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 Strategic Advisor Presentations

May 14, 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

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

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

Dec 1, 2025
This study used 2018 to 2019 Medicare claims data from over 42,000 AL residents to examine whether hospice staff visits were associated with end-of-life transitions, place of death, and discharges, and whether state AL regulations influence these outcomes. More frequent visits were associated with less end-of-life transitions, discharges, and increased likelihood of dying in place. Regulations requiring on-site staffing and medication delegation were also associated with fewer transitions and increased dying in place, highlighting the role that both organizational and regulatory policies in shaping end-of-life outcomes.

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

by Lea Efird-Green

This study used 2018 to 2019 Medicare claims data from over 42,000 AL residents to examine whether hospice staff visits were associated with end-of-life transitions, place of death, and discharges, and whether state AL regulations influence these outcomes. More frequent visits were associated with less end-of-life transitions, discharges, and increased likelihood of dying in place. Regulations requiring on-site staffing and medication delegation were also associated with fewer transitions and increased dying in place, highlighting the role that both organizational and regulatory policies in shaping end-of-life outcomes.

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

Dec 1, 2025
This qualitative study examined safety concerns from 32 residents, 34 family caregivers, and 38 staff members of AL communities across the US. Overall, 29 safety concerns emerged, with resident condition-related falls as the most commonly cited concern. Residents and family members were more likely than staff to report prompt use of assistive devices/technology, communication, and self-care as concerns, whereas staff were more likely to report environmental-related falls as a concern.

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

by Lea Efird-Green

This qualitative study examined safety concerns from 32 residents, 34 family caregivers, and 38 staff members of AL communities across the US. Overall, 29 safety concerns emerged, with resident condition-related falls as the most commonly cited concern. Residents and family members were more likely than staff to report prompt use of assistive devices/technology, communication, and self-care as concerns, whereas staff were more likely to report environmental-related falls as a concern.

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

Dec 1, 2025
This study of nursing homes and AL communities (ALCs) in Florida compared over 5,200 staff's 2-dose COVID-19 vaccination rate by February 2021 to understand the differences between settings and organizational factors influencing vaccination rates. ALCs initially had lower rates, but by the end of the study period, rates had increased, especially smaller communities. Factors such as for-profit status and rural location were significant predictors of vaccine reception, with smaller, urban ALCs that accepted state funding having higher rates.

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

by Lea Efird-Green

This study of nursing homes and AL communities (ALCs) in Florida compared over 5,200 staff’s 2-dose COVID-19 vaccination rate by February 2021 to understand the differences between settings and organizational factors influencing vaccination rates. ALCs initially had lower rates, but by the end of the study period, rates had increased, especially smaller communities. Factors such as for-profit status and rural location were significant predictors of vaccine reception, with smaller, urban ALCs that accepted state funding having higher rates.

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

Dec 1, 2025
This study investigated residential care communities (RCCs) characteristics associated with care aide hours per resident day using data from 518 RCCs in the 2022 National Post-acute and Long-term Care Study. Factors related to higher staffing hours included reimbursement for training and occupancy greater than 85%, whereas factors such as initial training of more than 60 hours, increased Medicaid involement, and being a larger community were associated with lower staffing hours.

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

This study investigated residential care communities (RCCs) characteristics associated with care aide hours per resident day using data from 518 RCCs in the 2022 National Post-acute and Long-term Care Study. Factors related to higher staffing hours included reimbursement for training and occupancy greater than 85%, whereas factors such as initial training of more than 60 hours, increased Medicaid involement, and being a larger community were associated with lower staffing hours.

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

Nov 1, 2025
This article outlines the plan for developing organization sample frames and data collection methods for the National Dementia Workforce Study (NDWS). Since no national sampling frames for this workforce exist, a two-stage sampling framework was developed: stage 1 involved identifying organizations, inviting them to participate in a survey, and asking them to provide staff information; and stage 2 involved recruiting individual staff for the NDWS survey.

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

by Lea Efird-Green

This article outlines the plan for developing organization sample frames and data collection methods for the National Dementia Workforce Study (NDWS). Since no national sampling frames for this workforce exist, a two-stage sampling framework was developed: stage 1 involved identifying organizations, inviting them to participate in a survey, and asking them to provide staff information; and stage 2 involved recruiting individual staff for the NDWS survey.

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

Nov 1, 2025
This report describes the design of the National Dementia Workforce Study (NDWS) initial questionnaire. The process involved integrating literature reviews, validated questionnaire items, expert consultations, and cognitive interviews to ensure reliability and validity. The resulting data from the NDWS will be available to researchers to better understand the workforce serving people living with dementia.

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

by Lea Efird-Green

This report describes the design of the National Dementia Workforce Study (NDWS) initial questionnaire. The process involved integrating literature reviews, validated questionnaire items, expert consultations, and cognitive interviews to ensure reliability and validity. The resulting data from the NDWS will be available to researchers to better understand the workforce serving people living with dementia.

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

Nov 1, 2025
This article discusses the goals, data collection, and data release of the National Dementia Workforce Study (NDWS), a longitudinal study that will help track workforce changes over time in community-based medical practices, nursing homes, AL communities, and home care. The NDWS is the first nationally representative study of this workforce, including information on knowledge, skills, experiences, challenges, job retention, and financial struggles.

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

by Lea Efird-Green

This article discusses the goals, data collection, and data release of the National Dementia Workforce Study (NDWS), a longitudinal study that will help track workforce changes over time in community-based medical practices, nursing homes, AL communities, and home care. The NDWS is the first nationally representative study of this workforce, including information on knowledge, skills, experiences, challenges, job retention, and financial struggles.

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

Sep 1, 2025
This study examined the attitudes of 200 post-acute and long-term care (PALTC) staff towards immunization, job-related education, and training. This feedback led to the development of a 45-minute training related to vaccines, which included information on the benefits and risks of immunizations for both residents and staff with a focus on objective, reliable information and staff autonomy.

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

by Lea Efird-Green

This study examined the attitudes of 200 post-acute and long-term care (PALTC) staff towards immunization, job-related education, and training. This feedback led to the development of a 45-minute training related to vaccines, which included information on the benefits and risks of immunizations for both residents and staff with a focus on objective, reliable information and staff autonomy.

Mouth Care Without a Battle: Change in Assisted Living Staff Self-Efficacy and Attitudes

Sep 1, 2025
This study evaluated 24 AL communities to see if the modified Mouth Care Without a Battle (MCWB) for AL improved efficacy and attitudes of staff providing mouth care. AL staff's ratings of self-efficacy and attitudes did not significantly change after MCWB training, which differs from nursing home staff in another study. This may indicate AL staff do not view mouth care as high-priority, highlighting the need to emphasize it in training and supervision.

Mouth Care Without a Battle: Change in Assisted Living Staff Self-Efficacy and Attitudes

by Lea Efird-Green

This study evaluated 24 AL communities to see if the modified Mouth Care Without a Battle (MCWB) for AL improved efficacy and attitudes of staff providing mouth care. AL staff’s ratings of self-efficacy and attitudes did not significantly change after MCWB training, which differs from nursing home staff in another study. This may indicate AL staff do not view mouth care as high-priority, highlighting the need to emphasize it in training and supervision.

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

Sep 1, 2025
This study examined the relationships between AL community and staff characteristics and staff satisfaction/burnout, as well as psychometrically assessing the Direct Care Worker Staff Satisfaction Scale. Satisfaction was. On average, staff were "satisfied" (a three on a scale of four) and 18.5% of staff were experiencing symptoms of burnout. When satisfaction was higher, burnout was lower (negatively correlated), and there were significant associations between satisfaction and organizational characteristics, such as staff to resident ratios.

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

by Lea Efird-Green

This study examined the relationships between AL community and staff characteristics and staff satisfaction/burnout, as well as psychometrically assessing the Direct Care Worker Staff Satisfaction Scale. Satisfaction was. On average, staff were “satisfied” (a three on a scale of four) and 18.5% of staff were experiencing symptoms of burnout. When satisfaction was higher, burnout was lower (negatively correlated), and there were significant associations between satisfaction and organizational characteristics, such as staff to resident ratios.

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 qualitative study explored the perspectives of 59 administrative leaders, direct care staff, residents, and care partners in 4 long-term care communities in medically underserved areas about how collecting and sharing information can be used to support person-centered care. Effective communication strategies included communication logs, leaving notes, and verbal reports, and, to support person-centered care, interdisciplinary collaboration, engaging care partners, and peer mentorship. These strategies can improve information collection and sharing in long-term care.

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 qualitative study explored the perspectives of 59 administrative leaders, direct care staff, residents, and care partners in 4 long-term care communities in medically underserved areas about how collecting and sharing information can be used to support person-centered care. Effective communication strategies included communication logs, leaving notes, and verbal reports, and, to support person-centered care, interdisciplinary collaboration, engaging care partners, and peer mentorship. These strategies can improve information collection and sharing in long-term care.

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

Aug 1, 2025
This study examined questionnaires from 900 nursing home and AL workers in Puerto Rico to understand the factors that contributed to anxiety during the COVID-19 pandemic. Factors such as avoidance, emotional exhaustion, stress, and negative mood were major contributors to feelings of anxiety. The findings highlight the need for mental health support and interventions for long-term care workers both during and after crises to lessen feelings of anxiety and to prevent long-term impacts on well-being.

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

by Lea Efird-Green

This study examined questionnaires from 900 nursing home and AL workers in Puerto Rico to understand the factors that contributed to anxiety during the COVID-19 pandemic. Factors such as avoidance, emotional exhaustion, stress, and negative mood were major contributors to feelings of anxiety. The findings highlight the need for mental health support and interventions for long-term care workers both during and after crises to lessen feelings of anxiety and to prevent long-term impacts on well-being.

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

Jul 1, 2025
This scoping review examined 19 studies to understand determinants and effects of care refusal by long-term care residents living with dementia. Factors such as cognitive impairment, communication challenges, elderspeak, unfamiliar environments, and task-oriented care were identified as determinants of care refusal, while megative effects included compromised health outcomes, disrupted provision of care, and increased neuropsychiatric symptoms, highlighting factors that could be addressed to reduce care refusal.

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

by Lea Efird-Green

This scoping review examined 19 studies to understand determinants and effects of care refusal by long-term care residents living with dementia. Factors such as cognitive impairment, communication challenges, elderspeak, unfamiliar environments, and task-oriented care were identified as determinants of care refusal, while megative effects included compromised health outcomes, disrupted provision of care, and increased neuropsychiatric symptoms, highlighting factors that could be addressed to reduce care refusal.

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

Jul 1, 2025
This qualitative study examined 910 Finnish nurse managers in home care and AL to understand the impact of using care teams. Teams allowed nurses to improve planning and evaluation of care, increase well-being and ability to cope with the workload, and higher quality of care. Perceived challenges to team care were incorporating temporary workers, poor collaboration among teams, and hindering professional development.

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

by Lea Efird-Green

This qualitative study examined 910 Finnish nurse managers in home care and AL to understand the impact of using care teams. Teams allowed nurses to improve planning and evaluation of care, increase well-being and ability to cope with the workload, and higher quality of care. Perceived challenges to team care were incorporating temporary workers, poor collaboration among teams, and hindering professional development.

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.