Direct Care Workers Research Articles

Exploring the impact of nursing home managers' leadership on staff job satisfaction, health and intention to leave in nursing homes.

To explore the impact of nursing home leadership and staffing characteristics on staff job satisfaction, health and intention to leave. The number of older people has outpaced growth in the nursing home workforce worldwide. Identifying predictors with the potential to positively impact staff job satisfaction, health and intentions to leave are important. Leadership of the nursing home manager can be one such predictor. Cross-sectional design. A sample of 2985 direct care staff in 190 nursing homes in 43 randomly selected municipalities in Sweden completed surveys on leadership, job satisfaction, self-rated health and intention to leave (response rate 52%). Descriptive statistics and Generalised Estimating Equations were conducted. The STROBE reporting checklist was applied. Nursing home managers' leadership was positively related to job satisfaction, self-rated health and low intention to leave. Lower staff educational levels were related to poorer health and lower job satisfaction. Nursing home leadership plays a significant role in the job satisfaction, self-reported health and intention to leave of direct care staff. Low education levels among staff seem to negatively influence staff health and job satisfaction, suggesting that educational initiatives for less-educated staff could be beneficial for improving staff health and job satisfaction. Managers seeking to improve staff job satisfaction can consider how they support, coach and provide feedback. Recognising staff achievement at work can contribute to high job satisfaction. One important implication for managers is to offer continuing education to staff with lower or no education, given the large amount of uneducated direct care workers in aged care and the impact this may have on staff job satisfaction and health. No patient or public contribution was required to outcome measures in this study. Direct care staff and managers contributed with data.

Training Direct Care Staff to Empower Adults with Intellectual Disabilities and Their Families to Reduce Overmedication

ObjectivesPeople with intellectual and developmental disabilities (IDD) and autism are subject to restrictive practices like physical restraint and the overuse of psychotropic medications for challenging behavior. People with disabilities and their families are often not involved in shared decision-making for prescription and other care planning, which may violate the UN Human Rights Charter.MethodsOne way of reducing overmedication is by empowering adults with IDD and their family caregivers to collaborate in the decision to use medications. SPECTROM (https://spectrom.wixsite.com/project), a training program for direct care workers, was developed to help reduce the overmedication of these people. This article presents ideas on how SPECTROM resources could empower adults with IDD and their families to influence their care decisions, including psychotropic prescribing.ResultsInformation provided in 32 easy-read leaflets in SPECTROM on psychotropic medications can be used to improve shared decision-making involving people with IDD and their families. Similarly, the Yellow Passport, an easy-read health record, could help information sharing among care service providers, thus improving their health care. SPECTROM has one module devoted to effectively engaging with people with IDD to improve their communication and help them with their skills building.ConclusionsCurrently, very limited evidence exists on the effects of SPECTROM to empower individuals with IDD and their families in reducing psychotropic medications for challenging behaviors. In addition to the two pilot studies on SPECTROM from UK and Australia, further research is needed to explore the evidence supporting the above suggestions.

Paperwork, Paradox, and PRN: Psychotropic Medication Deficiencies in Assisted Living.

Individual state approaches to assisted living/residential care (AL/RC) licensing and oversight in the United States result in different practice standards and requirements, including psychotropic medication use. We examined 170 psychotropic medication deficiency citations issued to 152 Oregon AL/RC settings from 2015 to 2019. Applied thematic analysis resulted in the following themes: (1) documentation issues are primarily responsible for noncompliance, (2) unclear parameters place direct care workers in a role paradox, and (3) there is a persistent disconnect about when to seek qualified expertise before requesting psychotropic medications. AL/RC-specific mechanisms for medication prescription and administration are necessary to improve the structure and processes of care. Policymakers might consider how regulations unintentionally incentivize task-oriented versus person-centered care practices.

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

We examined the frequency and categories of end-of-life care transitions among assisted living community decedents and their associations with state staffing and training regulations. Cohort study. Medicare beneficiaries who resided in assisted living facilities and had validated death dates in 2018-2019 (N= 113,662). We used Medicare claims and assessment data for a cohort of assisted living decedents. Generalized linear models were used to examine the associations between state staffing and training requirements and end-of-life care transitions. The frequency of end-of-life care transitions was the outcome of interest. State staffing and training regulations were the key covariates. We controlled for individual, assisted living, and area-level characteristics. End-of-life care transitions were observed among 34.89% of our study sample in the last 30days before death, and among 17.25% in the last 7days. Higher frequency of care transitions in the last 7days of life was associated with higher regulatory specificity of licensed [incidence risk ratio (IRR)= 1.08; P= .002] and direct care worker staffing (IRR= 1.22; P < .0001). Greater regulatory specificity of direct care worker training (IRR= 0.75; P < .0001) was associated with fewer transitions. Similar associations were found for direct care worker staffing (IRR= 1.15; P < .0001) and training (IRR= 0.79; P < .001) and transitions within 30 days of death. There were significant variations in the number of care transitions across states. The frequency of end-of-life care transitions among assisted living decedents during the last 7 or 30days of life was associated with state regulatory specificity for staffing and staff training. State governments and assisted living administrators may wish to set more explicit guidelines for assisted living staffing and training to help improve end-of-life quality of care.

Feasibility and Acceptability of Community-Based Telehealth to Prevent Long-Term Care Readmission.

Transitioning to community living after long-term care requires multiple complex individualized interventions to prevent readmission. The current focus of home and community-based services (HCBS) is on increasing consumer engagement and individualizing care. Telehealth interventions provide additional services without the burden of face-to-face encounters and have yet to be evaluated for feasibility and acceptability in rural HCBS. West Virginia Bureau for Medical Services and West Virginia University implemented and evaluated a telehealth intervention with 26 Aged and Disabled Waiver or Traumatic Brain Injury Waiver participants who were transitioning back into their communities from a long-term care facility. Feasibility was assessed through recruitment process, fidelity to planned intervention, number of people eligible for participation, number of individuals enrolling in the intervention, enrollment process, completed enrollment, engagement in the intervention, number of weeks participating in the intervention, type of devices provided, attrition, and fidelity to original intervention. Satisfaction with services was used as a marker of acceptability for both participants and providers. Half (n = 12) of the enrolled population completed the full 24-week telehealth monitoring period and modification of the original intervention was necessary for most. Provider and participant satisfaction was high. Recruitment and enrollment may have been affected by COVID-19. Future implementation will continue to track recruitment and retention efforts. Individualized care plans, demonstration and practice with equipment, family or direct-care worker presence, and live technical support through the phone are needed. Primary care provider and in-home direct-care worker satisfaction workflow planning and evaluation are required.

Blessings and barriers: Achieving autonomous practice in Florida.

Florida advanced practice registered nurses have worked tirelessly for many years to practice to the fullest extent of their training and education, yet medical associations halted any progress they have tried to make. In the 2020 legislative session, House Bill 607, the Direct Care Workers bill was finally passed, allowing nurse practitioners who practice in specific primary care areas to practice autonomously. This still requires many Advanced Practice Registered Nurses in the state to have a collaborative practice agreement. Therefore, there is more work to be done to remove those practice barriers.

The development of a long-term care infection prevention compendium during the COVID-19 pandemic

Long-term care (LTC) facilitiesexperienced significant morbidity and mortality rates among both residents and staff during the COVID-19 pandemic, for which they were ill-prepared to practice adequate infection prevention and control (IPC). Our team developed a process for creating a compendium of curated IPC resources. This process harnessed the experience and expertise of nurses actively working in LTC during the pandemic. The publicly available online compendium of IPC resources is relevant to all departments found within LTC settings. The compendium contains a wide array of IPC tools, research, reports, international resources, and customizable educational slide decks. Online repositories of curated IPC resources can equip direct care workers with accurate, easily accessible resources to support the maintenance of proper IPC practice and protocol in LTC settings. Future research should evaluate the effectiveness and usefulness of this model and explore its utility in additional medical contexts.

Community aged care in Australia: the need for innovative programmes to boost workforce capacity

Across Western nations, ‘ageing in place’ policies rely on having a sufficient and skilled aged care workforce. In Australia, due to the impact of successive policy reforms, this workforce including the sector that provides community-based services has declined in number and skills. At the same time the need to upskill and sustain this workforce has intensified as the frailty and health needs of consumers have increased. This paper reports on an integrative literature review undertaken during 2021 to describe workforce needs and peer reviewed reports of programs instituted in aged care settings that aimed to address these needs. The review sought to examine programs implemented in both long-term and community care settings and to draw from these elements that may be utilised in future program design across the sector. It focussed primarily on workforce deficits in the community aged care sector and on the capacity of rurally-based services to meet and respond to growing consumer demand. The findings emphasise current workforce deficits while they also reveal a paucity of peer-reviewed reports of implemented programs across the sector as a whole. Nevertheless, the few programs examined in this review provide examples of the capacity and willingness of workers and providers to trial measures that aim to increase the recruitment, retention, skill and job-satisfaction of direct care workers. We propose that the key elements of the programs identified in this paper provide the foundation for the development of strategically designed programs that address particular workforce needs such as those shaped by rural contexts.

Perceptions of direct care workers in two sustainable communities on services provided

Currently, outcomes for people with autism and intellectual disabilities are poor, leaving some needing optimal life-long services. Little is known regarding the services provided at sustainable communities. This study’s purpose is to explore the make-up of sustainable communities, those participating in them, and the services provided. One survey containing demographic, descriptive, and quality of life questions was sent to sustainable communities. Survey results revealed that the two communities offer similar services, employ similar staff, and have a common central theme throughout their community. However, the two communities carry out services in very different ways. Quantitative results demonstrate participants achieving statistically similar mean quality of life scores. A correlation indicates that as the frequency of services increases, so does the quality of life. This research suggests these two communities deliver services leading to high levels of quality of life. Results should guide future avenues of research. We also make recommendations for sustainable communities and those considering sustainable communities.

A Profile of the Direct Care Workforce in Home- and Community-Based Services.

We used data from the 2020 American Community Survey to compare direct care workers (DCWs) in home and community-based services (HCBS) with workers in other long-term supportive services (LTSS), such as skilled nursing facilities (SNFs) and assisted living facilities (ALFs). Compared to DCWs in SNFs and ALFs, a higher proportion of DCWs in HCBS were over age 65, Latino/a, and single. A lower proportion of DCWs in HCBS worked for a for-profit company, worked year-round and full-time, and had employer-based health insurance.

The Impact of Wages on Care Home Quality in England.

In many countries, a large proportion of long-term care staff are paid at, or near, minimum wage, leading to concerns of negative effects on care outcomes. This study analyzed the effect of staff wages on care home quality ratings in England. A national staffing database of long-term care providers was matched with local-area information on needs and supply to construct a 3-year panel (2016-2018) of English care home observations. Using multiple imputation methods to address missing data provided a data set of 12,055 observations of 5,556 care facilities (both residential and nursing homes). We analyzed the effect of the facility-level average hourly wage of care staff on national regulator quality ratings. A measure of the impact of exogenous changes in the national minimum wage on care facilities was used as an instrument for wage. We find that wages positively affect care home quality ratings. Other things equal, a 10% increase in the average hourly wage of direct care workers would lead to a 7.1% increase in the likelihood that a care home will have a high-quality rating. The wage effect on quality was significant when controlling for staff skill mix, measured as the share of registered nurses in nursing home staff. This study provides important evidence of the positive impact that staff pay can have on the quality of long-term care. Our finding has important implications for appropriate levels of pay and the funding of long-term care.

Stabilizing the Direct Care Workforce: Challenges and Progress

The pandemic intensified a 25-year direct care worker (DCW) crisis in the United States. COVID-19 along with preexisting recruitment and retention challenges have pushed many workers to leave their positions caring for some of the most vulnerable of our society when economic challenges, illness, fear, and family responsibilities became too much to handle (Johnson et al., 2021). Projections predict an additional 1.2 million new positions are needed by 2030, predominately in home- and community-based services (HCBS), leading some experts to recast this situation from workforce crisis to systemic failure (Johnson et al., 2021; Paraprofessional Healthcare Institute, 2022). However, collaborative work among researchers, advocates, and politicians at the state and federal level in a variety of states has led to actionable plans poised to make meaningful progress toward righting the complex and cumbersome ship that is the long-term services and supports (LTSS) system here in the United States and the workforce that is its “backbone” (Bogenschutz et al., 2014).

Factors Affecting Mealtime Difficulties in Older Adults with Dementia Living in Long-Term Care Facilities: A Multilevel Model Analysis

Aim(s). This study conducted a multilevel analysis of mealtime difficulties in older adults with dementia based on the social-ecological model. Background. Mealtime difficulty in this population should be examined from an extensive perspective, rather than approaching it as an individual problem. Method(s). This was a cross-sectional study involving 342 participant dyads from 57 long-term care facilities; 114 direct care workers; and 342 older adults with dementia. A multilevel regression analysis was conducted using the MPlus 8.0 program. Results. Among intrapersonal factors, age, cognitive function, activities of daily living, and number of beds in the facility were identified as affecting mealtime difficulty. Environmental factors included meal assistant education experience and whether an environment suitable for eating had been established. Conclusion(s). The results show that intrapersonal factors exert a large influence on the mealtime difficulties of older adults with dementia in long-term care facilities and support the need to improve environmental factors, which are modifiable. Implications for Nursing Management. This study provided useful information about the influence of leaders on mealtime difficulties in older adults with dementia. Leaders should establish an environment in the facility for reduced mealtime difficulties.

Who Will Care for Rural Older Adults? Measuring the Direct Care Workforce in Rural Areas.

Using the 2021 Occupational Employment and Wage Statistics (OEWS) dataset, we calculate the ratio of direct care workers relative to the population of older adults (ages 65+) across rural and urban areas in the US. We find that there are, on average, 32.9 home health aides per 1000 older adults (age 65+) in rural areas and 50.4 home health aides per 1000 older adults in urban areas. There are, on average, 20.9 nursing assistants per 1000 older adults in rural areas and 25.3 nursing assistants per 1000 older adults in urban areas. There is substantial regional variation. Greater investment needs to be made in improving wages and job quality for direct care workers to attract workers to these critical occupations, especially in rural areas where the need for direct care is greater.

“It's your Liangxin that tells you what to do”: Interpreting workplace-induced emotions in a Chinese nursing home

How Direct Care Workers (DCWs) interpret their work and perform care activities undeniably impacts the well-being of institutionalized older adults. Despite the emotionally charged nature of paid care work, little is known about how Chinese DCWs talk about their work and construct meaning within China's unique social context of a burgeoning institutional care market and changing cultural expectations for long-term care. This study qualitatively explored Chinese DCWs' emotion work as they navigate among institutional pressures and low social recognition in an urban government-sponsored nursing home in central China. Results revealed that DCWs used Liangxin (the good heart/mind) – a ubiquitous Chinese moral notion emphasizing the unity of feeling, thought, and action – as an interpretive framework, including its four dimensions (ceyin, xiue, cirang, and shifei), to inform care practice, manage emotions, and find dignity within what can be personally demeaning and socially devalued work. Our study delineated the processes through which DCWs sympathized with the pain and struggles of the older adults in their care (ceyin xin), shamed unjust attitudes and behaviors embedded in institutional care (xiue xin), delivered family-like relational care (cirang xin), and formed and reinforced principles of good (versus bad) care (shifei xin). We also revealed the nuanced role that the cultural value of xiao (filial piety), working in tandem with liangxin, both shaped the emotional terrain of the institutional care setting and impacted how DCWs engaged in emotion work. While recognizing the effect of liangxin for incentivizing DCWs to provide relational care and renegotiate their role status, we were also alerted to the risks of overburdening and exploiting DCWs who relied solely on their liangxin to meet complex care needs.

The Impact of COVID-19 on the Person-Centered Care Practices in Nursing Homes.

The COVID-19 pandemic has had a significant impact on long-term care residents, family, and staff. Nursing homes are facing persistent challenges such as staff shortage, lack of personal protective equipment (PPE), and staff experiencing mental health issues including burnout. COVID-19 precautions may have made implementing person-centered care (PCC) in nursing homes more difficult. This report provides a descriptive analysis of perceived COVID-19 impact on the PCC practice in nursing homes. Surveys (N = 379) were collected from 11 nursing homes across Georgia. PCC practice barriers include reduced choice for residents, staff anxiety related to COVID-19 precautions, increased prevalence of short-staffing, and expanded duties for direct care workers. Facilitators for PCC were also present and included staff engagement, the provision of mental health resources, supervisor support, and empowerment of staff. Applied practice and research to address these barriers and expand implementation of facilitators is needed.

Job Quality and Job Separation of Direct Care Workers in England.

Most job leavers in the long-term care (LTC) sector in England do not leave the sector, but rather move to other LTC employers. Nevertheless, the high "churn" can have a negative impact on continuity and quality of care, care providers' recruitment and training costs, and the remaining staff workload and motivation. This study aimed to provide quantitative evidence on the drivers of direct care workers' job separation in England, with a focus on job quality. We used yearly data (2016-19) from the Adult Social Care Workforce Data Set, the leading source of LTC workforce data in England, including information on both LTC workers and employers. The analysis considered panel data econometric methods that accounted for unobserved heterogeneity at worker and employer levels. After controlling for observed individual, organizational, and local market characteristics as well as unobserved worker and employer heterogeneity, we found that everything else being equal, wages and employment conditions (i.e., full-time contracts and contracts with guaranteed working hours) significantly reduce job separation. For example, a 10% wage increase from the sample mean would reduce the job separation rate by about 3 percentage points. This wage effect was more than halved (i.e., downward biased) when not accounting for unobserved effects. The persistent high staff turnover in LTC in England highlights the need for finding practical solutions faced by care providers and policy-makers. Our findings showed that improving pay and employment conditions can be the way forward while methodologically stressing the importance of accounting for unobserved variable bias.

Insights and Innovation: How a Local Public-Private Partnership is Building Home Care.

Recent national reports asserted an urgent imperative for transforming working conditions for the direct care workforce in the US. These clarion reports identified key influencers in reform as federal and state governments, workers' unions and coalitions, individual and organizational employers. Equally essential and well-positioned local actors have been overlooked in the conversation-namely, municipalities, area agencies on aging, higher education, philanthropic entities, and community. Although deemed "essential," direct care workers have been disproportionately affected by the COVID-19 pandemic. This paper examines an early public-private partnership initiative designed to recruit and train PCAs in Virginia.

“They Can’t See Me Smile”: Communication and Relationship Challenges of Providing Home Care During a Pandemic

ABSTRACT Providing home care to individuals with intellectual and developmental disabilities can be challenging in the best of times. Communication and relationships, which are both critical to the care provided by Direct Support Professionals (DSPs), were impacted significantly during the COVID-19 pandemic. Using interpretive research methods with DSPs at a Midwestern agency, this study identifies communication and relationship challenges brought on by the COVID-19 pandemic and strategies used to manage those challenges. COVID-19 protocols like masking, cleaning procedures, and cared-for individuals’ home confinement created significant relational challenges including misunderstandings, changing routines, and fluctuating roles. DSPs also discussed how those challenges were overcome, including communication adaptation, creativity, and empathy. By examining the strategies DSPs used to negotiate the challenges and their changing roles, insight can be gained into how organizations might best support direct care workers in times of significant stress and uncertainty. This study builds on the growing scholarship exploring the impact of COVID-19 on health care communication.

Deinstitutionalization, Disease, and the HCBS Crisis

Primarily funded by Medicaid, home- and community-based services (HCBS) allow disabled people and seniors to receive vital health and personal services in their own homes and communities rather than in institutions like nursing homes and other congregant care facilities. The HCBS system is facing a growing crisis of care nationwide; more than 600,000 people are waitlisted for services, thousands of direct care workers are leaving the industry, and states are not committed to deinstitutionalization. The COVID-19 pandemic has highlighted and exacerbated these problems, as people in institutional settings face infection and death at far higher rates than those housed outside them. This Note offers solutions to the HCBS crisis. In particular, it explores two strategies that could help expand access to HCBS, regardless of whether the federal government increases its funding: (1) expanding and creatively using Olmstead, a landmark disability rights case, to force states to deinstitutionalize; and (2) adding a new title to the Americans with Disabilities Act focused on emergency relief. Together, these two solutions would help get people out of institutions while creating a more resilient healthcare infrastructure for future emergencies.