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.

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CEAL@UNC Strategic Advisor Presentations

Nov 24, 2025
CEAL@UNC regularly invites organizations and individuals committed to advancing well-being in assisted living through practice, research, and policy to present emerging and relevant topics to its Strategic Advisors. View Presentations

CEAL@UNC Strategic Advisor Presentations

by Lea Efird-Green

CEAL@UNC regularly invites organizations and individuals committed to advancing well-being in assisted living through practice, research, and policy to present emerging and relevant topics to its Strategic Advisors. View Presentations

From Nursing Homes to Home Care: Examining the Impact of the COVID-19 Pandemic on Direct Care Worker Transitions

Jun 1, 2025
WHAT THIS MEANS FOR YOU: This study examined over 8,000 direct care workers employed in residential or long-term care (LTC) communities from 2016-2018 and from 2020-2022 to examine workers' exits from LTC settings and if hazard pay mediated the impact of the pandemic. Worker exits were highest in 2020, but in 2021-2022, worker exits decreased relative to prepandemic numbers, and if workers did switch jobs, they were more likely to remain in healthcare relative to prepandemic. Hazard pay or other wage support policies did not have an effect on worker decisions to exit LTC during or after the pandemic.

From Nursing Homes to Home Care: Examining the Impact of the COVID-19 Pandemic on Direct Care Worker Transitions

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined over 8,000 direct care workers employed in residential or long-term care (LTC) communities from 2016-2018 and from 2020-2022 to examine workers’ exits from LTC settings and if hazard pay mediated the impact of the pandemic. Worker exits were highest in 2020, but in 2021-2022, worker exits decreased relative to prepandemic numbers, and if workers did switch jobs, they were more likely to remain in healthcare relative to prepandemic. Hazard pay or other wage support policies did not have an effect on worker decisions to exit LTC during or after the pandemic.

Differences in Quality of Care Interactions Across Care Tasks in Assisted Living

May 1, 2025
WHAT THIS MEANS FOR YOU: This descriptive study of four assisted living communities in Maryland examined 152 staff-resident interactions to understand if quality of care interactions differs by care task type. Different categories of care interactions were identified with positive care interactions being the most common (36%), and supportive care being the most common type of task (34%). Supportive/ambulatory care (i.e., distracting, transferring, and walking) interactions were more negative than intimate personal care (i.e., bathing, dressing, and toileting) interactions, suggesting improvements in care interaction quality may be needed for supportive care.

Differences in Quality of Care Interactions Across Care Tasks in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This descriptive study of four assisted living communities in Maryland examined 152 staff-resident interactions to understand if quality of care interactions differs by care task type. Different categories of care interactions were identified with positive care interactions being the most common (36%), and supportive care being the most common type of task (34%). Supportive/ambulatory care (i.e., distracting, transferring, and walking) interactions were more negative than intimate personal care (i.e., bathing, dressing, and toileting) interactions, suggesting improvements in care interaction quality may be needed for supportive care.

Trends in the Use of Medicare Home Health Care among Congregate Living Residents

Apr 1, 2025
WHAT THIS MEANS FOR YOU: This cohort study examined trends in home health care (HHC) of nearly 10 million Medicare patients across congregate and non-congregate care settings between 2014-2019. Of all HHC episodes, 15.9% happened in congregate care, and traditional Medicare beneficiaries in congregate care used HHC more frequently and were more likely to use high-quality agencies than those in other settings. However, dual-eligible and minoritized populations were less likely to receive high quality HHC services.

Trends in the Use of Medicare Home Health Care among Congregate Living Residents

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This cohort study examined trends in home health care (HHC) of nearly 10 million Medicare patients across congregate and non-congregate care settings between 2014-2019. Of all HHC episodes, 15.9% happened in congregate care, and traditional Medicare beneficiaries in congregate care used HHC more frequently and were more likely to use high-quality agencies than those in other settings. However, dual-eligible and minoritized populations were less likely to receive high quality HHC services.

Understanding the Experience of Employees in Assisted Living Facilities during the COVID-19 Pandemic: A Qualitative Case Study

Apr 1, 2025
WHAT THIS MEANS FOR YOU: This study involved interviews with 29 employees at an assisted living community in Oregon to assess challenges employees faced during the pandemic. The main theme that emerged was staff's need to balance "policing" residents, their families, and themselves to comply with state COVID-19-related policies, although this was often counter to their training. This issue often led to increased stress for employees, highlighting the need for policies that support AL staff during emergencies.

Understanding the Experience of Employees in Assisted Living Facilities during the COVID-19 Pandemic: A Qualitative Case Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study involved interviews with 29 employees at an assisted living community in Oregon to assess challenges employees faced during the pandemic. The main theme that emerged was staff’s need to balance “policing” residents, their families, and themselves to comply with state COVID-19-related policies, although this was often counter to their training. This issue often led to increased stress for employees, highlighting the need for policies that support AL staff during emergencies.

CEAL@UNC Guest Columns: McKnight’s Senior Living

Feb 3, 2025
Dr. Sheryl Zimmerman, Executive Director of CEAL@UNC, is a guest columnist for McKnight’s Senior Living. These regularly published articles reflect the perspectives of CEAL@UNC advisors, and address timely topics relevant to the well-being of the people who live and work in assisted living. View Articles

CEAL@UNC Guest Columns: McKnight’s Senior Living

by Lea Efird-Green

Dr. Sheryl Zimmerman, Executive Director of CEAL@UNC, is a guest columnist for McKnight’s Senior Living. These regularly published articles reflect the perspectives of CEAL@UNC advisors, and address timely topics relevant to the well-being of the people who live and work in assisted living. View Articles

Current State of Healthcare Robots for Older Adults in Care Facilities in Japan and the Related Ethical Issues for Nurses

Feb 1, 2025
WHAT THIS MEANS FOR YOU: This review of healthcare robots in Japan examined their introduction from a nursing ethics perspective. Healthcare robots have the potential to help staff with tasks, but ethical concerns need to be considered and weighed against the six principles of nursing ethics. Patients' rights and are the most important thing for nurses to consider when working with healthcare robots.

Current State of Healthcare Robots for Older Adults in Care Facilities in Japan and the Related Ethical Issues for Nurses

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This review of healthcare robots in Japan examined their introduction from a nursing ethics perspective. Healthcare robots have the potential to help staff with tasks, but ethical concerns need to be considered and weighed against the six principles of nursing ethics. Patients’ rights and are the most important thing for nurses to consider when working with healthcare robots.

Assisted Living, Residential Care, and Memory Care Staffing Level Dynamics: Oregon, 2017-2023

Jan 1, 2025
WHAT THIS MEANS FOR YOU: This longitudinal study examined staffing levels, as measured by care hours per resident per day, from 535 long-term care communities in Oregon between 2017-2023. There was an increase in staff immediately after the pandemic and staffing levels were, on average, 28 minutes higher in 2023 than 2017. However, there was significant variation among AL communities' staffing levels, likely due to organizational-level factors like resource allocation, resident case mix, and operational structures.

Assisted Living, Residential Care, and Memory Care Staffing Level Dynamics: Oregon, 2017-2023

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This longitudinal study examined staffing levels, as measured by care hours per resident per day, from 535 long-term care communities in Oregon between 2017-2023. There was an increase in staff immediately after the pandemic and staffing levels were, on average, 28 minutes higher in 2023 than 2017. However, there was significant variation among AL communities’ staffing levels, likely due to organizational-level factors like resource allocation, resident case mix, and operational structures.

Measurement of Quality in Assisted Living in the United States of America: A Scoping Review

Jan 1, 2025
WHAT THIS MEANS FOR YOU: This scoping review examined 49 peer-reviewed and 45 gray literature articles from 2009-2019 to assess approaches to, and indicators of, quality in assisted living. After thematic analysis, nine domains emerged, with resident qualiy of life and satisfaction being the most prioritized. These nine domains may help inform future standardized quality measurement for AL settings.

Measurement of Quality in Assisted Living in the United States of America: A Scoping Review

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This scoping review examined 49 peer-reviewed and 45 gray literature articles from 2009-2019 to assess approaches to, and indicators of, quality in assisted living. After thematic analysis, nine domains emerged, with resident qualiy of life and satisfaction being the most prioritized. These nine domains may help inform future standardized quality measurement for AL settings.

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
WHAT THIS MEANS FOR YOU: This cross-sectional study used questionnaire data from 391 professional caregivers from 13 facilities in 3 states to examine coping and its relationship with demographic characteristics of direct caregivers in long-term care. Older staff used adaptive psychological strategies more than younger staff, and traditionally minoritized staff used more adaptive and less maladaptive psychological strategies than white staff. Using avoidance and maladaptive coping strategies was associated with depressive and anxiety symptoms, as well as burnout. Professional caregivers use a variety of coping mechanisms, and training on adaptive coping could improve outcomes for this population.

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

WHAT THIS MEANS FOR YOU: This cross-sectional study used questionnaire data from 391 professional caregivers from 13 facilities in 3 states to examine coping and its relationship with demographic characteristics of direct caregivers in long-term care. Older staff used adaptive psychological strategies more than younger staff, and traditionally minoritized staff used more adaptive and less maladaptive psychological strategies than white staff. Using avoidance and maladaptive coping strategies was associated with depressive and anxiety symptoms, as well as burnout. Professional caregivers use a variety of coping mechanisms, and training on adaptive coping could improve outcomes for this population.

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

Dec 1, 2024
WHAT THIS MEANS FOR YOU: This study developed a new measure for how professional caregivers cope with stress. Data was collected from 391 caregivers in 13 long-term care communities across 3 states using the Long-Term Care Cope instrument. Coping strategies were found to be highly individual with many reporting using multiple strategies. Further testing of the scale is needed to understand and narrow the items in the subcomponents.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study developed a new measure for how professional caregivers cope with stress. Data was collected from 391 caregivers in 13 long-term care communities across 3 states using the Long-Term Care Cope instrument. Coping strategies were found to be highly individual with many reporting using multiple strategies. Further testing of the scale is needed to understand and narrow the items in the subcomponents.

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
WHAT THIS MEANS FOR YOU: This study examined 503 nurses from 44 AL communities in Finland to examine the relationship between workday characteristics and perceived stress and time pressure. More care task events, clients with greater needs, reduced break times, and disruptions during the day were related to stress and time pressure for staff. Findings indicate that dividing workload evenly among nursing teams can help reduce stress and time pressure.

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

WHAT THIS MEANS FOR YOU: This study examined 503 nurses from 44 AL communities in Finland to examine the relationship between workday characteristics and perceived stress and time pressure. More care task events, clients with greater needs, reduced break times, and disruptions during the day were related to stress and time pressure for staff. Findings indicate that dividing workload evenly among nursing teams can help reduce stress and time pressure.

Staffing Patterns in Nursing Homes, Assisted Living Communities, and Memory Care Units: Variation Across Shifts

Nov 1, 2024
WHAT THIS MEANS FOR YOU: This study used observational data from 678 nursing staff at NHs and 432 nursing staff at AL communities in Ohio to assess their direct care nursing staffing patterns. Both NHs and AL communities had better daytime staffing ratios than overnights, although NH staffing ratios were superior to those in AL communities. In AL and NH memory care units, staffing patterns were similar. As acuity increases in AL communities, more nursing staff will likely be required, especially on overnight shifts.

Staffing Patterns in Nursing Homes, Assisted Living Communities, and Memory Care Units: Variation Across Shifts

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study used observational data from 678 nursing staff at NHs and 432 nursing staff at AL communities in Ohio to assess their direct care nursing staffing patterns. Both NHs and AL communities had better daytime staffing ratios than overnights, although NH staffing ratios were superior to those in AL communities. In AL and NH memory care units, staffing patterns were similar. As acuity increases in AL communities, more nursing staff will likely be required, especially on overnight shifts.

Health of the Pandemic: Dementia Paid Staff and Unpaid Caregiver Workforce in Congregate Care and Community Settings

Oct 1, 2024
WHAT THIS MEANS FOR YOU: This study used questionnaires to capture the experiences of 182 paid staff and 148 unpaid caregivers of people living with dementia living in the community and long-term care settings across the US during theCOVID-19 pandemic. Paid staff were more likely to have been exposed, tested, hospitalized, or been ill with COVID-19 and had more medical and mental health services impacts than unpaid caregivers. Unpaid caregivers showed higher rates of depressive symptom severity and scored lower for hope than paid staff, showing disparate negative impacts from COVID-related stressors.

Health of the Pandemic: Dementia Paid Staff and Unpaid Caregiver Workforce in Congregate Care and Community Settings

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study used questionnaires to capture the experiences of 182 paid staff and 148 unpaid caregivers of people living with dementia living in the community and long-term care settings across the US during theCOVID-19 pandemic. Paid staff were more likely to have been exposed, tested, hospitalized, or been ill with COVID-19 and had more medical and mental health services impacts than unpaid caregivers. Unpaid caregivers showed higher rates of depressive symptom severity and scored lower for hope than paid staff, showing disparate negative impacts from COVID-related stressors.

An Initial Exploration into Job Satisfaction Among Long-Term Care Administrators and State Tested Nursing Assistants in Ohio

Oct 1, 2024
WHAT THIS MEANS FOR YOU: This pilot study used 2 surveys to examine 28 licensed nursing home administrators' and 17 state-tested nursing assistants' opinions on job satisfaction, future plans, potential changes, and how to reduce turnover in Ohio. Working with residents and families contributed to satisfaction, but wages were a concern, and many employees face burnout. These factors should be addressed in order to address turnover and staffing shortages in long-term care settings.

An Initial Exploration into Job Satisfaction Among Long-Term Care Administrators and State Tested Nursing Assistants in Ohio

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This pilot study used 2 surveys to examine 28 licensed nursing home administrators’ and 17 state-tested nursing assistants’ opinions on job satisfaction, future plans, potential changes, and how to reduce turnover in Ohio. Working with residents and families contributed to satisfaction, but wages were a concern, and many employees face burnout. These factors should be addressed in order to address turnover and staffing shortages in long-term care settings.

Determinants of Received Care Time among Finnish Home Care Clients and Assisted Living Facility Residents: A Time-Motion Study

Sep 1, 2024
WHAT THIS MEANS FOR YOU: This cross-sectional observational study examined individual and organizational factors associated with received care time for 1477 home care clients and 1538 residents from 61 AL care units in Finland. Physical functioning associated with activities of daily living was the highest predictor of care time in both settings. In home care greater pain, unstable health, and care team autonomy were associated with more care time, whereas depressive mood and higher staffing ratios were associated in AL care units.

Determinants of Received Care Time among Finnish Home Care Clients and Assisted Living Facility Residents: A Time-Motion Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This cross-sectional observational study examined individual and organizational factors associated with received care time for 1477 home care clients and 1538 residents from 61 AL care units in Finland. Physical functioning associated with activities of daily living was the highest predictor of care time in both settings. In home care greater pain, unstable health, and care team autonomy were associated with more care time, whereas depressive mood and higher staffing ratios were associated in AL care units.

Nursing Staff’s Perspectives of Care Robots for Assisted Living Facilities: Systematic Literature Review

Sep 1, 2024
WHAT THIS MEANS FOR YOU: This systematic review examined the results of 15 studies about nurses' attitudes toward care robots in assisted living communities. The studies were conducted with small sample sizes, and there were concerns from nurses regarding ethics, safety, accessibility, and Overall, nurses supported care robots for assisting with physical tasks and reducing workload, but were mixed about whether they should help with social tasks.

Nursing Staff’s Perspectives of Care Robots for Assisted Living Facilities: Systematic Literature Review

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This systematic review examined the results of 15 studies about nurses’ attitudes toward care robots in assisted living communities. The studies were conducted with small sample sizes, and there were concerns from nurses regarding ethics, safety, accessibility, and Overall, nurses supported care robots for assisting with physical tasks and reducing workload, but were mixed about whether they should help with social tasks.

Reliability and Validity Testing of the Modified Quality of Interaction Scale

Sep 1, 2024
WHAT THIS MEANS FOR YOU: This study used observational data from 152 staff-resident interactions in 4 AL communities to test the reliability and validity of the Modified Quality of Interaction Scale. There was some evidence for both reliability and validity, as resident engagement was significantly associated with positive social and care interactions, but reliability and validity were not comprehensively supported in this setting.

Reliability and Validity Testing of the Modified Quality of Interaction Scale

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study used observational data from 152 staff-resident interactions in 4 AL communities to test the reliability and validity of the Modified Quality of Interaction Scale. There was some evidence for both reliability and validity, as resident engagement was significantly associated with positive social and care interactions, but reliability and validity were not comprehensively supported in this setting.

Impact of Antecedent and Organizational Differences on Nurse-Social Worker Collaboration in a Retirement and Assisted Living Community with Skilled Nursing Care

Aug 1, 2024
WHAT THIS MEANS FOR YOU: This qualitative thematic study of 23 workers at a Midwestern AL community explored nurses' and social workers' collaborative experiences. Contrasts arose in responding to resident complexity and peer-to-peer work, with a main difference being social workers' focus on resident self-determination and nurses' focus on resident safety. Social workers showed greater openness to working with nurses while nurses showed greater separation, which has implications for teamwork in these settings.

Impact of Antecedent and Organizational Differences on Nurse-Social Worker Collaboration in a Retirement and Assisted Living Community with Skilled Nursing Care

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This qualitative thematic study of 23 workers at a Midwestern AL community explored nurses’ and social workers’ collaborative experiences. Contrasts arose in responding to resident complexity and peer-to-peer work, with a main difference being social workers’ focus on resident self-determination and nurses’ focus on resident safety. Social workers showed greater openness to working with nurses while nurses showed greater separation, which has implications for teamwork in these settings.

A Cross-Sectional Study of Nurse Turnover in Residential Care Communities

Aug 1, 2024
WHAT THIS MEANS FOR YOU: This cross-sectional study examined 2018 public data of RNs and aides in residential care communities (RCCs) to examine factors related to turnover. On average, RN turnover was 72% and aide turnover was 48%. Non-profit RCCs had lower turnover and chain facilities had higher turnover. Contrary to predictions, large RCCs had lower turnover rates.

A Cross-Sectional Study of Nurse Turnover in Residential Care Communities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This cross-sectional study examined 2018 public data of RNs and aides in residential care communities (RCCs) to examine factors related to turnover. On average, RN turnover was 72% and aide turnover was 48%. Non-profit RCCs had lower turnover and chain facilities had higher turnover. Contrary to predictions, large RCCs had lower turnover rates.

Adaptive Biking for Assisted Living Memory Care Residents and Staff: A Feasibility Study

Aug 1, 2024
WHAT THIS MEANS FOR YOU: This study paired 8 memory care residents and 7 staff members from an AL community to test a biking program as an intervention to improve health and well-being. The pairs completed eight 20-30 minute bike rides over 4 weeks. The rides gave residents and staff a chance to discuss issues around health and well-being. Qualitative results indicate further piloting of the program could be warranted given its acceptability and feasibility.

Adaptive Biking for Assisted Living Memory Care Residents and Staff: A Feasibility Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study paired 8 memory care residents and 7 staff members from an AL community to test a biking program as an intervention to improve health and well-being. The pairs completed eight 20-30 minute bike rides over 4 weeks. The rides gave residents and staff a chance to discuss issues around health and well-being. Qualitative results indicate further piloting of the program could be warranted given its acceptability and feasibility.

The Prevalence and Benefits of Self-Compassion Among Professional Caregivers

Aug 1, 2024
WHAT THIS MEANS FOR YOU: This cross-sectional study examined the relationship between self-compassion, anxiety and depressive symptoms, and job satisfaction from 391 caregivers across 13 nursing homes and assisted living communities in 3 states. Older caregivers, those with higher education, and those who were born outside the US reported highest self-compassion, while white caregivers reported the lowest. Self-compassion was negatively associated with mental health symptoms and positively associated with job satisfaction, meaning that its use could be beneficial as one method to address workforce issues in long-term care.

The Prevalence and Benefits of Self-Compassion Among Professional Caregivers

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This cross-sectional study examined the relationship between self-compassion, anxiety and depressive symptoms, and job satisfaction from 391 caregivers across 13 nursing homes and assisted living communities in 3 states. Older caregivers, those with higher education, and those who were born outside the US reported highest self-compassion, while white caregivers reported the lowest. Self-compassion was negatively associated with mental health symptoms and positively associated with job satisfaction, meaning that its use could be beneficial as one method to address workforce issues in long-term care.

Assessing the Potential of Technology to Describe Resident and Staff Interactions in Assisted Living Facilities

Jul 1, 2024
WHAT THIS MEANS FOR YOU: This study examined 83 staff at an AL community in New York using a remote surveillance technology to assess nurse-resident interactions and improve falls prevention over 170 days. Data showed that staff visited residents an average of 20.7 times a day. As compared to traditional in-person methods, staff responded faster through the app (2.7 minutes via app vs. 3.3 minutes via in-person call requests) to urgent alerts.

Assessing the Potential of Technology to Describe Resident and Staff Interactions in Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined 83 staff at an AL community in New York using a remote surveillance technology to assess nurse-resident interactions and improve falls prevention over 170 days. Data showed that staff visited residents an average of 20.7 times a day. As compared to traditional in-person methods, staff responded faster through the app (2.7 minutes via app vs. 3.3 minutes via in-person call requests) to urgent alerts.

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 […]