Long-term Care Research Research Articles

A REFLECTION OF A STUDENT-LED VIRTUAL REALITY ADOPTION PROGRAM FOR PEOPLE LIVING WITH DEMENTIA IN LONG-TERM CARE

Abstract Previous research suggests that virtual reality (VR) holds promise in improving residents’ well-being in long-term care (LTC). With ongoing staff shortages, there is a critical need to explore, evaluate and share learnings on innovative approaches for adopting technologies, including VR, in LTC. In our research study conducted at two LTC homes in Vancouver, Canada, undergraduate students supported staff members in VR adoption. This study reflects on the opportunities and challenges of VR adoption from the students’ perspectives. Utilizing a critical reflection framework, our interdisciplinary team engaged in extensive discussions and reflections via Zoom meetings, resulting in the following five themes: (1) Challenging the stigma towards dementia in LTC, (2) Addressing ageism in older adults’ technology usage, (3) Building relationships through consistent and repeated visits to facilitate technology adoption, (4) Recognizing students’ value in technology implementation and their potential impact on LTC’s future workforce, and (5) Recognizing the importance of emotional and organizational support. Based on these reflections, our team devised the “ENRICH” framework, offering six practical tips to support student involvement in enhancing technology adoption in LTC. The team’s insights highlight the potential of engaging university students in promoting technology adoption in LTC settings. The “ENRICH” framework provides a practical approach to fostering technology uptake while offering valuable learning experiences for students. This study encourages further exploration of student participation in LTC research to advance future initiatives in this field.

Using large language model (LLM) to identify high-burden informal caregivers in long-term care

BackgroundThe rising global elderly population increases the demand for caregiving, yet traditional methods may not fully assess the challenges faced by vital informal caregivers. ObjectiveTo investigate the efficacy of Large Language Model (LLM) in detecting overburdened informal caregivers, benchmarking against rule-based and machine learning methods. Methods1,791 eligible informal caregivers from Southern Taiwan and utilized their textual case summary reports for the LLM. We also employed structured questionnaire results for machine learning models. Furthermore, we leveraged the visualization of the LLM's attention mechanisms to enhance our understanding of the model's interpretative capabilities. ResultsThe LLM achieved an Area Under the Receiver Operating Characteristic (AUROC) curve of 0.84 and an Area Under the Precision-Recall Curve (AUPRC) of 0.70, marking an 8% and 14% improvement over traditional methods. The visualization of the attention mechanism accurately reflected the evaluations of human experts, concentrating on descriptions of high-burden descriptions and the relationships between caregivers and recipients. ConclusionThis research demonstrates the notable capability of LLM to accurately identify high-burden caregivers in Long-term Care (LTC) settings. Compared to traditional approaches, LLM offers an opportunity for the future of LTC research and policymaking.

An example of conducting participatory action research within the Living Lab in Ageing and Long-Term Care: Developing, evaluating, and implementing a reablement training programme

Demand for long-term care is rising, because of the aging of the population and the increase in chronic and degenerative diseases. Both community and institutional care services are facing challenges, not only caused by aggregated care needs but also through technological and related health care innovations. At the same time, the number of well-trained staff is decreasing, partly due to a negative image of care provision within the field of geriatrics. Innovations that address the changing needs and demands of the future are highly warranted and there is a strong need to develop and implement evidence-based practice and technology. Unfortunately, it may take on average up to 17 years before scientific knowledge is adopted in daily practice, and there is not a strong tradition of scientific research in long-term care. The result is that older people and their families, health care professionals, policy makers, and educators do not benefit sufficiently from new advancements and best available evidence.
 In this oral paper a model for a sustainable and successful interdisciplinary collaboration between scientists, care providers, and educators in long-term care will be presented: the “Living Lab in Ageing and Long-Term Care” by Maastricht University in the Netherlands. It is a structural collaboration between academia, educational institutions, long-term care providers and clients. It covers approximately 185 long-term care facilities (e.g. nursing homes, assisted and group living facilities) as well as professional home care, and includes about 50,000 clients and more than 27,000 staff. Their mission is to contribute with scientific research to improving i) quality of life of older people and their families; ii) quality of care and iii) quality of work of those working in long-term care. Key working mechanisms are the Linking Pins and interdisciplinary partnership using a team science approach, with great scientific and societal impact. For 25 years this structural collaboration has served as an infrastructure that drives scientific research in long-term care in co-creation with end-users, including older people and their relatives, health care professionals, policy makers and educators. More recently, the model of the living lab is replicated in other countries such as the UK, Belgium, Germany and Austria.
 After a brief description of the living lab, the collaboration between academia, educational institutions, long-term care providers and clients will be illustrated by introducing the “Stay Active at Home” study. In this study a reablement training programme for home care staff is developed, evaluated and implemented. The programme aims to teach home care staff how to stimulate clients’ autonomy and participation in meaningful daily activities. Finally, the symposium will end with suggestions how to replicate the model of the Living Lab in Ageing and Long-term Care in other places.

NATURAL ENVIRONMENTS’ INFLUENCE ON RESPONSIVE BEHAVIOUR, WORK-RELATED STRESS, BURNOUT, AND TURNOVER INTENTION

Abstract Natural environments in healthcare design are thought to promote health. However, its empirical research in long-term care (LTC) has been limited; the degree of rigor is mixed, focusing on older adults with little research on professional caregivers. This study examined the relationships between the natural environment and the mental health and well-being of older adults 65+ living with Alzheimer’s disease and related dementias (residents) and of their professional caregivers in LTC homes using a rigorously developed survey to standardize an approach to the evaluation of natural environments for these population groups. A cross-sectional, multiphase mixed method study was conducted that included a scoping review (n=137), a Delphi panel (n=24 experts), cognitive debriefing interviews (n=33), psychometric evaluations (n=83 LTC home areas), and multilevel modeling and regression analyses (n=1599 residents; n=563 professional caregivers). A conceptual framework on the natural environment in healthcare was developed, which informed the development of the Natural Environment Survey for Long-Term Care. This survey evaluates 1) the design of natural environments, 2) residents’ usage of and exposure to natural environments, and 3) professional caregivers’ usage of, exposure to, and perception of natural environments. Unlocked doors to outdoor spaces, outdoor activities, and indoor activities were significantly associated with residents’ responsive behavior in secure home areas (i.e., locked access and egress). Usage of and exposure to the natural environment during breaks and leisure were associated with their professional caregivers’ work-related stress, burnout, and turnover intention in secure and non-secure home areas. These findings have potential utility for decision-makers transforming LTC.

POLICY SERIES: THE MOVING FORWARD NURSING HOME COALITION: NURSING HOME REFORM AND THE RESIDENTS’ GOALS, PREFERENCES, AND PRIORITIES

Abstract The 2022 National Academies of Sciences, Engineering, and Medicine (NASEM) report called for nursing facilities to provide “care aligned to the individual’s goals and preferences.” Missing has been an efficient process to uncover the individual’s detailed goals, preferences, and priorities (GPPs). GPPs are a care planning process that translates into actionable interventions, supported by quality measurement to determine whether the care provided aligns with those GPPs, and health information technology to collect GPPs efficiently and to determine if the care provided is concordant with the individual’s GPPs. A diverse set of experts representing the Moving Forward Nursing Home Quality Coalition are collaborating to develop an integrated approach to these shortcomings and will discuss these issues in detail including new approaches to the identification and documentation of GPPs for use in a modified care planning process, the status of health information technologies (HIT) processes being developed to support these changes and the development of new quality measures. While the Moving Forward Coalition is focused on nursing facilities, the approaches being developed here to improve care and to standardize the vocabulary for GPPs are applicable to all care settings. Three committees from the Moving Forward Nursing Home Coalition will present work focused on the development of a standardized GPP care planning process to enhance the identification, documentation, communication, and implementation of resident GPPs, the measurement of the care planning process to support process improvement, and the creation of a HIT-enabled process to measure the concordance of care provided with an individual’s GPPs. This is a collaborative symposium between the Aging Workforce, Hospital Elder Life Program, Measurement, Statistics, and Research Design, Systems Research in Long Term-Care, and Technology and Aging Interest Groups.

Systematic review of research barriers, facilitators, and stakeholders in long-term care and geriatric settings, and a conceptual mapping framework to build research capacity

BackgroundOlder adults are underrepresented in research. Heterogeneity of research processes in this population, specifically in long-term care (LTC) and geriatric acute care (GAC), is not well described and may impede the design, planning, and conduct of research. In this study, we identified, quantified, and mapped stakeholders, research stages, and transversal themes of research processes, to develop a mapping framework to improve research capacity by better characterizing this heterogeneity.MethodsMulticomponent mixed methods study. An environmental scan was used to initiate a preliminary framework. We conducted a systematic literature search on processes, barriers, and methods for clinical research in GAC and LTC to extract and update stakeholders, research stages, and themes. Importance and interactions of elements were synthesized via heatmaps by number of articles, mentions, and content intersections.ResultsFor our initial framework and environmental scan, we surveyed 24 stakeholders. Of 9277 records, 68 articles were included in our systematic review and allowed us to identify 12 stakeholders, 13 research stages, 17 transversal themes (either barriers, facilitators, general themes, or recommendations), and 1868 intersections. Differences in relative importance between LTC and GAC emerged for stakeholders (staff, managers vs. caregivers, ethics committees), and for research stages (funding, facility recruitment vs. ethics, individual recruitment). Crucial themes according to specific stakeholders were collaboration for the research team; communication, trust, and human resources for managers; heterogeneity for patients and residents. A heatmap framework synthesizing vital stakeholders and themes per research stage was generated.ConclusionsWe identified and quantified the interactions between stakeholders, stages, and themes to characterize heterogeneity in LTC and GAC research. Our framework may serve as a blueprint to co-construct and improve each stage of the research process.

Citizen Science as a Framework for Improving the Science-Society Interface in Long-Term Care Research

Citizen Science as a Framework for Improving the Science-Society Interface in Long-Term Care Research

Long-Term Care Research in the Context of COVID-19 Pandemic: A Bibliometric Analysis.

Despite the increasing awareness of long-term care (LTC) research after the outbreak of COVID-19 pandemic, little attention was given to quantitatively describe the evolution of the research field during this period. A total of 1024 articles retrieved from the Web of Science Core Collection database were systematically analyzed using CiteSpace visualization software. The overall characteristics analysis showed that, in the context of the pandemic, attention to LTC research increased significantly-over 800 articles were published in the past two years. The USA, Canada, Italy, and England formed the leading LTC research group, which was consistent with the conclusions of existing bibliometric studies on LTC research before the outbreak. A rigorous analysis based on a dual perspective of references and keywords was applied to reveal that, compared with previous studies, in the context of the pandemic, the focus shifted from the mental and physical health status of older adults in need of LTC to the impact of the pandemic on those of older adults in LTC facilities, from the prevention of general epidemics to the prevention and response of significant public health emergencies, from providing and paying for LTC to strategies for LTC facilities to improve the quality of LTC and well-being of their residents during the pandemic. These findings can provide help and reference for academics, civil folks, and LTC practitioners, as well as help with the sustainable development of LTC research in the context of COVID-19 pandemic.

Comparison of research hotspots and trends in long-term care for the elderly between China and Australia: a bibliometric analysis†

Abstract Objective: To explore the current status and development of long-term care (LTC) research in terms of publications in China and Australia, to identify the major contributing authors and institutions, and to compare the research hotspots and trends between China and Australia in order to encourage informed collaborations and work in future. Methods: We collected bibliometric data on the LTC of the elderly in China and Australia from 2009 to 2020 using Chinese National Knowledge Infrastructure (CNKI) and Web of Science (WOS). CiteSpace software was used to analyze co-authorships, co-institutions, and co-keywords. Results: A total of 826 articles in Chinese and 393 in English were included for analysis. The total number of publications showed an upward trend in both countries. The top 10 productive researchers and institutions in China and Australia were identified, and their collaboration network was revealed. Then, the knowledge maps of cooccurring keywords, respectively, showed the hotspots of “LTC insurance, disabled elderly, combination of medical and health care, nursing home” and “nursing home, dementia, quality of life, intervention” in China and Australia. Strong citation burst keywords illustrated the emerging trends of “combination of medical and health care, healthy aging” in China and “polypharmacy, prevention” in Australia. Conclusions: This article provided an insight into LTC of the elderly in China and Australia, and research in this field is developing rapidly and is being increasingly valued. The findings will be useful for future researchers to facilitate collaboration, identify new topics, and support urgently needed research of LTC in China.

Older Black Lesbians' Needs and Expectations in Relation to Long-Term Care Facility Use.

There is a dearth of long-term care research that focuses on the expectations and experiences of older sexual minority (SM) adults. That research dwindles further when examining subgroups within that population such as older Black lesbians. The purpose of this study was to explore older Black lesbians' needs and expectations in relation to the utilization of long-term care (LTC) facilities. We conducted secondary data analysis using data from 14 focus groups that discussed health and aging with older Black lesbians. Transcriptions were analyzed in NVivo using deductive content analysis and structural coding. Three themes were identified in relation to needs and expectations for LTC facility use: (1) consideration or established plans to utilize a LTC facility, (2) concern for care facility environment, and (3) a desire to build one's own community. These findings illustrate how older Black lesbians are planning for a potential need for LTC, their concerns about utilizing LTC, and alternative approaches to avoid LTC use. There remains a continued need for LTC communities that are inclusive and supportive of SM older adults as well as more SM-only communities where older adults can live openly and authentically.

Characteristics of Working-Age Adults With Schizophrenia Newly Admitted to Nursing Homes.

Persons aged <65years account for a considerable proportion of US nursing home residents with schizophrenia. Because they are often excluded from psychiatric and long-term care studies, a contemporary understanding of the characteristics and management of working-age adults (22-64years old) with schizophrenia living in nursing homes is lacking. This study describes characteristics of working-age adults with schizophrenia admitted to US nursing homes in 2015 and examines variations in these characteristics by age and admission location. Factors associated with length of stay and discharge destination were also explored. This is a cross-sectional study using the Minimum Data Set 3.0 merged to Nursing Home Compare. This study examines working-age (22-64years) adults with schizophrenia at admission to a nursing home. Descriptive statistics of resident characteristics (sociodemographic, clinical comorbidities, functional status, and treatments) and facility characteristics (ownership, geography, size, and star ratings) were examined overall, stratified by age and by admission location. Generalized estimating equation models were used to explore the associations of age, discharge to the community, and length of stay with relevant resident and facility characteristics. Coefficient estimates, adjusted odds ratios, and 95% CIs are presented. Overall, many of the 28,330 working-age adults with schizophrenia had hypertension, diabetes, and obesity. Those in older age subcategories tended to have physical functional dependencies, cognitive impairments, and clinical comorbidities. Those in younger age subcategories tended to exhibit higher risk of psychiatric symptoms. Nursing home admission is likely inappropriate for many nursing home residents with schizophrenia aged <65years, especially those in younger age categories. Future psychiatric and long-term care research should include these residents to better understand the role of nursing homes in their care and should explore facility-level characteristics that may impact quality of care.

Changing Care: Applying the Transtheoretical Model of Change to Embed Equity, Diversity, and Inclusion in Long-Term Care Research in Canada

Healthcare policy reform is evident when considering the past, present and future of long-term care (LTC) in Canada. Some of the most pressing issues facing the LTC sector include the changing demographic composition in Canadian LTC homes, minimal consideration for the role of intersectionality in LTC data collection and analysis, and the expanding need to engage diverse participants and knowledge users. Using the Transtheoretical Model of Change (TTMC) as a framework, we consider opportunities to address intersectionality in LTC research. Engaging diverse knowledge users in LTC (e.g., unpaid caregivers, paid care staff), community (e.g., advocacy groups, service providers) and policy decision-makers (e.g., provincial government) is crucial. Empowering individuals to participate, modifying environments to support engagement, and facilitating ongoing partnerships with knowledge users are critical aspects of change efforts. Addressing structural barriers (e.g., accessibility, capacity, jurisdictional policies, and mandates) to research in LTC is also essential. The TTMC offers a framework for planning and enacting individual, organizational, and system-level changes for the future of LTC.

Do Staff in Your Facility Have a Job or a Role?

Do Staff in Your Facility Have a Job or a Role?

Ask us! Adjusting experience-based codesign to be responsive to people with intellectual disabilities, serious mental illness or older persons receiving support with independent living.

Experience-based codesign (EBCD) is a valuable tool for participatory quality improvement. However, the EBCD process needs to be adjusted to make it suitable for long-term care. The focus of the improvement process needs to shift to the care relationship, as this is an important part of the quality of care in these settings. Furthermore, the EBCD process needs to be made more accessible to vulnerable populations. Through a participatory research approach, EBCD was adjusted to long-term care. The research was conducted in two care organisations: one supporting people with serious mental illness and intellectual disabilities in independent living and one providing homecare services for older persons. The participatory research resulted in the development of 'Ask us!'-a method for critical reflective codesign. The research furthermore provided valuable lessons for participatory projects with vulnerable clients. A common problem with participatory research in long-term care is ensuring the involvement of clients and informal carers. We report on various strategies developed to include experiences of a diverse set of services users, such as combining interviews with participant observation, photo-voice and involving experts-by-experiences as co-ethnographers. In close collaboration with an inclusive theatre company, these experiences were translated into 42 short videos on complex situations in the care relationship from the perspective of clients, professionalsor informal carers. These videos instigate critical reflection and accelerate the participatory quality improvement process. Moreover, practical tools were developed to overcome barriers regarding the involvement of people with disabilities. These include the use of photo-elicitation to enable participation of clients with disabilities in heterogeneous group discussions and involving experts-by-experience as proxies to share experiences of clients for whom participation in the 'Ask us' method remains inaccessible. The result of a robust participatory process, 'Ask us!' is a promising method for participatory quality improvement in long-term care. The research furthermore generated lessons for involving vulnerable populations in participatory research and codesign. Clients were involved as informants, sharing their experiences with the care relationship in interviews, photovoice and observations. They were also involved as consultants, helping to analyse input for the film scripts during data validation sessions.

Measuring What Matters Across International Long-Term Care Settings

Measuring what matters most to residents, relatives and staff in residential long-term care settings is critical, yet underdeveloped in our predominantly frailty and deficits-focused measurement frameworks. The Worldwide Elements to Harmonize Research in Long-Term Care Living Environments (WE-THRIVE) consortium has previously prioritized measurement concepts in the areas of care outcomes, workforce and staffing, person-centered care, and care context. These concepts include knowing the resident and what matters most to the resident, and outcomes such as quality of life, and personhood. We present findings of our currently recommended measures, including both general population and dementia-specific measures, such as the Person-Centered Care Assessment Tool (PCAT), the Personhood in Dementia Questionnaire (PDQ), and the ICEpop CAPability Measure for Older People (ICECAP-O). We also describe remaining gaps in existing measures that will need to be addressed to fully specify common data elements focused on measuring what matters most to residents, relatives and staff.

Measuring What Matters in Long-Term Care: Common Data Elements in Brazil, China, and the United States

Internationally sharable common data elements on residential long-term care (LTC) settings, such as nursing homes and assisted living facilities, can facilitate comparisons across diverse LTC settings for valuable insights on LTC regulation and oversight, practice and operations, infrastructure development, human resources issues, and quality and safety. However, such insights are predicated on the premise that data elements capture information that matters to the full LTC community, including residents, relatives and staff, and are able to be collected across diverse care settings, including low-resource contexts. A critique of much current LTC measurement is its focus on deficits and loss, rather than thriving, person-centered care, and healthy aging, which have been established as important to LTC communities internationally. Further, measurement burden, cultural differences in perceptions of data sharing, and data infrastructure differences are key issues for international data. An international collaborative of LTC researchers—Worldwide Elements to Harmonize Research in Long-Term Care Living Environments (WE-THRIVE)—has developed a set of common data elements that are recommended for parsimoniously assessing key outcomes, workforce and staffing, person-centered care, and the contexts within which LTC settings operate. The studies in this symposium provide insights into the validation and implementation of WE-THRIVE recommended measures in diverse, low-resource LTC contexts, including LTC settings in Brazil, China, and rural Midwest US. Study findings validate WE-THRIVE measures, and provide new knowledge to inform capacity-building for the measurement of person-centered care and healthy aging outcomes in diverse, low-resource, LTC settings.

What Long-Term Care Interventions and Policy Measures Have Been Studied During the Covid-19 Pandemic? Findings from a Rapid Mapping Review of the Scientific Evidence Published During 2020

<strong>Context:</strong> Throughout the Covid-19 pandemic, long-term care researchers have aimed to generate evidence rapidly to inform the pandemic response. It is unclear which areas were prioritised during this period of rapid evidence generation. <strong>Objectives: </strong>We aimed to map the international scientific evidence on interventions and policy measures to mitigate the impacts of the Covid-19 pandemic on people who use and provide long-term care. <strong>Methods:</strong> We conducted a pragmatic, rapid mapping review of international evidence to identify the range of interventions, policies, and measures in long-term care studied during the Covid-19 pandemic and published throughout 2020. Studies were primarily identified from two academic databases (MEDLINE; Web of Science). <strong>Findings: </strong>We included 137 studies from 22 countries, mostly focusing on the United States, Europe, and Canada. Half of the studies focused on preventing or controlling Covid-19 infections. Other common types of interventions were measures to treat Covid-19 or improve access to general healthcare and studies of possible targets for policies and interventions, such as care home ownership. Only 13 studies covered home-based or community-based care. <strong>Limitations:</strong> This was a pragmatic review that aimed to map key areas of research in long-term care during the pandemic, rather than a systematic review of all available studies. <strong>Implications: </strong>During the first year of the Covid-19 pandemic, a substantial body of evidence on interventions to mitigate impacts of the pandemic in the long-term care sector emerged. However, reflecting the context and speed with which they were carried out, most studies did not apply an analytical lens and instead provided descriptive findings only. There were very few studies on home-based or community-based care settings. As countries assess the lessons that can be learnt from the pandemic and improve the preparedness of their long-term care systems for future pandemics and other shocks, it will be important to consider the importance of facilitating rapid generation of more robust evidence.

Capacity of nurses working in long-term care: A systematic review qualitative synthesis.

The United Nations calculates there were 703million adults 65years and older globally as of 2019 with this number projected to double by 2050. A significant number of older adults live with comorbid health conditions, making the role of a nurse in long-term care (LTC) complex. Our objective was to identify the challenges, facilitators, workload, professional development and clinical environment issues that influence nurses and nursing students to seek work and continue to work in LTC settings. Eligibility criteria included being a nurse in a LTC setting and research with a substantial qualitative component. Multiple databases (including Medline and CINAHL) were searched between 2013 and 2019 along with grey literature. Covidence was used to organise a team of 10 into a paired review of titles and abstracts to the final full text screening, extraction and appraisal with the CASP Qualitative Studies Checklist. Analysis involved a thematic synthesis approach. The Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) checklist informed the writing of the review. The search resulted in 18 articles and dissertations. Areas investigated included recruitment, resilience, employment and retention, how nurses perceived their professional work, rewards and difficulties, supervision, student preceptorship and career aspiration, nurses' perceptions of occupational status, along with leadership, education and development needs, and intentions to manage resident deteriorating health. The five themes were (1) perspectives of nursing influenced by the organisation, (2) pride in, and capacity to build relationships, (3) stretching beyond the technical skills, (4) autonomy, and (5) taking on the challenge of societal perceptions. This review revealed what is required to recruit nursing students to careers in LTC and retain nurses. To be explored is how staff can work to their full scope of practice and the resultant impact on resident care, including how to maximise a meaningful life for residents and their families. National Institute for Health Research UK (Prospero ID: CRD42019125214).

Strengthening International Research in Long-Term Care: Recommended Common Data Elements to Support Clinical Staff Training.

The purpose of this study is to develop candidate common data element (CDE) items related to clinical staff training in long-term care (LTC) homes that can be used to enable international comparative research. This paper is part of the WE-THRIVE (Worldwide Elements to Harmonize Research in Long-Term Care Living Environments) group’s initiative which aims to improve international academic collaboration. We followed best practices to develop CDEs by conducting a literature review of clinical staff (i.e., Regulated Nurses, Health Care Aides) training measures, and convening a subgroup of WE-THRIVE experts to review the literature review results to develop suitable CDEs. The international expert panel discussed and critically reflected on the current knowledge gaps from the literature review results. The panel proposed three candidate CDEs which focused on the presence of and the measurement of training. These three proposed CDEs seek to facilitate international research as well as assist in policy and decision-making regarding LTC homes worldwide. This study is a critical first step to develop candidate CDE items to measure staff training internationally. Further work is required to get feedback from other researchers about the proposed CDEs, and assess the feasibility of these CDEs in high and low resourced settings.

Intersectionality: Mapping Critical Relations for Quality in Long-Term Care Research

Intersectionality is a useful method (Lutz, 2015) for interdisciplinary long-term care (LTC) research to advance a more critical understanding of how experiences of quality are shaped by mutually reproducing social divisions, identities and relations of power that shape LTC. This paper discusses insights from the “Mapping Care Relationships” stream of the Seniors – Adding Life to Years (SALTY) project, a pan-Canadian program of research examining clinical, social and policy perspectives on quality in LTC. “Mapping Care Relationships” mapped how promising approaches to care relationships are organized and experienced in LTC. From January 2018-August 2019 our team of nine researchers conducted rapid ethnographies in eight nursing homes, two in each of four provinces across Canada. We purposively observed and interviewed workers from a wide variety of positions and backgrounds, informed by an intersectionality approach. We traced how promising approaches in person-centred dementia care (PCDC) in particular may reify the subordinated status of care workers (some more than others) and reinforce inequities within LTC systems. In multiple LTC homes, front-line care workers described experiencing physical and emotional harm in care relationships with residents which caused them distress. However, consistent with a PCDC approach, the harm was attributed to ‘behaviours’ clinically symptomatic of dementia. In framing power differentials from a medical perspective, PCDC makes it possible to interpret harmful experiences as 'part of the job’ and something workers should know to expect, prevent, avoid, redirect, or ignore. Lutz, H. (2015). Intersectionality as method. DiGeSt. Journal of diversity and gender studies, 2(1-2), 39-44.