the window open, Rose said she and her daughter shared a fleeting look that Rose interpreted as “we were a go.”    Consistent with the close relationships in her family however, she waited to give her final response until after she had talked with her children.  In this portion of her narrative Rose described some tender moments with her daughter and oldest son, as they collectively realized what this move meant. Although they all agreed that it fulfilled Rose’s most important requirements, it seems that they just then recognized the weight of the decision and the phase of life that Rose had now entered. With some tears, she recalled the conversation with her son as he drove her home.    ...He said, “Just don’t worry about it; we’ll just get you home.” And I said, “Well could you at least tell me what you think?” He says, “You can’t ask me that question.” And I said, “Well why?”  He said, “Because I don’t want you in any home”...So I said, “Well, I know that’s true. But as it can’t happen, what do you think?” He said,” I think it was ok.” (Long pause); (original emphasis).   At this point in the story, there is a shift from waiting and wondering, to actively preparing for the move. As the poem shows, Rose now began to realize the social cost of moving 152  – something she hadn’t allowed herself to dwell on during her year on the waitlist. Not only would she be losing the activity and sense of purpose she gained from volunteering at the community centre, she would also be leaving her best friend Jane. Talking about saying goodbye to Jane and her community was the only other time Rose became tearful in the interview. Immediately after describing this loss, however, Rose shared how she began coaching herself to see the positives of the move, such as the new places to walk and the mountain view from her suite. Part of her preparation to move also involved strategizing with Jane on how they would maintain their relationship by means of email, telephone, and public transit.  With just three weeks before she had to move, Rose began to focus on the practicalities of relocating, such as downsizing her belongings. I did not expect this part of the narrative to be so extensive, but Rose described in great detail how she came to give away most of her possessions. It was important to her that items that still had value either functionally or aesthetically be placed with individuals who would enjoy or benefit from them. For example, she opened her kitchen to a neighbour to take whatever utensils she did not already possess; she made bundles of items that she “knew would be useful” for another neighbour to take on her rounds to homeless people; and a treasured set of prints was given to a friend who had always admired them. Rose indicated she felt glad to be able to give her this present and to know she could go see them from time to time. Going about downsizing in this manner seemed to be a way that Rose could take control of the situation and to perform one more act of caring for the community and people to whom she was connected.   The fact that she could not shift her large furniture until three days before the move, however, caused her a great deal of stress. Beyond it “breaking [her] heart” to take good furniture to the dump when she was sure someone could use it, Rose said that she was concerned 153  that if she could not clear the furniture, she would not be able to move in to Forest Place on the specific date and would lose her suite. In the last few days before moving, she found someone who promised to find homes for all of it, which she found relieving: “All I knew was, that he was going to look after that furniture, and I knew it would not end up in the dump. And, that it was going to be safe (original emphasis).” She said that the whole process of downsizing, and especially of worrying about the furniture, took a toll on her emotionally: “I think a lot of it was getting mixed up with, this is it, there’s no turning back.”  At this point in her narrative, Rose described an event that greatly influenced how she moved into Forest Place and her experience of her first days there. On the day of the move, Rose got up in the early morning, tripped on a piece of furniture in the dark, and fell in an awkward position. She laughed when recalling how she must have looked and how long it took to figure out how to get up, in light of the limited strength and mobility of her hands. Yet the fall was serious enough to cause real pain in Rose’s hip that night, and for several days following she was not able to walk or stand. Because Rose’s injury meant that she had a diminished physical presence in the move, Rose had to continually negotiate her authority throughout the process. In some areas she was successful, such as refusing the care aide’s suggestions to go to the hospital, or assertively coaching her family members to arrange furniture where she wanted it. In other areas, Rose was clearly frustrated. For example, she described being “manhandled” when she was carried out of the car and up to her suite at Forest Place, at the same time as she recognized that it was done out of necessity. She was also unable to unpack in the manner to which she was accustomed.   So, now, the hardest part for me [tapping the table with each word for emphasis] is sitting in that chair, and watching people put my stuff [in]. I have moved many times in 154  my life with 3 children, and while they were at school, I have moved an entire house. And had tea [supper] waiting for them when got home from school. No one has ever unpacked any of my stuff. (original emphasis)   For someone who had learned to maintain a great deal of independence despite her arthritis, and for someone who so enjoyed organizing and maintaining her home, it must have been an unusual and uncomfortable position in which to be. At the same time, Rose genuinely appreciated her family’s efforts to help her settle in and was able to consciously call upon her relational values in order to help her deal with this frustration. She remembers telling herself at the time:  ... it doesn’t matter. All it means is, next few days, you can simply move some from to one shelf or another, so you know, don’t make a bigger deal out it. Yes, it’d be much easier to unpack them and put them in the right place, but people are here and they’re helping you and they are happy with what they are doing. So forget it. In this way, Rose was able to recognize what others were doing as demonstrating care, and then allow them the experience of feeling good about helping.   Rose’s injury also had a direct influence on the type of interaction she had with Forest Place and its staff in the first few days. The afternoon of her move-in, Rose was visited by one of Forest Place’s care aides. After an initial discussion over the injury and the offer of a walker, Rose said no one returned to see her for two days. This inattention is the crux of the dissatisfaction that Rose felt upon moving to AL, and which motivated her to share her story. The Forest Place Handbook provided to Rose had a phone number for residents to call if they needed assistance. Rose felt that even though she did not particularly need to phone because nothing in her condition had changed, the onus was on the staff to check in on her, given that 155  they were concerned enough to suggest an x-ray and a wheelchair. Because care and compassion were such a core part of Rose’s way of life, for her to not receive such attention in a setting specifically meant to provide support and care seems to have been a real affront. She described a brief exchange on the third day, when a staff member “put her head in” the door and asked, “‘Are you going down for lunch today?’  And I said ‘No, I’m not. I’m not feeling well enough to do that.’ ‘Alright,’ she said. And that was that.”   Rose had been able to get around her apartment and to make meals of the groceries her children had left, but she says she was beginning to feel “isolated.” Characteristic of her tendency to face problems with action, Rose therefore decided that she needed to steel herself to go down to the dining room. I was surprised that such a seemingly social woman would be “dreading” visiting the dining room, but she explained that she is actually “quite shy.” Rose had no idea of what to expect of her dining experience – “All you’ve got is a piece of paper saying, ‘Welcome to Forest Place. Your table number is 25’.” Her social anxiety, compounded by her injury and temporary use of a walker, meant that she was feeling physically and emotionally vulnerable when taking this first step into her new life. Adding to this was the perceived indifference of several staff and the hostility from some of the residents when she asked for help locating her table. “So my first impression was, ‘I can’t wait to go back up to my room. I don’t need to be part of this’.” Rose also discovered that residents from complex care, many of whom had dementia or cognitive impairment, dined with residents from AL. Rose found this “pretty disturbing”, not so much because of prejudice but because one of her dining partners was prone to swearing, scowling and “mean” comments. The other woman was “sweet” but “not with us” and the first resident would talk disparagingly to her. Rose found this upsetting. The final 156  disillusionment of that first meal was the food itself, which Rose described as “dreadful.” She decided at that point that she would not be eating in the dining room very often.   5.4 Settling In  The entire experience of her first few days left Rose with a very vivid and negative impression. Yet, Rose was convinced that there was a better way to welcome new residents and help them feel comfortable. As she circulated around the building more and began settling in, she also she made observations about aspects of life in Forest Place that she could not reconcile with her values or her lifestyle. These observations, and her ideas for improvement, were a large part of our remaining interviews. When discussing these topics, she often used a voice I came to call ‘frustrated oversight’. In her position as an operator of an after school care program and as a high-level volunteer at her community centre, Rose had direct ability to influence the delivery of services. In Forest Place she continued to use her keen sense of observation for service improvement, but for almost a year she had little outlet to do anything with her ideas.   Initially, the one exception to her frustration was the opportunity to work with Forest Place on redeveloping their Resident Handbook. About five weeks after she moved in, Rose attended an inaugural meeting for AL residents only. The new Director of Resident Services wanted to create dialogue between this group and the management, and also to gather input from residents on how to improve the resident Handbook. Rose immediately volunteered for the project. She described to me in great detail the changes she made in her version of the Handbook, such as adding a thorough description of the neighbourhood amenities and transit. When she moved in, she said very few people could answer basic questions she had such where to find services or what bus routes to take. In describing her project to me, Rose carefully chose 157  her words to demonstrate the warm and courteous language with which she intended to write the section, restarting one sentence several times until she felt she captured the correct sentiment. At the time of our first interview, Rose had already spoken with the staff overseeing the project about how their language in the booklet was inappropriate or even inaccurate in places. For example, she requested they remove a line that said, “A pleasant dining experience awaits you.” She clearly felt comfortable in her advisory role.   In addition, Rose proposed two actions that she felt would enhance the comfort and support of new residents. First, she suggested a change to the move in procedure, where a care worker would not only meet the new resident at the beginning of the move, but also invite him or her to call after getting settled. At this point, the care worker would come back with the Handbook, offer help if needed and be available to answer any questions. Whether this procedure was adopted is unknown. It would involve a procedural change so presumably it would require a somewhat formal process to be passed. However, it demonstrates Rose’s intuition around what makes people feel cared for. Second, she initiated a “buddy system” where new residents are given the name and phone number of a Forest Place resident who has volunteered to show them to them around, help them find their table in the dining room, and answer questions. As Rose put it, “It’s no good saying, welcome, welcome, welcome but you’re going to have to make your own way and your own friends.” This system actually was implemented over the course of our interviews – both Rose and another AL resident volunteered to be buddies. At the time of our final interview, her additions and suggestions for the Handbook had been submitted. The new cover photo had just been taken for the Handbook, and Rose was involved in designing this as well. She was not sure if all her edits would be accepted, but she was satisfied to have done her part.  158   But while Rose was positive about the new, friendlier Handbook, she remained dissatisfied with certain aspects of life in Forest Place. In particular, the poor quality of the food and the physical, social, and recreational environment were continued sources of frustration. Regarding the food, for example, Rose stopped eating the majority of her meals in the dining room “within ten days of moving in.” Beyond her personal taste, Rose felt that a diet low in sugar, fats and refined or processed products was very important in managing her arthritis symptoms:    The one thing that I can control myself is what I eat, which has got a lot of to do with what affects the arthritis. Eating good food and controlling what good blood cells I’ve got is the most important thing!  Rose was therefore unhappy with the food ‘choices’ offered to her at Forest Place, which appeared to be of a more stereotypical institutional variety – overcooked vegetables, instant potatoes, frozen foods, fried foods, menus based around meat, and minimal whole grains. Knowing that there could be ways of improving food quality, but that Forest Place was not pursuing them, seemed particularly frustrating for her. Drawing on her life experience, Rose observed:   ...they can’t even get the salad out without having the celery brown and curled and the broccoli, it’s brown...All I know is, by the time I left [the before and after school care program] I had a hundred and twenty-five children between two schools...and I could give them carrots, celery sticks, cucumber, sliced apples, sliced oranges- and it was all looking as if it had just been [prepared]. Yes, there is a way.  Given the large emphasis on meal provision as a hospitality service in AL regulation and policy, I asked Rose if it was a requirement that she go to the dining room for meals (lunch and 159  supper). She responded, “They actually tell you that at the interview. It’s what you pay for. And you pay a lot.” Rose opted, instead, to go to meals from time to time, eat whatever seemed palatable or check with other residents if anything had improved, and excuse herself.  The rest of the time she ate what she prepared in her suite’s kitchen and the food her family brought when visiting. I asked Rose what she would have done if she did not have a kitchen in her suite. She responded without hesitation that her children would bring her food. “And they’re quite prepared anytime; all I have to do is give them the word...And that would be that I can assure you.” In fact, her children offered to “go to the press” about the food quality, because they felt it was “terrible for everybody”, not just their mother. Rose clearly felt supported by this, but preferred to try to work with Forest Place to bring about change (as I will discuss below).    In addition to the quality of the food, Rose was disappointed with the dining atmosphere. To her, the absence of tablecloths, or even placemats, was a further demonstration of a lack of care. She described a haphazard system of centrepieces: “Sometimes, you may have a single flower in a bud vase; the next table won’t have anything, another table will have four or five going rotten.” She felt that, “if it looked nice before we even sat down...it would improve the socialization. No two people ever sit at a table and talk afterwards. Even when they’re really good friends.” There also appeared to be an implicit understanding that the dining room was functional – not social. Rose commented that “you would not be welcome” to gather in the dining room between meals, because immediately after one meal was cleared the room was set for the next meal. This practice is understandable between the two lunch seatings and two dinner seatings, but I observed staff setting tables for supper as I walked through at 2:45 one afternoon.  The other issue Rose had with dining atmosphere during her first months was that the seating arrangements appeared random and did not encourage social connections. And although 160  Rose had compassion for residents with dementia, she felt that some of the behavioural challenges that occurred during meals made dining more of an unpredictable undertaking than a comfortable, social experience.  She observed, “Even if we all had one person like this [at our table]... It’s fine. But at least two people have got to be able to talk and get to know each other.” At our last interview, Rose was pleased to report that Forest Place management had begun offering AL residents meals as a separate group, which initially came about during a period of extensive plumbing renovations at Forest Place. Because the dining room was not accessible, management had begun serving meals using various arrangements, including AL residents in the library or TV room. Rose felt that this made a “better atmosphere” because “you’re sitting with people either you relate to or you’ve been used to for x number of years.” Rose even hoped that giving the AL re