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.

Staff/Staffing

CEAL@UNC Guest Columns: McKnight’s Senior Living

May 4, 2026
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

CEAL@UNC Strategic Advisor Presentations

Feb 19, 2026
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

Exploring Safety Concerns in Assisted Living Communities: A Qualitative Comparison of Resident, Family, and Staff Perspectives

Dec 1, 2025
Objectives: Safety concerns in assisted living (AL) communities are critical, yet understudied from the perspectives of residents, family caregivers, and staff. This study aimed to explore and compare safety concerns across these 3 groups. Design: This qualitative study conducted structured interviews to identify safety concerns from the perspectives of residents, family caregivers, and staff. Setting […]

Exploring Safety Concerns in Assisted Living Communities: A Qualitative Comparison of Resident, Family, and Staff Perspectives

by Lea Efird-Green

Objectives: Safety concerns in assisted living (AL) communities are critical, yet understudied from the perspectives of residents, family caregivers, and staff. This study aimed to explore and compare safety concerns across these 3 groups. Design: This qualitative study conducted structured interviews to identify safety concerns from the perspectives of residents, family caregivers, and staff. Setting […]

Vaccination Rates Among Long-Term Care Staff During the COVID-19 Pandemic

Dec 1, 2025
Objective: The COVID-19 pandemic had a profound impact on long-term care facilities, particularly nursing homes and assisted living communities (ALCs), leading to high mortality rates among residents. Vaccination of residents and staff in long-term care mitigated virus spread. However, we know little about vaccine uptake in assisted living compared with the nursing home setting. The […]

Vaccination Rates Among Long-Term Care Staff During the COVID-19 Pandemic

by Lea Efird-Green

Objective: The COVID-19 pandemic had a profound impact on long-term care facilities, particularly nursing homes and assisted living communities (ALCs), leading to high mortality rates among residents. Vaccination of residents and staff in long-term care mitigated virus spread. However, we know little about vaccine uptake in assisted living compared with the nursing home setting. The […]

End-of-Life Outcomes and Staff Visits for Hospice Recipients Residing in Assisted Living

Dec 1, 2025
Objectives: To examine (1) whether hospice staff visits are associated with end-of-life (EOL) transitions, place of death (POD), and live discharges among assisted living (AL) residents, and (2) whether state AL regulations on staffing and medication administration influence these outcomes. We hypothesized that more frequent staff visits and specific regulatory provisions would be associated with […]

End-of-Life Outcomes and Staff Visits for Hospice Recipients Residing in Assisted Living

by Lea Efird-Green

Objectives: To examine (1) whether hospice staff visits are associated with end-of-life (EOL) transitions, place of death (POD), and live discharges among assisted living (AL) residents, and (2) whether state AL regulations on staffing and medication administration influence these outcomes. We hypothesized that more frequent staff visits and specific regulatory provisions would be associated with […]

Personal Care Aide Staffing in U.S. Residential Care Communities: The Role of Aide Training Hours, Training Reimbursement, and Organizational Structures

Dec 1, 2025
Residential care communities (RCCs) employ nearly 660,000 personal care aides but few studies have examined personal care aide staffing nationwide. This study examines RCC characteristics associated with aide hours per resident day. We used the 2022 National Post-acute and Long-term Care Study to analyze variables of interest without missing data (n = 518) and produced […]

Personal Care Aide Staffing in U.S. Residential Care Communities: The Role of Aide Training Hours, Training Reimbursement, and Organizational Structures

by Lea Efird-Green

Residential care communities (RCCs) employ nearly 660,000 personal care aides but few studies have examined personal care aide staffing nationwide. This study examines RCC characteristics associated with aide hours per resident day. We used the 2022 National Post-acute and Long-term Care Study to analyze variables of interest without missing data (n = 518) and produced […]

The National Dementia Workforce Study: The Plan for Organization Sample Frames and Data Collection

Nov 1, 2025
The National Dementia Workforce Study was designed to improve our understanding of the individuals and systems who care for people with dementia, but designing and implementing such a study is challenging due to the large number of patient care organizations, clinical and direct care roles, and locations in which care is provided. Specifically, developing a […]

The National Dementia Workforce Study: The Plan for Organization Sample Frames and Data Collection

by Lea Efird-Green

The National Dementia Workforce Study was designed to improve our understanding of the individuals and systems who care for people with dementia, but designing and implementing such a study is challenging due to the large number of patient care organizations, clinical and direct care roles, and locations in which care is provided. Specifically, developing a […]

The National Dementia Workforce Study: Development of Questionnaires for Home Care, Assisted Living, and Nursing Home Settings

Nov 1, 2025
The growing aging population and rising prevalence of dementia are driving increased demand for long-term care services and supports in the United States. People with dementia require substantial support and care, often from direct care workers in private homes, assisted living communities, and nursing homes. Despite their crucial role, these workers receive highly variable training, […]

The National Dementia Workforce Study: Development of Questionnaires for Home Care, Assisted Living, and Nursing Home Settings

by Lea Efird-Green

The growing aging population and rising prevalence of dementia are driving increased demand for long-term care services and supports in the United States. People with dementia require substantial support and care, often from direct care workers in private homes, assisted living communities, and nursing homes. Despite their crucial role, these workers receive highly variable training, […]

The National Dementia Workforce Study: Perspective From the National Institute on Aging

Nov 1, 2025
As the population of individuals living with Alzheimer’s disease and related dementias (AD/ADRD) continues to grow, so does the need for a well-prepared and stable dementia care workforce. The National Dementia Workforce Study (NDWS) represents a significant investment to understand the demographics, experiences, and magnitude and scope of challenges faced by the professional and direct […]

The National Dementia Workforce Study: Perspective From the National Institute on Aging

by Lea Efird-Green

As the population of individuals living with Alzheimer’s disease and related dementias (AD/ADRD) continues to grow, so does the need for a well-prepared and stable dementia care workforce. The National Dementia Workforce Study (NDWS) represents a significant investment to understand the demographics, experiences, and magnitude and scope of challenges faced by the professional and direct […]

Developing and Implementing an Intervention to Increase Immunization Coverage Among Frontline Long-Term Care Staff

Sep 1, 2025
In the years following the COVID-19 pandemic, immunization coverage has declined among frontline post-acute and long-term care (PALTC) staff, such as nurses, certified nursing assistants, and kitchen staff. We took a novel approach to addressing these declines by engaging frontline staff in design of immunization-focused professional development by surveying a convenience sample of 200 frontline […]

Developing and Implementing an Intervention to Increase Immunization Coverage Among Frontline Long-Term Care Staff

by Lea Efird-Green

In the years following the COVID-19 pandemic, immunization coverage has declined among frontline post-acute and long-term care (PALTC) staff, such as nurses, certified nursing assistants, and kitchen staff. We took a novel approach to addressing these declines by engaging frontline staff in design of immunization-focused professional development by surveying a convenience sample of 200 frontline […]

Staff Satisfaction and Burnout in Assisted Living and Validity of the DCW Job Satisfaction Scale

Sep 1, 2025
Objectives: Professional caregivers (ie, direct care workers) provide the majority of support for long-term care residents. Unfortunately, they have consistently high turnover, which is associated with low job satisfaction and decreased care quality. Most research on this topic has been conducted in nursing homes; in contrast, this study investigated relationships between staff satisfaction, burnout, and […]

Staff Satisfaction and Burnout in Assisted Living and Validity of the DCW Job Satisfaction Scale

by Lea Efird-Green

Objectives: Professional caregivers (ie, direct care workers) provide the majority of support for long-term care residents. Unfortunately, they have consistently high turnover, which is associated with low job satisfaction and decreased care quality. Most research on this topic has been conducted in nursing homes; in contrast, this study investigated relationships between staff satisfaction, burnout, and […]

Collecting, Sharing, and Using Information for Person-Centered Dementia Care: Perspectives of Residents, Care Partners, and Staff in Low-Resource Long-Term Care Settings

Aug 1, 2025
This study explored stakeholder perspectives on how information is collected, shared, and used to support person-centered dementia care in low-resource long-term care settings. This qualitative study was conducted in four long-term care settings situated in federally designated medically underserved areas (two rural, two urban). In-depth semi-structured interviews were conducted with administrative leaders (n = 7), […]

Collecting, Sharing, and Using Information for Person-Centered Dementia Care: Perspectives of Residents, Care Partners, and Staff in Low-Resource Long-Term Care Settings

by Lea Efird-Green

This study explored stakeholder perspectives on how information is collected, shared, and used to support person-centered dementia care in low-resource long-term care settings. This qualitative study was conducted in four long-term care settings situated in federally designated medically underserved areas (two rural, two urban). In-depth semi-structured interviews were conducted with administrative leaders (n = 7), […]

Anxiety Among Workers in Institutions for Older Adults During the COVID-19 Pandemic

Aug 1, 2025
Objective: The present study examined the factors that predict anxiety in workers of institutions for older adults in Puerto Rico during the COVID-19 pandemic. Methods: Nine hundred nursing home and assisted living workers were assessed via self-administered questionnaires. Data were collected online from October 2020 to February 2021, during Puerto Rico’s third COVID-19 wave peak. […]

Anxiety Among Workers in Institutions for Older Adults During the COVID-19 Pandemic

by Lea Efird-Green

Objective: The present study examined the factors that predict anxiety in workers of institutions for older adults in Puerto Rico during the COVID-19 pandemic. Methods: Nine hundred nursing home and assisted living workers were assessed via self-administered questionnaires. Data were collected online from October 2020 to February 2021, during Puerto Rico’s third COVID-19 wave peak. […]

Care Refusal by Older Adults With Dementia Receiving Professional Care: A Scoping Review

Jul 1, 2025
Care refusal behaviors by institutionalized older adults with dementia pose significant challenges for professional caregivers in residential care settings. This scoping review mapped the determinants and effects of care refusal in this population. A systematic search of five databases identified 19 studies published between 2013 and 2023. The findings indicated that personal, relational, environmental, and […]

Care Refusal by Older Adults With Dementia Receiving Professional Care: A Scoping Review

by Lea Efird-Green

Care refusal behaviors by institutionalized older adults with dementia pose significant challenges for professional caregivers in residential care settings. This scoping review mapped the determinants and effects of care refusal in this population. A systematic search of five databases identified 19 studies published between 2013 and 2023. The findings indicated that personal, relational, environmental, and […]

Teamwork and Use of Teams in Services for Older People: A Qualitative Study of Finnish Nurse Managers’ Experiences

Jul 1, 2025
Background: In Finnish services for older people, teams (a permanent group with a common task, divided for example by geographical or spatial criteria) have been implemented with the goal of improving the quality of care, individualized care and continuity of care as well as the wellbeing of nurses. Our aim was to describe nurse managers’ […]

Teamwork and Use of Teams in Services for Older People: A Qualitative Study of Finnish Nurse Managers’ Experiences

by Lea Efird-Green

Background: In Finnish services for older people, teams (a permanent group with a common task, divided for example by geographical or spatial criteria) have been implemented with the goal of improving the quality of care, individualized care and continuity of care as well as the wellbeing of nurses. Our aim was to describe nurse managers’ […]

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.

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.

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.

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.