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

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

Jun 1, 2024
WHAT THIS MEANS FOR YOU: An analysis of 2007-2015 Medicare data for over 12,000 AL residents with ADRD in 455 Ohio AL communities showed that higher levels of RN staffing hours per resident per day led to a 53% decrease in injury-related emergency department visits.

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

WHAT THIS MEANS FOR YOU: An analysis of 2007-2015 Medicare data for over 12,000 AL residents with ADRD in 455 Ohio AL communities showed that higher levels of RN staffing hours per resident per day led to a 53% decrease in injury-related emergency department visits.

Does Assisted Living Provide Assistance And Promote Living?

May 1, 2024
WHAT THIS MEANS FOR YOU: AL communities in the United States serve more than 918,000 older adults as of 2018. In this commentary, the authors examined how workforce limitations, the complexity of regulations, consumer needs, and lack of financing contribute to negative consequences for aging in place and well-being. They suggest policy changes in those four areas, such as increased staffing, boosting wages and training, encouraging uniform data reporting, and making community disclosure statements more accessible.

Does Assisted Living Provide Assistance And Promote Living?

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: AL communities in the United States serve more than 918,000 older adults as of 2018. In this commentary, the authors examined how workforce limitations, the complexity of regulations, consumer needs, and lack of financing contribute to negative consequences for aging in place and well-being. They suggest policy changes in those four areas, such as increased staffing, boosting wages and training, encouraging uniform data reporting, and making community disclosure statements more accessible.

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
WHAT THIS MEANS FOR YOU: Eight participants were surveyed and interviewed to inform an intervention that would prevent direct care workers from sending residents with do-not-hospitalize orders to the hospital. Results revealed care workers were unfamiliar with do-not-hospitalize orders and had binary thinking (e.g., residents had to be sent to hospice or the hospital) on end-of-life issues. Supportive leaders in the assisted living communities that could assist direct care workers during these complex situations were found to be helpful.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Eight participants were surveyed and interviewed to inform an intervention that would prevent direct care workers from sending residents with do-not-hospitalize orders to the hospital. Results revealed care workers were unfamiliar with do-not-hospitalize orders and had binary thinking (e.g., residents had to be sent to hospice or the hospital) on end-of-life issues. Supportive leaders in the assisted living communities that could assist direct care workers during these complex situations were found to be helpful.

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

Apr 1, 2024
WHAT THIS MEANS FOR YOU: Elderspeak, which includes terms of endearment used by healthcare workers for older adults, was examined via interviews with 15 New York AL residents. Participants’ opinions varied; some liked the terms, some were neutral, and some thought they were disrespectful; thus, it is recommended that healthcare workers adjust their communication based on residents’ personal preferences.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Elderspeak, which includes terms of endearment used by healthcare workers for older adults, was examined via interviews with 15 New York AL residents. Participants’ opinions varied; some liked the terms, some were neutral, and some thought they were disrespectful; thus, it is recommended that healthcare workers adjust their communication based on residents’ personal preferences.

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

Apr 1, 2024
WHAT THIS MEANS FOR YOU: In 129 Florida AL communities, higher staff absences due to fear of infection, sickness, or family responsibilities during the COVID-19 pandemic were statistically significantly associated with provision of memory care services; care processes (challenges hiring new staff, staff sent home to comply with COVID-19 precautions, and staff anxiety); and local COVID-19 infection rates.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: In 129 Florida AL communities, higher staff absences due to fear of infection, sickness, or family responsibilities during the COVID-19 pandemic were statistically significantly associated with provision of memory care services; care processes (challenges hiring new staff, staff sent home to comply with COVID-19 precautions, and staff anxiety); and local COVID-19 infection rates.

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

Apr 1, 2024
WHAT THIS MEANS FOR YOU: Expert interviews, cognitive walkthroughs, and semi-structured interviews were conducted with 7 caregivers and 5 residents from an AL community to understand the role that health monitoring technology plays in their work and lives. Monitoring technology was viewed as a way to reduce caregivers' workload and improve team communication. Residents were open to using the technology, but protecting their privacy and autonomy was a concern for its implementation.

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

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Expert interviews, cognitive walkthroughs, and semi-structured interviews were conducted with 7 caregivers and 5 residents from an AL community to understand the role that health monitoring technology plays in their work and lives. Monitoring technology was viewed as a way to reduce caregivers’ workload and improve team communication. Residents were open to using the technology, but protecting their privacy and autonomy was a concern for its implementation.

Using Assisted Living Communities to Enhance Nursing Student Attitudes Toward Older Adults

Feb 1, 2024
WHAT THIS MEANS FOR YOU: A total of 70 nursing students at one Western US university participated in a clinical project in which they interviewed an AL resident and provided an educational session to residents at an AL community. Students, AL communities, and instructors all reported positive experiences in this clinical experience, and students reported more positive attitudes towards older adults.

Using Assisted Living Communities to Enhance Nursing Student Attitudes Toward Older Adults

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A total of 70 nursing students at one Western US university participated in a clinical project in which they interviewed an AL resident and provided an educational session to residents at an AL community. Students, AL communities, and instructors all reported positive experiences in this clinical experience, and students reported more positive attitudes towards older adults.

Practitioner Burnout and Productivity Levels in Skilled Nursing and Assisted Living Facilities, Part 1: A Descriptive Quantitative Account

Jan 1, 2024
WHAT THIS MEANS FOR YOU: When 366 AL and NH therapy practitioners (occupational therapists, physical therapists, speech-language pathologists, and occupational/physical therapy assistants) across the US were surveyed, results showed that 21% of practitioners were burned out, with high levels of emotional exhaustion and depersonalization (unfeeling and impersonal response towards service recipients), and reduced personal accomplishment (feelings of competence in one’s work) on the Maslach Burnout Inventory. There were statistically significant relationships between high productivity demands and burnout, as well as between high productivity demands and engaging ethically questionable service behaviors.

Practitioner Burnout and Productivity Levels in Skilled Nursing and Assisted Living Facilities, Part 1: A Descriptive Quantitative Account

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: When 366 AL and NH therapy practitioners (occupational therapists, physical therapists, speech-language pathologists, and occupational/physical therapy assistants) across the US were surveyed, results showed that 21% of practitioners were burned out, with high levels of emotional exhaustion and depersonalization (unfeeling and impersonal response towards service recipients), and reduced personal accomplishment (feelings of competence in one’s work) on the Maslach Burnout Inventory. There were statistically significant relationships between high productivity demands and burnout, as well as between high productivity demands and engaging ethically questionable service behaviors.

A Collaborative Approach to Improving Care Outcomes for Residents in Assisted Living

Jan 1, 2024
WHAT THIS MEANS FOR YOU: A longitudinal study of 50 residents and 119 care partners in 8 AL communities in Georgia over 2 years examined the concept of a “care convoy” (a dynamic network of formal and informal care partners) for AL residents. This model was supported by formal and informal interviewing, participant observation, and record review. The model is recommended for use by physicians and other healthcare providers to assist them in supporting the needs and goals of the residents and their care convoys, which is theorized to achieve better care outcomes.

A Collaborative Approach to Improving Care Outcomes for Residents in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A longitudinal study of 50 residents and 119 care partners in 8 AL communities in Georgia over 2 years examined the concept of a “care convoy” (a dynamic network of formal and informal care partners) for AL residents. This model was supported by formal and informal interviewing, participant observation, and record review. The model is recommended for use by physicians and other healthcare providers to assist them in supporting the needs and goals of the residents and their care convoys, which is theorized to achieve better care outcomes.

From 65 to 103, Older Adults Experience Virtual Reality Differently Depending on Their Age: Evidence from a Large-Scale Field Study in Nursing Homes and Assisted Living Facilities

Dec 1, 2023
WHAT THIS MEANS FOR YOU: Two related studies examined the experiences of 245 assisted living and nursing homes residents across 10 US states who used virtual reality (VR), as well as 39 caregiving staff who facilitated the VR experiences. Older residents enjoyed VR less, a result that was less strong when asked about other technologies such as phones and voice assistants. Staff who facilitated the experiences saw VR as generally enjoyable compared to other work activities and felt it improved their relationships with residents.

From 65 to 103, Older Adults Experience Virtual Reality Differently Depending on Their Age: Evidence from a Large-Scale Field Study in Nursing Homes and Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Two related studies examined the experiences of 245 assisted living and nursing homes residents across 10 US states who used virtual reality (VR), as well as 39 caregiving staff who facilitated the VR experiences. Older residents enjoyed VR less, a result that was less strong when asked about other technologies such as phones and voice assistants. Staff who facilitated the experiences saw VR as generally enjoyable compared to other work activities and felt it improved their relationships with residents.

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

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

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

by Lea Efird-Green

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

End-of-Life Care Transitions in Assisted Living: Associations With State Staffing and Training Regulations

Jun 1, 2023
WHAT THIS MEANS FOR YOU: This study examined associations between end-of-life care transitions (meaning stays in hospitals and nursing homes in either the 7 or 30 days before death in this study) and state staffing and training requirements for nearly 114,000 Medicare beneficiaries who died in an assisted living community in 2018-2019. A higher proportion of transitions was associated with stricter regulations about licensed and direct care worker staffing, whereas a lower proportion was associated with more specific regulations about direct care worker training. Therefore, policymakers and practitioners may want to implement regulations that make staff training requirements more specific to better address end-of-life care.

End-of-Life Care Transitions in Assisted Living: Associations With State Staffing and Training Regulations

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study examined associations between end-of-life care transitions (meaning stays in hospitals and nursing homes in either the 7 or 30 days before death in this study) and state staffing and training requirements for nearly 114,000 Medicare beneficiaries who died in an assisted living community in 2018-2019. A higher proportion of transitions was associated with stricter regulations about licensed and direct care worker staffing, whereas a lower proportion was associated with more specific regulations about direct care worker training. Therefore, policymakers and practitioners may want to implement regulations that make staff training requirements more specific to better address end-of-life care.

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

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

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

by Lea Efird-Green

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

“You Gotta Have Your Cry”: Administrator and Direct Care Worker Experiences of Death in Assisted Living

Dec 1, 2022
WHAT THIS MEANS FOR YOU: Qualitative data from 27 administrators and 38 direct care workers in 7 assisted living communities found that when residents died, staff members balanced their personal feelings about death and their work role in a process called “managing the normalization of death” with varying levels of perceived success. Additional resources and training about managing resident death, including improved collaboration with hospice services and clearer end-of-life care policies, might be helpful for staff.

“You Gotta Have Your Cry”: Administrator and Direct Care Worker Experiences of Death in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Qualitative data from 27 administrators and 38 direct care workers in 7 assisted living communities found that when residents died, staff members balanced their personal feelings about death and their work role in a process called “managing the normalization of death” with varying levels of perceived success. Additional resources and training about managing resident death, including improved collaboration with hospice services and clearer end-of-life care policies, might be helpful for staff.

Patient Safety Culture in Assisted Living: Staff Perceptions and Association with State Regulations

Dec 1, 2022
WHAT THIS MEANS FOR YOU: A total of 714 administrators and direct care workers in 257 assisted living communities reported that direct care workers had a more negative perception of patient safety culture (PSC) than administrators. Stricter state regulations, particularly regarding staffing, were associated with better perceptions of PSC among direct care workers.

Patient Safety Culture in Assisted Living: Staff Perceptions and Association with State Regulations

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A total of 714 administrators and direct care workers in 257 assisted living communities reported that direct care workers had a more negative perception of patient safety culture (PSC) than administrators. Stricter state regulations, particularly regarding staffing, were associated with better perceptions of PSC among direct care workers.

Staff Attitudes Related to Antipsychotic Prescribing in Assisted Living

Sep 1, 2022
WHAT THIS MEANS FOR YOU: Data from over 13,500 residents from 247 assisted living communities indicated that healthcare supervisors who were more supportive of using medication to treat behaviors were more likely to have higher rates of antipsychotic prescribing in their communities. Health care supervisor attitudes may be leveraged to reduce antipsychotic prescribing.

Staff Attitudes Related to Antipsychotic Prescribing in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Data from over 13,500 residents from 247 assisted living communities indicated that healthcare supervisors who were more supportive of using medication to treat behaviors were more likely to have higher rates of antipsychotic prescribing in their communities. Health care supervisor attitudes may be leveraged to reduce antipsychotic prescribing.

Pilot Testing of the Promoting Positive Care Interactions Intervention in Assisted Living

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Promoting Positive Care Interactions, a staff training program to establish positive care interactions with residents, was tested with 17 care staff in the memory care unit of one assisted living community. Although there were no significant changes in staff outcomes, participants’ perception of the community’s environment and policies improved, and staff showed good engagement throughout the study.

Pilot Testing of the Promoting Positive Care Interactions Intervention in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Promoting Positive Care Interactions, a staff training program to establish positive care interactions with residents, was tested with 17 care staff in the memory care unit of one assisted living community. Although there were no significant changes in staff outcomes, participants’ perception of the community’s environment and policies improved, and staff showed good engagement throughout the study.

Administrator Turnover in Oregon Assisted Living and Residential Care Communities, March 2020–February 2021

Jun 1, 2022
WHAT THIS MEANS FOR YOU: This study analyzed staffing records from 549 assisted living communities in Oregon and found approximately one-third of administrators left their jobs between March 2020 and February 2021. Nonprofit communities and those with more beds had less administrator turnover; administrators who had been in their roles for a longer time before the pandemic were less likely to leave their jobs. Offering memory care services, accepting Medicaid, rurality, and number of assisted living communities in the county did not relate to administrator turnover.

Administrator Turnover in Oregon Assisted Living and Residential Care Communities, March 2020–February 2021

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study analyzed staffing records from 549 assisted living communities in Oregon and found approximately one-third of administrators left their jobs between March 2020 and February 2021. Nonprofit communities and those with more beds had less administrator turnover; administrators who had been in their roles for a longer time before the pandemic were less likely to leave their jobs. Offering memory care services, accepting Medicaid, rurality, and number of assisted living communities in the county did not relate to administrator turnover.

Factors Associated with the Quality of Staff-Resident Interactions in Assisted Living

Jun 1, 2022
WHAT THIS MEANS FOR YOU: Using data from 379 residents from 59 assisted living communities, residents who were more frequently agitated tended to have worse care interactions with staff, while being in a for-profit community was associated with more positive interactions. Staff training in how to minimize resident agitation may improve the positivity of care interactions.

Factors Associated with the Quality of Staff-Resident Interactions in Assisted Living

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Using data from 379 residents from 59 assisted living communities, residents who were more frequently agitated tended to have worse care interactions with staff, while being in a for-profit community was associated with more positive interactions. Staff training in how to minimize resident agitation may improve the positivity of care interactions.

“We Weathered the Storm”: A Qualitative Phenomenological Study of the Lived Experience of Assisted Living Administrators during the COVID-19 Pandemic

May 1, 2022
WHAT THIS MEANS FOR YOU: A qualitative study interviewing five assisted living administrators about their experiences during the COVID-19 pandemic found frequent changes in the administrators' experiences during the pandemic, including having limited resources and responding to rapid policy shifts.

“We Weathered the Storm”: A Qualitative Phenomenological Study of the Lived Experience of Assisted Living Administrators during the COVID-19 Pandemic

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A qualitative study interviewing five assisted living administrators about their experiences during the COVID-19 pandemic found frequent changes in the administrators’ experiences during the pandemic, including having limited resources and responding to rapid policy shifts.

Bridging the Transition to Assisted Living: A Framework for Faith Community Nursing

Apr 1, 2022
WHAT THIS MEANS FOR YOU: Using an example of an 85-year-old resident, the article proposes a framework for faith community nursing, emphasizing observation, meaningful conversations, advocacy, and assertive communication to ease the move from independent to assisted living.

Bridging the Transition to Assisted Living: A Framework for Faith Community Nursing

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Using an example of an 85-year-old resident, the article proposes a framework for faith community nursing, emphasizing observation, meaningful conversations, advocacy, and assertive communication to ease the move from independent to assisted living.

“What Keeps Me Awake at Night”: Assisted Living Administrator Responses to COVID-19

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study assessed how the early COVID-19 pandemic (Feb-Aug 2020) affected 40 assisted living administrators in Oregon. Three resulting themes from the interviews were emotion and burnout management (e.g., monitoring staff reactions), information management (e.g., monitoring latest recommendations and safety protocols), and crisis management (e.g., decision-making, emergency planning).

“What Keeps Me Awake at Night”: Assisted Living Administrator Responses to COVID-19

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study assessed how the early COVID-19 pandemic (Feb-Aug 2020) affected 40 assisted living administrators in Oregon. Three resulting themes from the interviews were emotion and burnout management (e.g., monitoring staff reactions), information management (e.g., monitoring latest recommendations and safety protocols), and crisis management (e.g., decision-making, emergency planning).

Staff Reports of Behavioral Expressions of Persons with Dementia in 250 Assisted Living Communities 

Mar 1, 2022
WHAT THIS MEANS FOR YOU: This study included health care supervisors from 250 assisted living communities in 7 states to understand how staff respond to behavioral expressions of residents with dementia. The most commonly reported expressions were combativeness and anxiety. A thematic analysis found that in about 25% of cases, staff recognized the events preceding behavioral expressions (antecedents). Staff in smaller and memory-care only communities were more adept at identifying antecedents; additional training to anticipate expressions may help prevent them.

Staff Reports of Behavioral Expressions of Persons with Dementia in 250 Assisted Living Communities 

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study included health care supervisors from 250 assisted living communities in 7 states to understand how staff respond to behavioral expressions of residents with dementia. The most commonly reported expressions were combativeness and anxiety. A thematic analysis found that in about 25% of cases, staff recognized the events preceding behavioral expressions (antecedents). Staff in smaller and memory-care only communities were more adept at identifying antecedents; additional training to anticipate expressions may help prevent them.