Center for Excellence in Assisted Living CEAL@UNC

Advancing the well-being of the people who live and work in assisted living through research, practice, and policy.

Mental Health

Stress-Related Coping and its Relationship to Well-Being in Nursing Assistants and Personal Care Aides in Nursing Homes and Assisted Living

Dec 1, 2024
INTRODUCTION Professional caregivers (nursing assistants and personal care aides) in nursing homes (NH) and assisted living (AL) provide the majority of long‐term residential care for persons with Alzheimer’s disease and related dementias. Their work is stressful, but until recently, no measures were available to assess stress in this workforce. Using the new Long‐Term Care Cope […]

Stress-Related Coping and its Relationship to Well-Being in Nursing Assistants and Personal Care Aides in Nursing Homes and Assisted Living

by Lea Efird-Green

INTRODUCTION Professional caregivers (nursing assistants and personal care aides) in nursing homes (NH) and assisted living (AL) provide the majority of long‐term residential care for persons with Alzheimer’s disease and related dementias. Their work is stressful, but until recently, no measures were available to assess stress in this workforce. Using the new Long‐Term Care Cope […]

A New Measure of Professional Caregiver Coping in Long-Term Care: The LTC COPE

Dec 1, 2024
INTRODUCTION: The professional caregiver workforce (nursing assistants and personal care aides) is critical to quality of care and quality of life in nursing home (NH) and assisted living (AL) settings. The work is highly stressful, so improving responses to stress in this workforce could contribute to satisfaction and retention. This research developed a coping measure […]

A New Measure of Professional Caregiver Coping in Long-Term Care: The LTC COPE

by Lea Efird-Green

INTRODUCTION: The professional caregiver workforce (nursing assistants and personal care aides) is critical to quality of care and quality of life in nursing home (NH) and assisted living (AL) settings. The work is highly stressful, so improving responses to stress in this workforce could contribute to satisfaction and retention. This research developed a coping measure […]

The Role of Workday Characteristics on Perceived Stress and Time Pressure among Nurses in Finnish Long-Term Care – A Cross-Sectional Study

Dec 1, 2024
Background Aging populations and nursing workforce issues are causing challenges for long-term care globally, and therefore, improving the work-related wellbeing and retention of nurses is crucial. As such, gaining a further understanding of the factors that affect work strain in long-term care is important. Previously, the effect of job demands on the wellbeing of nurses […]

The Role of Workday Characteristics on Perceived Stress and Time Pressure among Nurses in Finnish Long-Term Care – A Cross-Sectional Study

by Lea Efird-Green

Background Aging populations and nursing workforce issues are causing challenges for long-term care globally, and therefore, improving the work-related wellbeing and retention of nurses is crucial. As such, gaining a further understanding of the factors that affect work strain in long-term care is important. Previously, the effect of job demands on the wellbeing of nurses […]

Progress of Rehabilitation in Assisted Living for Mentally Ill According to STAX-SA Taxonomy

Nov 1, 2024
Objective: The transition from institutional psychiatric care to community-based mental health services has resulted in the rapid development of assisted living services (AL) for mentally ill. Focus of the current study is to add internationally comparable evidence-based knowledge on the rehabilitation of AL residents by examining progression and mortality in relation to the level of […]

Progress of Rehabilitation in Assisted Living for Mentally Ill According to STAX-SA Taxonomy

by Lea Efird-Green

Objective: The transition from institutional psychiatric care to community-based mental health services has resulted in the rapid development of assisted living services (AL) for mentally ill. Focus of the current study is to add internationally comparable evidence-based knowledge on the rehabilitation of AL residents by examining progression and mortality in relation to the level of […]

Effects of a Meaning in Life Enhancement Program on Depression among Older Adult Residents of Assisted Living Facilities

Nov 1, 2024
Older adults residing in assisted living facilities often experience higher rates of depression. This study aimed to examine the effects of a program to enhance meaning in life on depression among older adult residents. The samples included 60 older adults living in two assisted living facilities. The experimental group participated in the meaning in life […]

Effects of a Meaning in Life Enhancement Program on Depression among Older Adult Residents of Assisted Living Facilities

by Lea Efird-Green

Older adults residing in assisted living facilities often experience higher rates of depression. This study aimed to examine the effects of a program to enhance meaning in life on depression among older adult residents. The samples included 60 older adults living in two assisted living facilities. The experimental group participated in the meaning in life […]

The Prevalence and Benefits of Self-Compassion Among Professional Caregivers

Aug 1, 2024
Objective Self-compassion is a healthy way of responding to challenges that may help long-term care professional caregivers (ie, nursing assistants and personal care aides) cope with stress, but its use may vary in important ways. This study explored the relationships between self-compassion and caregiver demographic characteristics, anxiety and depressive symptoms, and job satisfaction in a […]

The Prevalence and Benefits of Self-Compassion Among Professional Caregivers

by Lea Efird-Green

Objective Self-compassion is a healthy way of responding to challenges that may help long-term care professional caregivers (ie, nursing assistants and personal care aides) cope with stress, but its use may vary in important ways. This study explored the relationships between self-compassion and caregiver demographic characteristics, anxiety and depressive symptoms, and job satisfaction in a […]

Be Well in AL Recommendations: Resident/Family Checklist

Jun 10, 2024
CEAL@UNC recognizes the benefit of ongoing quality improvement in assisted living, including through the implementation of consensus medical and mental health care recommendations disseminated through the Be Well in AL Initiative. This checklist, to be used by residents and their families considering or residing in assisted living, is a helpful tool to understand recommended care […]

Be Well in AL Recommendations: Resident/Family Checklist

by Lea Efird-Green

CEAL@UNC recognizes the benefit of ongoing quality improvement in assisted living, including through the implementation of consensus medical and mental health care recommendations disseminated through the Be Well in AL Initiative. This checklist, to be used by residents and their families considering or residing in assisted living, is a helpful tool to understand recommended care […]

Serious Mental Illness in Assisted Living Communities: Association with Nursing Home Placement

May 1, 2024
Objectives Assess prevalence of serious mental illness (SMI) alone, and co-occurring with Alzheimer disease and related dementias (ADRD), among Medicare beneficiaries in assisted living (AL). Examine the association between permanent nursing home (NH) placement and SMI, among residents with and without ADRD. Design 2018-2019 retrospective cohort of Medicare beneficiaries in AL. Residents were followed for […]

Serious Mental Illness in Assisted Living Communities: Association with Nursing Home Placement

by Lea Efird-Green

Objectives Assess prevalence of serious mental illness (SMI) alone, and co-occurring with Alzheimer disease and related dementias (ADRD), among Medicare beneficiaries in assisted living (AL). Examine the association between permanent nursing home (NH) placement and SMI, among residents with and without ADRD. Design 2018-2019 retrospective cohort of Medicare beneficiaries in AL. Residents were followed for […]

Estimated Prevalence of Resident-to-Resident Aggression in Assisted Living

May 1, 2024
Importance Resident-to-resident aggression in assisted living facilities can result in physical and psychological harm, but its prevalence is unknown. Objective To estimate the prevalence of resident-to-resident aggression, including physical, verbal, and sexual, among residents in assisted living facilities. Design, Setting, and Participants This study used cross-sectional, observational data from a clinical trial, in which residents […]

Estimated Prevalence of Resident-to-Resident Aggression in Assisted Living

by Lea Efird-Green

Importance Resident-to-resident aggression in assisted living facilities can result in physical and psychological harm, but its prevalence is unknown. Objective To estimate the prevalence of resident-to-resident aggression, including physical, verbal, and sexual, among residents in assisted living facilities. Design, Setting, and Participants This study used cross-sectional, observational data from a clinical trial, in which residents […]

Examining Pain, Function, Behavioral Symptoms and Associations with Engagement in Meaningful Activity for Residents with Dementia in Assisted Living

Apr 1, 2024
Objectives The purpose of this study was to examine factors associated with engagement in meaningful activity among residents with dementia in assisted living. We hypothesized that greater functional independence, less pain, and lower behavioral and psychological symptom severity would be associated with higher engagement in meaningful activity after controlling for residents’ age, gender, comorbidities, and […]

Examining Pain, Function, Behavioral Symptoms and Associations with Engagement in Meaningful Activity for Residents with Dementia in Assisted Living

by Lea Efird-Green

Objectives The purpose of this study was to examine factors associated with engagement in meaningful activity among residents with dementia in assisted living. We hypothesized that greater functional independence, less pain, and lower behavioral and psychological symptom severity would be associated with higher engagement in meaningful activity after controlling for residents’ age, gender, comorbidities, and […]

Assisted Living Residents with Dementia: Disparities in Mental Health Services Pre and During COVID-19

Apr 1, 2024
Background Little is known about mental health among Medicare beneficiaries with Alzheimer’s disease or related dementias (ADRD) who reside in assisted living (AL) communities. The COVID-19 pandemic may have curtailed ambulatory care access for these residents, but telehealth may have expanded it. We examined in-person and telehealth use of ambulatory mental health visits among AL […]

Assisted Living Residents with Dementia: Disparities in Mental Health Services Pre and During COVID-19

by Lea Efird-Green

Background Little is known about mental health among Medicare beneficiaries with Alzheimer’s disease or related dementias (ADRD) who reside in assisted living (AL) communities. The COVID-19 pandemic may have curtailed ambulatory care access for these residents, but telehealth may have expanded it. We examined in-person and telehealth use of ambulatory mental health visits among AL […]

Effect of Immersive Virtual Reality Reminiscence versus Traditional Reminiscence Therapy on Cognitive Function and Psychological Well-being among Older Adults in Assisted Living Facilities: A Randomized Controlled Trial

Nov 1, 2023
WHAT THIS MEANS FOR YOU: A study of 60 assisted living residents observed the effects of virtual reality reminiscence and traditional reminiscence therapy on residents’ cognitive function and psychological wellbeing. Compared to a control group, there was a statistically significant increase in cognition and psychological wellbeing in both the reminiscence groups.

Effect of Immersive Virtual Reality Reminiscence versus Traditional Reminiscence Therapy on Cognitive Function and Psychological Well-being among Older Adults in Assisted Living Facilities: A Randomized Controlled Trial

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A study of 60 assisted living residents observed the effects of virtual reality reminiscence and traditional reminiscence therapy on residents’ cognitive function and psychological wellbeing. Compared to a control group, there was a statistically significant increase in cognition and psychological wellbeing in both the reminiscence groups.

The Complexity of Providing Behavioral Healthcare in Assisted Living

Oct 1, 2023
WHAT THIS MEANS FOR YOU: This editorial discussed the difficulty providing mental and behavioral healthcare in assisted living. Increasing numbers of residents experience high rates of behavioral health issues, but only 40% of communities offer treatment for these issues, despite the fact that lack of treatment is associated with negative outcomes such as severe depression and suicidal ideation. To improve behavioral healthcare in assisted living, adequate staffing and staff education is required, as well as insurance reimbursements for mental health services at similar levels to those for medical care.

The Complexity of Providing Behavioral Healthcare in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This editorial discussed the difficulty providing mental and behavioral healthcare in assisted living. Increasing numbers of residents experience high rates of behavioral health issues, but only 40% of communities offer treatment for these issues, despite the fact that lack of treatment is associated with negative outcomes such as severe depression and suicidal ideation. To improve behavioral healthcare in assisted living, adequate staffing and staff education is required, as well as insurance reimbursements for mental health services at similar levels to those for medical care.

Exploring Constraints to Well-Being for Older Adults in Transition Into an Assisted Living Home: A Qualitative Study

Jul 1, 2023
WHAT THIS MEANS FOR YOU: A theory-based thematic analysis was conducted on 14 interviews with assisted living residents from one community in the rural southeastern US. When asked to report experiences when transitioning to the community, residents felt a loss of independence, space, and belongings due to necessary downsizing. Results support the Modified Constraints to Wellbeing model, which theorizes that structural and intrapersonal constraints (e.g., loss of independence) lead to changes in social leisure pursuits after transitioning into assisted living, which negatively affects wellbeing. However, more research is needed.

Exploring Constraints to Well-Being for Older Adults in Transition Into an Assisted Living Home: A Qualitative Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A theory-based thematic analysis was conducted on 14 interviews with assisted living residents from one community in the rural southeastern US. When asked to report experiences when transitioning to the community, residents felt a loss of independence, space, and belongings due to necessary downsizing. Results support the Modified Constraints to Wellbeing model, which theorizes that structural and intrapersonal constraints (e.g., loss of independence) lead to changes in social leisure pursuits after transitioning into assisted living, which negatively affects wellbeing. However, more research is needed.

Attachment Behaviours in Adults with Intellectual Disabilities in Assisted Living Facilities: Representations from Direct-Care Staff

Jun 1, 2023
WHAT THIS MEANS FOR YOU: In this study, 19 support staff from 7 assisted living communities in Belgium were interviewed to understand about how adults with intellectual disabilities related to these staff. Themes revealed that staff often struggled finding a balance between supporting select attachment behaviors and maintaining a professional distance from residents to prevent negative impact on their work.

Attachment Behaviours in Adults with Intellectual Disabilities in Assisted Living Facilities: Representations from Direct-Care Staff

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: In this study, 19 support staff from 7 assisted living communities in Belgium were interviewed to understand about how adults with intellectual disabilities related to these staff. Themes revealed that staff often struggled finding a balance between supporting select attachment behaviors and maintaining a professional distance from residents to prevent negative impact on their work.

“I Have a Lotta Sad Feelin'” – Unaddressed Mental Health Needs and Self-Support Strategies in Medicaid-Funded Assisted Living

Jun 1, 2023
WHAT THIS MEANS FOR YOU: This study investigated mental health needs and barriers among residents at Medicaid-funded AL communities. At one AL community in the Bronx, 13 residents completed questionnaires and interviews; analysis revealed patterns of mental health needs, feelings of losing control, mistrust of organizational staff, and lack of resources and support.

“I Have a Lotta Sad Feelin'” – Unaddressed Mental Health Needs and Self-Support Strategies in Medicaid-Funded Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study investigated mental health needs and barriers among residents at Medicaid-funded AL communities. At one AL community in the Bronx, 13 residents completed questionnaires and interviews; analysis revealed patterns of mental health needs, feelings of losing control, mistrust of organizational staff, and lack of resources and support.

Well-being of professional older adults’ caregivers in Alberta’s assisted living and long-term care facilities: a cross-sectional study

Feb 1, 2023
WHAT THIS MEANS FOR YOU: A study in AL and other long-term care communities in Alberta assessed nurses’ and professional care aides’ physical, mental, and emotional health, behavior, stress, quality of life, turnover, and absenteeism. Mental and emotional health, quality of life, and stress related to turnover and absenteeism. Although 68% of caregivers reported being satisfied with their general health, they experienced heavy workloads and high stress. These issues may result in decreased job satisfaction, absenteeism, and higher turnover.

Well-being of professional older adults’ caregivers in Alberta’s assisted living and long-term care facilities: a cross-sectional study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A study in AL and other long-term care communities in Alberta assessed nurses’ and professional care aides’ physical, mental, and emotional health, behavior, stress, quality of life, turnover, and absenteeism. Mental and emotional health, quality of life, and stress related to turnover and absenteeism. Although 68% of caregivers reported being satisfied with their general health, they experienced heavy workloads and high stress. These issues may result in decreased job satisfaction, absenteeism, and higher turnover.

Coping Behaviors and Health Status during the COVID-19 Pandemic among Caregivers of Assisted Living Residents in Western Canada

Dec 1, 2022
WHAT THIS MEANS FOR YOU: Surveys from 673 assisted living direct caregivers revealed that coping behaviors such as alcohol and smoking/cannabis use, and psychotropic drug use increased during the first two waves of the COVID-19 pandemic and were more common among caregivers who had anxiety or depression symptoms before the pandemic. These caregivers are thus particularly vulnerable to negative coping behaviors during stressful events and may require additional support.

Coping Behaviors and Health Status during the COVID-19 Pandemic among Caregivers of Assisted Living Residents in Western Canada

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Surveys from 673 assisted living direct caregivers revealed that coping behaviors such as alcohol and smoking/cannabis use, and psychotropic drug use increased during the first two waves of the COVID-19 pandemic and were more common among caregivers who had anxiety or depression symptoms before the pandemic. These caregivers are thus particularly vulnerable to negative coping behaviors during stressful events and may require additional support.

Caregivers’ Concerns about Assisted Living Residents’ Mental Health during the COVID-19 Pandemic: A Cross-Sectional Survey Study

Sep 1, 2022
WHAT THIS MEANS FOR YOU: Surveys with 673 caregivers from Western Canada found that concerns about residents' depressed mood, loneliness, and anxiety doubled three months after the COVID-19 pandemic started, compared with three months before the pandemic. Factors that may alleviate concerns in the future include improving residents' access to counseling services and better informing caregivers about resident care.

Caregivers’ Concerns about Assisted Living Residents’ Mental Health during the COVID-19 Pandemic: A Cross-Sectional Survey Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Surveys with 673 caregivers from Western Canada found that concerns about residents’ depressed mood, loneliness, and anxiety doubled three months after the COVID-19 pandemic started, compared with three months before the pandemic. Factors that may alleviate concerns in the future include improving residents’ access to counseling services and better informing caregivers about resident care.

Recommendations for Medical and Mental Health Care in Assisted Living Based on an Expert Delphi Consensus Panel

Sep 1, 2022
Importance: Assisted living (AL) is the largest provider of residential long-term care in the US, and the morbidity of AL residents has been rising. However, AL is not a health care setting, and concern has been growing about residents’ medical and mental health needs. No guidance exists to inform this care. Objective: To identify consensus […]

Recommendations for Medical and Mental Health Care in Assisted Living Based on an Expert Delphi Consensus Panel

by Lea Efird-Green

Importance: Assisted living (AL) is the largest provider of residential long-term care in the US, and the morbidity of AL residents has been rising. However, AL is not a health care setting, and concern has been growing about residents’ medical and mental health needs. No guidance exists to inform this care. Objective: To identify consensus […]

Depression within the First Year of Relocation to Residential Care/Assisted Living: Where You Come From Matters

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Data from a national survey of 2,651 assisted living residents found that approximately 35% moved to assisted living from an acute/post-acute facility; they were more likely to have depression compared to those moving from community-based residences.

Depression within the First Year of Relocation to Residential Care/Assisted Living: Where You Come From Matters

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Data from a national survey of 2,651 assisted living residents found that approximately 35% moved to assisted living from an acute/post-acute facility; they were more likely to have depression compared to those moving from community-based residences.

A Home, an Institution and a Community – Frames of Social Relationships and Interaction in Assisted Living

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Through qualitative observations of an AL community and interviews with ten residents, those who perceived the assisted living community as a home reported more meaningful, informal relationships. When the community was perceived as an institution, residents reported impersonal, formal interactions.

A Home, an Institution and a Community – Frames of Social Relationships and Interaction in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Through qualitative observations of an AL community and interviews with ten residents, those who perceived the assisted living community as a home reported more meaningful, informal relationships. When the community was perceived as an institution, residents reported impersonal, formal interactions.

Prevalence and Correlates of Anxiety and Depression in Caregivers to Assisted Living Residents during COVID-19: A Cross-Sectional Study

Aug 1, 2022
WHAT THIS MEANS FOR YOU: A study of 673 family and friend caregivers of residents in AL from two Canadian provinces from Oct 2020 – Mar 2021 found that 29% had clinically significant anxiety and 39% had clinically significant depression. Caregivers who faced personal stressors such as health issues, reduced income, and lack of social support, along with concerns about residents due to COVID-19, were more likely to experience anxiety and depression. Healthcare providers and assisted living staff should be aware of caregivers' mental health challenges during public health crises and provide appropriate screening and support.

Prevalence and Correlates of Anxiety and Depression in Caregivers to Assisted Living Residents during COVID-19: A Cross-Sectional Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A study of 673 family and friend caregivers of residents in AL from two Canadian provinces from Oct 2020 – Mar 2021 found that 29% had clinically significant anxiety and 39% had clinically significant depression. Caregivers who faced personal stressors such as health issues, reduced income, and lack of social support, along with concerns about residents due to COVID-19, were more likely to experience anxiety and depression. Healthcare providers and assisted living staff should be aware of caregivers’ mental health challenges during public health crises and provide appropriate screening and support.

Interactions, Relationships and Belonging: Comparing Social Connectedness and Perceived Isolation among Older Women Living Alone in Private Homes and in Assisted Living

Jul 1, 2022
WHAT THIS MEANS FOR YOU: This qualitative study of social connections among 16 women aged 75 and older found that those living in the community focus on feeling connected to the world at large, while those in assisted living have more casual interactions and feel like they are a part of the community. Most women in both groups did not experience perceived isolation; they had adjusted their expectations about socializing to fit their living situation.

Interactions, Relationships and Belonging: Comparing Social Connectedness and Perceived Isolation among Older Women Living Alone in Private Homes and in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This qualitative study of social connections among 16 women aged 75 and older found that those living in the community focus on feeling connected to the world at large, while those in assisted living have more casual interactions and feel like they are a part of the community. Most women in both groups did not experience perceived isolation; they had adjusted their expectations about socializing to fit their living situation.