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

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

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 […]

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

Nov 1, 2024
Objectives To assess the staffing patterns of direct care nursing staff by shift in nursing homes (NHs), assisted living communities (ALCs), and their corresponding memory care units (MCUs). Design Observational study of the 2021 Ohio Biennial Survey of Long-Term Care Facilities and the Payroll-Based Journal data for December 2021. Setting and Participants NHs (n = 678) and […]

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

by Lea Efird-Green

Objectives To assess the staffing patterns of direct care nursing staff by shift in nursing homes (NHs), assisted living communities (ALCs), and their corresponding memory care units (MCUs). Design Observational study of the 2021 Ohio Biennial Survey of Long-Term Care Facilities and the Payroll-Based Journal data for December 2021. Setting and Participants NHs (n = 678) and […]

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

Oct 1, 2024
Objectives The objective of this study was to assess the impact of the pandemic on the health, well-being, and access to services of paid staff and unpaid caregivers of persons living with dementia. Design Questionnaires were developed to capture the experiences of paid staff and unpaid caregivers throughout the pandemic, leveraging a pre-existing clinical trial […]

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

by Lea Efird-Green

Objectives The objective of this study was to assess the impact of the pandemic on the health, well-being, and access to services of paid staff and unpaid caregivers of persons living with dementia. Design Questionnaires were developed to capture the experiences of paid staff and unpaid caregivers throughout the pandemic, leveraging a pre-existing clinical trial […]

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

Oct 1, 2024
This pilot study examines Ohio’s licensed nursing home administrators and state tested nursing assistant’s perspectives about job satisfaction, future career and employment plans, potential beneficial changes to their organizations, and their thoughts on reducing turnover rates in their field. Ohio Board of Executives of Long-Term Services and Supports provided their contact list of all 1,969 […]

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

by Lea Efird-Green

This pilot study examines Ohio’s licensed nursing home administrators and state tested nursing assistant’s perspectives about job satisfaction, future career and employment plans, potential beneficial changes to their organizations, and their thoughts on reducing turnover rates in their field. Ohio Board of Executives of Long-Term Services and Supports provided their contact list of all 1,969 […]

Managers’ Perspectives on their Role in Implementing Fall Prevention Interventions: A Qualitative Interview Study in Norwegian Homecare Services

Sep 1, 2024
Introduction: The implementation of fall prevention interventions in homecare services is crucial for reducing falls among older adults and effective leadership could determine success. Norwegian homecare services provide home nursing, rehabilitation, and practical assistance, to residents living in private homes or assisted living facilities. This study aims to explore how managers in Norwegian homecare services […]

Managers’ Perspectives on their Role in Implementing Fall Prevention Interventions: A Qualitative Interview Study in Norwegian Homecare Services

by Lea Efird-Green

Introduction: The implementation of fall prevention interventions in homecare services is crucial for reducing falls among older adults and effective leadership could determine success. Norwegian homecare services provide home nursing, rehabilitation, and practical assistance, to residents living in private homes or assisted living facilities. This study aims to explore how managers in Norwegian homecare services […]

Reliability and Validity Testing of the Modified Quality of Interaction Scale

Sep 1, 2024
Background and Purpose: Limited care interaction measurements capture important interaction characteristics that occur during staff-resident care interactions. The purpose of this study was to test the reliability and validity of Modified Quality of Interaction Scale (MQuIS). Methods: Data from an observational study in four assisted living facilities was used. Results: A total of 152 staff-resident […]

Reliability and Validity Testing of the Modified Quality of Interaction Scale

by Lea Efird-Green

Background and Purpose: Limited care interaction measurements capture important interaction characteristics that occur during staff-resident care interactions. The purpose of this study was to test the reliability and validity of Modified Quality of Interaction Scale (MQuIS). Methods: Data from an observational study in four assisted living facilities was used. Results: A total of 152 staff-resident […]

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

Sep 1, 2024
Background Ageing populations and care workforce shortages across Europe are causing challenges for care services for older people. Therefore, it is paramount that limited care resources are allocated optimally, based on the clients’ care needs. Multiple functioning-related factors have been identified that determine the amount of care time clients receive, while organizational and other factors […]

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

by Lea Efird-Green

Background Ageing populations and care workforce shortages across Europe are causing challenges for care services for older people. Therefore, it is paramount that limited care resources are allocated optimally, based on the clients’ care needs. Multiple functioning-related factors have been identified that determine the amount of care time clients receive, while organizational and other factors […]

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

Sep 1, 2024
Background: Care robots have been proposed in response to nursing shortages in assisted living facilities (ALFs) and the growing population of older adults. While the use of care robots may improve the general health and well-being of older adults, their introduction changes the work of nursing staff fundamentally, and it has implications for the entire […]

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

by Lea Efird-Green

Background: Care robots have been proposed in response to nursing shortages in assisted living facilities (ALFs) and the growing population of older adults. While the use of care robots may improve the general health and well-being of older adults, their introduction changes the work of nursing staff fundamentally, and it has implications for the entire […]

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

Aug 1, 2024
This study examined the feasibility of implementing an adaptive biking program to concurrently address health and well-being in assisted living memory care residents and staff. Using an intervention protocol designed around the Flourishing Through Leisure Model, resident and staff participants were matched into biking pairs to engage in eight 20-30 minute bike rides over four […]

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

by Lea Efird-Green

This study examined the feasibility of implementing an adaptive biking program to concurrently address health and well-being in assisted living memory care residents and staff. Using an intervention protocol designed around the Flourishing Through Leisure Model, resident and staff participants were matched into biking pairs to engage in eight 20-30 minute bike rides over four […]

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

Aug 1, 2024
We examine what facility characteristics are associated with nurse turnover in residential care communities (RCCs). This is a cross-sectional study using the 2018 National Study of Long-term Care Provider Public Use File. There were 3331 RCCs (unweighted n = 272) represented when examining registered nurse (RN) turnover and when examining aide turnover there was a […]

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

by Lea Efird-Green

We examine what facility characteristics are associated with nurse turnover in residential care communities (RCCs). This is a cross-sectional study using the 2018 National Study of Long-term Care Provider Public Use File. There were 3331 RCCs (unweighted n = 272) represented when examining registered nurse (RN) turnover and when examining aide turnover there was a […]

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 […]

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
Nurse–social worker collaborative interactions in long-term care settings have received limited attention. This qualitative thematic study of 23 participants (11 social workers and 12 nurses) at an urban retirement and assisted living community explores experiences of collaborative work. Two themes of contrasts in responding to resident complexity and contrasts in peer-to-peer work highlight four subthemes […]

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

Nurse–social worker collaborative interactions in long-term care settings have received limited attention. This qualitative thematic study of 23 participants (11 social workers and 12 nurses) at an urban retirement and assisted living community explores experiences of collaborative work. Two themes of contrasts in responding to resident complexity and contrasts in peer-to-peer work highlight four subthemes […]

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

Jul 1, 2024
PURPOSE: Falls are a significant financial burden and health hazard for residents in assisted living facilities (ALFs). However, limited capacity to observe residents has hindered understanding of resident–staff interactions within rooms. The current study aimed to describe nurse–resident interactions using data from a remote technology combining computer vision and staff location tracking. METHOD: Eighty-three staff […]

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

by Lea Efird-Green

PURPOSE: Falls are a significant financial burden and health hazard for residents in assisted living facilities (ALFs). However, limited capacity to observe residents has hindered understanding of resident–staff interactions within rooms. The current study aimed to describe nurse–resident interactions using data from a remote technology combining computer vision and staff location tracking. METHOD: Eighty-three staff […]

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 […]

Changes in Nursing Staff Levels and Injury-Related Emergency Department Visits among Assisted Living Residents with Alzheimers Disease and Related Dementias

Jun 1, 2024
Objectives To examine the relationship between changes in nursing staff-hours per resident-day and injury-related emergency department (ED) visits among assisted living (AL) residents with Alzheimer disease and related dementias (ADRD). Design Retrospective cohort study. Setting and Participants We leveraged a data set of AL community characteristics in Ohio linked to Medicare claims data from 2007 […]

Changes in Nursing Staff Levels and Injury-Related Emergency Department Visits among Assisted Living Residents with Alzheimers Disease and Related Dementias

by Lea Efird-Green

Objectives To examine the relationship between changes in nursing staff-hours per resident-day and injury-related emergency department (ED) visits among assisted living (AL) residents with Alzheimer disease and related dementias (ADRD). Design Retrospective cohort study. Setting and Participants We leveraged a data set of AL community characteristics in Ohio linked to Medicare claims data from 2007 […]

Does Assisted Living Provide Assistance And Promote Living?

May 1, 2024
Assisted living has promised assistance and quality of living to older adults for more than eighty years. It is the largest residential provider of long-term care in the United States, serving more than 918,000 older adults as of 2018. As assisted living has evolved, the needs of residents have become more challenging; staffing shortages have […]

Does Assisted Living Provide Assistance And Promote Living?

by Lea Efird-Green

Assisted living has promised assistance and quality of living to older adults for more than eighty years. It is the largest residential provider of long-term care in the United States, serving more than 918,000 older adults as of 2018. As assisted living has evolved, the needs of residents have become more challenging; staffing shortages have […]

Potential Actions to Advance Well-being in Assisted Living

Apr 23, 2024
CEAL@UNC recognizes the benefit of ongoing quality improvement in assisted living. Numerous feasible solutions have been suggested that may improve care and outcomes in assisted living, including those in this information sheet. Feel free to utilize and distribute this information sheet among your networks to advance the well-being of the people who live and work […]

Potential Actions to Advance Well-being in Assisted Living

by Lea Efird-Green

CEAL@UNC recognizes the benefit of ongoing quality improvement in assisted living. Numerous feasible solutions have been suggested that may improve care and outcomes in assisted living, including those in this information sheet. Feel free to utilize and distribute this information sheet among your networks to advance the well-being of the people who live and work […]

Do-Not-Hospitalize Orders in Assisted Living Facilities: Direct Care Workers’ Perspectives

Apr 1, 2024
Purpose: To gather sufficient qualitative data to create an intervention that would prevent direct care workers (DCWs) from sending residents with do-not-hospitalize (DNH) orders to the hospital. Method: This was a qualitative study with eight participants that included a descriptive survey followed by semi-structured interviews. Results: DCWs were unfamiliar with DNH orders and their thinking […]

Do-Not-Hospitalize Orders in Assisted Living Facilities: Direct Care Workers’ Perspectives

by Lea Efird-Green

Purpose: To gather sufficient qualitative data to create an intervention that would prevent direct care workers (DCWs) from sending residents with do-not-hospitalize (DNH) orders to the hospital. Method: This was a qualitative study with eight participants that included a descriptive survey followed by semi-structured interviews. Results: DCWs were unfamiliar with DNH orders and their thinking […]

A Step Toward Better Care: Understanding What Caregivers and Residents in Assisted Living Facilities Value in Health Monitoring Systems

Apr 1, 2024
The past several decades have seen significant advances in monitoring older adults’ health and well-being. However, creating viable, practical monitoring systems for informing caregivers requires understanding which behaviors and signs to track and what approaches best present that information. To investigate how technology can be leveraged to better augment caregivers’ workflows, we take a multi-stage, […]

A Step Toward Better Care: Understanding What Caregivers and Residents in Assisted Living Facilities Value in Health Monitoring Systems

by Lea Efird-Green

The past several decades have seen significant advances in monitoring older adults’ health and well-being. However, creating viable, practical monitoring systems for informing caregivers requires understanding which behaviors and signs to track and what approaches best present that information. To investigate how technology can be leveraged to better augment caregivers’ workflows, we take a multi-stage, […]

Perceptions of the Use of Terms of Endearment among Older Adults in an Assisted Living Facility

Apr 1, 2024
Background ‘Elderspeak’ has been defined as a form of communication overaccommodation used with older adults that typically involves inappropriate simplified speech. One aspect of elderspeak is the use of terms of endearment such as ‘honey’, sweetie’ and ‘dear’. There is disagreement regarding the use of terms of endearment with older adults, with differing views on […]

Perceptions of the Use of Terms of Endearment among Older Adults in an Assisted Living Facility

by Lea Efird-Green

Background ‘Elderspeak’ has been defined as a form of communication overaccommodation used with older adults that typically involves inappropriate simplified speech. One aspect of elderspeak is the use of terms of endearment such as ‘honey’, sweetie’ and ‘dear’. There is disagreement regarding the use of terms of endearment with older adults, with differing views on […]

The Impact of Assisted Living Organizational Structure and Process Characteristics on Staff Absence During COVID-19

Apr 1, 2024
Quality of care in assisted living communities (ALCs) is important to consumers. The coronavirus disease of 2019 (COVID-19) pandemic and associated emergency policies have posed major challenges on staff recruitment and retention. This study aimed to examine the relationship between organizational characteristics of ALCs in Florida and challenges with staff absence during COVID-19 (N = 129 ALCs). […]

The Impact of Assisted Living Organizational Structure and Process Characteristics on Staff Absence During COVID-19

by Lea Efird-Green

Quality of care in assisted living communities (ALCs) is important to consumers. The coronavirus disease of 2019 (COVID-19) pandemic and associated emergency policies have posed major challenges on staff recruitment and retention. This study aimed to examine the relationship between organizational characteristics of ALCs in Florida and challenges with staff absence during COVID-19 (N = 129 ALCs). […]