Perspectives of certified nursing assistants and administrators on staffing the nursing home frontline during the COVID-19 pandemic.

OBJECTIVE: To identify best practices to support and grow the frontline nursing home workforce based on the lived experience of certified nursing assistants (CNAs) and administrators during COVID-19. STUDY SETTING: Primary data collection with CNAs and administrators in six New York metro area nursing homes during fall 2020. STUDY DESIGN: Semi-structured interviews and focus groups exploring staffing challenges during COVID-19, strategies used to address them, and recommendations moving forward. DATA COLLECTION: We conducted interviews with 6 administrators and held 10 focus groups with day and evening shift CNAs (n = 56) at 6 nursing homes. Data were recorded and transcribed verbatim and analyzed through directed content analysis using a combined inductive and deductive approach to compare perceptions across sites and roles. PRINCIPAL FINDINGS: CNAs and administrators identified chronic staffing shortages that affected resident care and staff burnout as a primary concern moving forward. CNAs who felt most supported and confident in their continued ability to manage their work and the pandemic described leadership efforts to support workers' emotional health and work-life balance, teamwork across staff and management, and accessible and responsive leadership. However, not all CNAs felt these strategies were in place. CONCLUSIONS: Based on priorities identified by CNAs and administrators, we recommend several organizational/industry and policy-level practices to support retention for this workforce. Practices to stabilize the workforce should include 1) teamwork and person-centered operational practices including transparent communication; 2) increasing permanent staff to avoid shortages; and 3) evaluating and building on successful COVID-related innovations (self-managed teams and flexible benefits). Policy and regulatory changes to promote these efforts are necessary to developing industry-wide structural practices that target CNA recruitment and retention.

In Their Own Words: The Challenges Experienced by Certified Nursing Assistants and Administrators During the COVID-19 Pandemic.

This qualitative study aimed to provide an in-depth understanding of the challenges experienced by certified nursing assistants and administrators during the unprecedented COVID-19 crisis. We conducted 6 administrator interviews and 10 remote focus groups with day and evening CNAs at 5 nursing homes (N = 56) in downstate New York. Content analysis was conducted, and emerging themes were identified across sites and roles. Results showed numerous challenges for both CNAs and administrators including many that were personal. These personal challenges included feeling helpless, anxious, or fearful; experience of COVID illness; and balancing high concurrent demands of work and family. There were also many operational challenges such as a lack of COVID testing capacity, information, and consistent guidance and support, staffing and equipment. Understanding these challenges can facilitate goals to promote future safety, skill refinement, and enhanced resilience in the workforce.

A Substance Misuse Intervention Program in Postacute Care: Who Declines Participation?

OBJECTIVES: Alcohol and substance misuse has been under-acknowledged and underidentified in older adults. However, promising treatment approaches exist (e.g., brief interventions) that can support older adults with at-risk alcohol and substance use. Postacute rehabilitation settings of Skilled Nursing Facilities (SNFs) can offer such programs, but little is known about patient characteristics that are associated with the likelihood of participating in interventions offered in postacute rehabilitation care. Thus, the objective of this study was to identify individual patient characteristics (predisposing, enabling, and need-related factors) associated with participation in a brief alcohol and substance misuse intervention at a SNF. METHODS: This cross-sectional study analyzed medical record data of postacute care patients within a SNF referred to a substance misuse intervention. Participants were 271 patients with a history of substance misuse, 177 of whom enrolled in the intervention and 94 refused. Data collected upon patient admission were used to examine predisposing, enabling, and need-related factors related to likelihood of program participation. RESULTS: Older age and ethnic minority status were associated with a reduction in likelihood to participate, while widowhood increased the likelihood of participation. CONCLUSION: Upon referral to a substance misuse intervention, clinicians in SNFs should be cognizant that some patients may be more likely to refuse intervention, and additional efforts should be made to engage patients at-risk for refusal.

Participation in a Substance Misuse Intervention in Post-acute Care Is Associated With More Optimal Rehabilitation Outcomes.

BACKGROUND AND OBJECTIVES: Alcohol and substance misuse is prevalent among older adults, yet underdiagnosed and undertreated. More substance misuse intervention programs specifically designed for older adults and offered in various settings are needed. This project's objectives were to (a) provide a detailed description of a Geriatric Substance Abuse Recovery Program (GSARP) designed and implemented at post-acute rehabilitation units of a skilled nursing facility and (b) report findings of a study conducted to evaluate if GSARP participation among post-acute care patients with substance misuse issues can optimize rehabilitation outcomes (i.e., being discharged home vs. another setting). RESEARCH DESIGN AND METHODS: A pretest-posttest study design with data obtained from patients' electronic medical record upon facility admission, during post-acute stay, and after discharge (N = 271). Based on Andersen's model of health care utilization, we investigated which predisposing factors (e.g., ethnicity), enabling factors (e.g., cognition and social support), and need-related factors (e.g., activities of daily living functioning), as well as health behaviors (e.g., GSARP participation) predicted likelihood of being discharged home versus another discharge setting. RESULTS: Patients participating in the GSARP and patients who received social support from family members and friends during their post-acute stay were more likely to be discharged home. Patients with severe cognitive impairment were less likely to be discharged home. DISCUSSION AND IMPLICATIONS: The GSARP eliminates some common barriers often encountered in the screening and delivery process of substance misuse interventions for older adults. Findings support the effectiveness of the GSARP in optimizing rehabilitation outcomes for older adults with substance misuse issues.

Dementia-Focused Person-Directed Care Training With Direct Care Workers in Nursing Homes: Effect on Symptom Reduction.

The majority of older adult nursing home residents have dementia and are at risk of not having their care needs met, largely due to communication deficits. Promoting comfort and minimizing distress for these residents is important. Direct care workers (DCW) and clinical staff completed a 6-day training on a person-directed care (PDC) model-a model guided by the needs of the individual that focuses on empowering DCW to understand and support resident preferences and remaining abilities supported by relationship development and consistent staffing. A retrospective comparison was conducted of residents in two PDC communities with matched residents (n = 72) and three traditional communities (n = 72) on functional and clinical outcomes over a 6-month period. A two-way analysis of variance showed a significant interaction between group and time, where only those in the PDC group had a decreased number of clinical symptoms (e.g., pain, depression, agitation) over time. This study found support for the benefit of PDC on clinical outcomes of interest over time. PDC training for DCW and clinical staff promotes quality care and the reduction of clinical symptoms, leading to improved quality of life. [Journal of Gerontological Nursing, 46(8), 7-11.].

Use of an Exercise Technology in Post-Acute Care of a Skilled Nursing Facility: A Feasibility Study.

OBJECTIVES: Use of exercise technologies has benefits for community-dwelling older adults in terms of improved gait and balance. But research on the feasibility of use of exercise technologies in various geriatric health care settings is lacking. Hence, the current study examined the feasibility of implementing an exercise technology intended to augment rehabilitation in patients receiving post-acute care (PAC) in a skilled nursing facility (SNF). We focused on 3 indicators of feasibility: extent of usage (including predictors of more intense use), patients' acceptability of the technology, and limited efficacy. DESIGN: Cross-sectional study with data from patients' electronic medical records (EMR), exercise technology portal, and patient interviews. SETTING: SNF. PARTICIPANTS: A sample of post-acute patients (n = 237). MEASUREMENTS: Sociodemographic and health-related variables, time spent using the technology, and 8 items of the Physical Activity Enjoyment Scale (PACES). RESULTS: Average time spent using the technology varied greatly (range, 1-460 minutes). A regression analysis showed that patients who had a longer length of stay (ß = .01, P < .05) and were younger (ß = -0.01, P < .05) spent significantly more time using the technology. Acceptability of technology was high among patients. Finally, patients who used the technology had lower 30-day rehospitalization rates. CONCLUSION: Exercise technology is feasible to use in supporting rehabilitation in patients receiving PAC in a SNF and seems to have beneficial effects.

Depression recognition and capacity for self-report among ethnically diverse nursing homes residents: Evidence of disparities in screening.

AIMS AND OBJECTIVES: To examine agreement between Minimum Data Set clinician ratings and researcher assessments of depression among ethnically diverse nursing home residents using the 9-item Patient Health Questionnaire. BACKGROUND: Although depression is common among nursing homes residents, its recognition remains a challenge. DESIGN: Observational baseline data from a longitudinal intervention study. METHODS: Sample of 155 residents from 12 long-term care units in one US facility; 50 were interviewed in Spanish. Convergence between clinician and researcher ratings was examined for (i) self-report capacity, (ii) suicidal ideation, (iii) at least moderate depression, (iv) Patient Health Questionnaire severity scores. Experiences by clinical raters using the depression assessment were analysed. The intraclass correlation coefficient was used to examine concordance and Cohen's kappa to examine agreement between clinicians and researchers. RESULTS: Moderate agreement (κ = 0.52) was observed in determination of capacity and poor to fair agreement in reporting suicidal ideation (κ = 0.10-0.37) across time intervals. Poor agreement was observed in classification of at least moderate depression (κ = -0.02 to 0.24), lower than the maximum kappa obtainable (0.58-0.85). Eight assessors indicated problems assessing Spanish-speaking residents. Among Spanish speakers, researchers identified 16% with Patient Health Questionnaire scores of 10 or greater, and 14% with thoughts of self-harm whilst clinicians identified 6% and 0%, respectively. CONCLUSION: This study advances the field of depression recognition in long-term care by identification of possible challenges in assessing Spanish speakers. RELEVANCE TO CLINICAL PRACTICE: Use of the Patient Health Questionnaire requires further investigation, particularly among non-English speakers. Depression screening for ethnically diverse nursing home residents is required, as underreporting of depression and suicidal ideation among Spanish speakers may result in lack of depression recognition and referral for evaluation and treatment. Training in depression recognition is imperative to improve the recognition, evaluation and treatment of depression in older people living in nursing homes.

Coping With Client Death: How Prepared Are Home Health Aides and What Characterizes Preparedness?

This study explored the experiences of 80 home health aides (HHAs) whose client died within the last 2 months. Data collection involved comprehensive semi-structured in-person interviews to try to better understand characteristics of HHAs and their clients associated with preparedness for death. Among those, personal end-of-life (EOL) care preferences of HHAs and having knowledge of preferences and decisions regarding client's EOL care showed significant links to preparedness. Findings suggest that HHAs' preparedness for client death could be enhanced both by addressing their personal views on EOL care and by providing more information about the client's EOL care plans.

Preparedness for Resident Death in Long-Term Care: The Experience of Front-Line Staff.

CONTEXT: Although resident death is a common occurrence in long-term care, little attention has focused on how prepared certified nursing assistants (CNAs), who provide most of residents' daily care, are for this experience. OBJECTIVES: To identify characteristics of the resident, CNA, and care context associated with CNAs' preparedness for resident death and to determine differential patterns for emotional versus informational preparedness. METHODS: One hundred forty CNAs completed semistructured, in-person interviews concerning their experiences regarding resident death. The associations of CNA characteristics (e.g., personal end-of-life [EOL] care preferences), CNAs' perceptions of resident status (e.g., knowledge of resident's condition), and the caregiving context (e.g., support from coworkers and hospice involvement) with emotional and informational preparedness were examined by the use of bivariate and multivariate analyses. RESULTS: CNAs who reported that their resident was "aware of dying" or "in pain" expressed greater levels of both emotional and informational preparedness. CNAs who endorsed an EOL care preference of wanting all possible treatments regardless of chances for recovery were likely to report lesser emotional preparedness. More senior CNAs, both in regard to age and tenure, reported greater preparedness levels. Greater support from coworkers and hospice involvement also were associated with greater levels of both facets of preparedness, the latter in particular when hospice care was viewed positively by the CNA. CONCLUSION: Having more information about resident status and more exchange opportunities within the care team around EOL-related challenges may help CNAs feel more prepared for resident death and strengthen their ability to provide good EOL care.

Nursing home practices following resident death: the experience of Certified Nursing Assistants.

This study examined certified nursing assistants' (CNAs) experiences of nursing home practices following resident death. Participants were 140 CNAs who had experienced recent resident death. In semi-structured, in-person interviews, CNAs were asked about their experiences with the removal of the resident's body, filling the bed with a new resident, and how they were notified about the death. The facilities' practice of filling the bed quickly was most often experienced as negative. Responses to body removal and staff notification varied, but negative experiences were reported by a substantial minority. Being notified prior to returning to work was associated with a more positive experience. Learning about the death by walking into a room to find the bed empty or already filled was the most negative experience. Study findings suggest that more mindful approaches to the transitions related to resident deaths would be valued by CNAs and could improve their work experience.

Grief after patient death: direct care staff in nursing homes and homecare.

CONTEXT: Patient death is common in long-term care (LTC). Yet, little attention has been paid to how direct care staff members, who provide the bulk of daily LTC, experience patient death and to what extent they are prepared for this experience. OBJECTIVES: To 1) determine how grief symptoms typically reported by bereaved family caregivers are experienced among direct care staff, 2) explore how prepared the staff members were for the death of their patients, and 3) identify characteristics associated with their grief. METHODS: This was a cross-sectional study of direct care staff experiencing recent patient death. Participants were 140 certified nursing assistants and 80 homecare workers. Standardized assessments and structured questions addressed staff (e.g., preparedness for death), institutional (e.g., support availability), and patient/relational factors (e.g., relationship quality). Data analyses included bivariate group comparisons and hierarchical regression. RESULTS: Grief reactions of staff reflected many of the core grief symptoms reported by bereaved family caregivers in a large-scale caregiving study. Feelings of being "not at all prepared" for the death and struggling with "acceptance of death" were prevalent among the staff. Grief was more intense when staff-patient relationships were closer, care was provided for longer, and staff felt emotionally unprepared for the death. CONCLUSION: Grief symptoms like those experienced by family caregivers are common among direct care workers after patient death. Increasing preparedness for this experience via better training and support is likely to improve the occupational experience of direct care workers and ultimately allow them to provide better palliative care in nursing homes and homecare.

The impact of culture change on elders' behavioral symptoms: a longitudinal study.

OBJECTIVES: Distressing behavioral symptoms often associated with dementia are not uncommon in the long term care setting. Culture change with its "person-centered approach to care" provides a potential nonpharmacological intervention to reduce these symptoms. The purpose of this study was to examine the relationship between a culture change initiative and nursing home elders' behavioral symptoms. DESIGN: Seven long term care communities (nursing units in 3 skilled nursing facilities) participated in a culture change intervention designed to transform the nursing home experience from a traditional hospital-model of care to one that is person-centered. Six comparison communities were matched to the intervention communities and continued to function along the typical nursing home organizational structure. Data were collected at baseline and 2 years later. METHODS: Subjects were 101 elders (intervention group n = 50, comparison group n = 51). Each elder's primary day certified nursing assistant completed the Cohen-Mansfield Agitation Inventory, examining frequency of behavioral symptoms, including verbal and physical agitation as well as more forceful behaviors (eg, hitting, kicking) at both data collection periods. RESULTS: After controlling for functional status and race, a significant condition by time interaction was found for physical agitation and forceful behaviors with the person-centered group maintaining levels of behavioral symptoms as compared with a significant increase over time among the comparison group. A trend with the same pattern was found for verbal agitation. CONCLUSIONS: Person-centered care demonstrated potential as a nonpharmacological intervention for distressing behavioral symptoms. The positive impact of culture change appears to extend to elders with cognitive impairment who are less obvious beneficiaries of this model, featuring the central principals of autonomy and person-centered care.

What matters most to nursing home elders: quality of life in the nursing home.

OBJECTIVE: A growing number of nursing homes across the country are embarking on culture change transformations that focus on maximizing elder residents' quality of life (QOL). Challenges to culture change implementation include the wide range of possible interventions as well as a lack of research-based evidence to guide these choices. The purpose of this study was to determine those components of nursing home QOL that are associated with elder satisfaction so as to provide direction in the culture change journey. DESIGN: A cross-sectional study using a survey administered face-to-face. SETTING: Three large urban nursing homes within a long term care system in New York State. PARTICIPANTS: Sixty-two elder nursing home residents participated in face-to-face interviews. All elders had resided in their nursing communities for at least 3 months before participation. MEASUREMENTS: The survey included the Quality of Life Scales for Nursing Home Residents, which examines elder QOL in 11 domains: autonomy, dignity, food enjoyment, functional competence, individuality, meaningful activity, physical comfort, privacy, relationships, security, and spiritual well-being. Elder satisfaction with the nursing home and nursing home staff were also examined. RESULTS: After accounting for cognitive and physical functioning, among the QOL domains, dignity, spiritual well-being, and food enjoyment remained predictors of overall nursing home satisfaction. Additionally, dignity remained a significant predictor of elder satisfaction with staff. CONCLUSION: These results provide one possible path in the culture change journey based on empirical findings.

Perceived barriers to communication between hospital and nursing home at time of patient transfer.

OBJECTIVES: To identify perceived barriers to communication between hospital and nursing home at the time of patient transfer and examine associations between perceived barriers and hospital and nursing home characteristics. DESIGN: Mailed survey. SETTING: Medicare- or Medicaid-certified nursing homes in New York State. PARTICIPANTS: Nursing home administrators, with input from other nursing home staff. MEASUREMENTS: Respondents rated the importance as a barrier to hospital-nursing home communication of (1) hospital providers' attitude, time, effort, training, payment, and familiarity with nursing home patients; (2) unplanned and off-hours transfers; (3) HIPAA privacy regulations; and (4) lost or failed information transmission. Associations were determined between barriers and the following organizational characteristics: (1) hospital-nursing home affiliations, pharmacy or laboratory agreements, cross-site staff visits, and cross-site physician care; (2) hospital size, teaching status, and frequency of geriatrics specialty care; (3) nursing home size, location, type, staffing, and Medicare quality indicators; and (4) hospital-to-nursing home communication, consistency of hospital care with health care goals, and communication quality improvement efforts. RESULTS: Of 647 questionnaires sent, 229 were returned (35.4%). The most frequently reported perceived barriers to communication were sudden or unplanned transfers (44.4%), transfers that occur at night or on the weekend (41.4%), and hospital providers' lack of effort (51.0%), lack of familiarity with patients (45.0%), and lack of time (43.5%). Increased hospital size, teaching hospitals, and urban nursing home location were associated with greater perceived importance of these barriers, and cross-site staff visits and hospital provision of laboratory and pharmacy services to the nursing home were associated with lower perceived importance of these barriers. CONCLUSIONS: Hospital and nursing home characteristics and interorganizational relationships were associated with nursing home administrators' perceptions of barriers to hospital-nursing home communication. These findings may inform design and targeting of interventions to improve intersite communication processes.

Organizational relationships between nursing homes and hospitals and quality of care during hospital-nursing home patient transfers.

OBJECTIVES: To identify organizational factors and hospital and nursing home organizational relationships associated with more-effective processes of care during hospital-nursing home patient transfer. DESIGN: Mailed survey. SETTING: Medicare- or Medicaid-certified nursing homes in New York State. PARTICIPANTS: Nursing home administrators, with input from other nursing home staff. MEASUREMENTS: Key predictor variables were travel time between the hospital and the nursing home, affiliation with the same health system, same corporate owner, trainees from the same institution, pharmacy or laboratory agreements, continuous physician care, number of beds in the hospital, teaching status, and frequency of geriatrics specialty care in the hospital. Key dependent variables were hospital-to-nursing home communication, continuous adherence to healthcare goals, and patient and family satisfaction with hospital care. RESULTS: Of 647 questionnaires sent, 229 were returned (35.4%). There was no relationship between hospital-nursing home interorganizational relationships and communication, healthcare goal adherence, and satisfaction measures. Geriatrics specialty care in the hospital (r=0.157; P=.04) and fewer hospital beds (r=-0.194; P=.01) were each associated with nursing homes more often receiving all information needed to care for patients transferred from the hospital. Teaching status (r=0.230; P=.001) and geriatrics specialty care (r=0.185; P=.01) were associated with hospital care more often consistent with healthcare goals established in the nursing home. CONCLUSION: No management-level organizational relationship between nursing home and hospital was associated with better hospital-to-nursing home transfer process of care. Geriatrics specialty care and characteristics of the hospital were associated with better hospital-to-nursing home transfer processes.