Long-term Care Staff Research Articles

Evaluating immunity to SARS-CoV-2 in nursing home residents using saliva IgG.

SARS-CoV-2 circulating variants coupled with waning immunity pose a significant threat to the long-term care (LTC) population. Our objective was to measure salivary IgG antibodies in residents and staff of an LTC facility to (1) evaluate IgG response in saliva post-natural infection and vaccination and (2) assess its feasibility to describe the seroprevalence over time. We performed salivary IgG sampling of all residents and staff who agreed to test in a 150-bed skilled nursing facility during three seroprevalence surveys between October 2020 and February 2021. The facility had SARS-CoV-2 outbreaks in May 2020 and November 2020, when 45 of 138 and 37 of 125 residents were infected, respectively; they offered two Federal vaccine clinics in January 2021. We evaluated quantitative IgG in saliva to the Nucleocapsid (N), Spike (S), and Receptor-binding domain (RBD) Antigens of SARS-CoV-2 over time post-infection and post-vaccination. One hundred twenty-four residents and 28 staff underwent saliva serologic testing on one or more survey visits. Over three surveys, the SARS-CoV-2 seroprevalence at the facility was 49%, 64%, and 81%, respectively. IgG to S, RBD, and N Antigens all increased post infection. Post vaccination, the infection naïve group did not have a detectable N IgG level, and N IgG levels for the previously infected did not increase post vaccination (p < 0.001). Fully vaccinated subjects with prior COVID-19 infection had significantly higher RBD and S IgG responses compared with those who were infection-naïve prior to vaccination (p < 0.001 for both). Positive SARS-COV-2 IgG in saliva was concordant with prior infection (Anti N, S, RBD) and vaccination (Anti S, RBD) and remained above positivity threshold for up to 9 months from infection. Salivary sampling is a non-invasive method of tracking immunity and differentiating between prior infection and vaccination to inform the need for boosters in LTC residents and staff.

Using Telemedicine to Assess and Manage Psychosis in Neurodegenerative Diseases in Long-Term Care.

The coronavirus disease 2019 (COVID-19) epidemic has forced a sudden global implementation of telemedicine strategies, including in long-term care (LTC) facilities where many people with dementia and Parkinson disease (PD) reside. Telemedicine offers a unique set of advantages for residents in LTC facilities if effectively supported and implemented, including expanded access to specialists in rural or underserved areas or for people with dementia who cannot travel for off-site visits. Many medical and psychiatric organizations have recently issued new or updated guidelines on the use of telemedicine. On October 22, 2020, a multidisciplinary consensus panel was convened to collate a list of best practices for LTC facilities and specialists when conducting telemedicine with residents with dementia-related psychosis or PD-related psychosis (PDP).A collaborative effort between specialists, facility administrators, and facility staff is essential for the success of telemedicine in the LTC setting. Telemedicine in LTC facilities comes with increased administrative and technical challenges that fall heavily on the shoulders of the LTC facility administrators and staff. Specialists can ease this burden by maintaining flexibility and ensuring expression of empathy and thanks to the staff who are facilitating the visits. LTC staff can provide specialists with valuable information about their patients to aid in evaluation and diagnosis. Specialists can facilitate this exchange of information by speaking to staff who work closely with the resident about any signs of hallucinations or delusions they may have observed. Educational efforts can increase staff understanding of dementia and PDP and empower them to engage with, and facilitate the resident's treatment plan. Using these strategies to take advantage of the benefits of telemedicine, specialists and LTC staff can together expand and improve care for LTC facility residents with dementia-related psychosis or PDP.

Dance Wherever You Are: The Evolution of Multimodal Delivery for Social Inclusion of Rural Older Adults.

Background and ObjectivesOlder adult social inclusion involves meaningful participation that is increasingly mediated by information communication technology and in rural areas requires an understanding of older adults’ experiences in the context of the digital divide. This article examines how the multimodal streaming (live, prerecorded, blended in-person) of the Sharing Dance Older Adults program developed by Canada’s National Ballet School and Baycrest influenced social inclusion processes and outcomes in rural settings.Research Design and MethodsData were collected from on-site observations of dance sessions, research team reflections, focus groups, and interviews with older adult participants and their carers in pilot studies in the Peterborough region of Ontario and the Westman region of Manitoba, Canada (2017–2019). There were 289 participants including older adults, people living with dementia, family carers, long-term care staff, community facilitators, and volunteers. Analytic themes were framed in the context of rural older adult social exclusion.ResultsRemote delivery addressed barriers of physical distance by providing access to the arts-based program and enhancing opportunities for participation. Constraints were introduced by the use of technology in rural areas and mitigated by in-person facilitators and different streaming options. Meaningful engagement in dynamic interactions in the dance was achieved by involving local staff and volunteers in facilitation of and feedback on the program and its delivery. Different streaming technologies influenced social inclusion in different ways: live-stream enhanced connectedness, but constrained technical challenges; prerecorded was reliable, but less social; blended delivery provided options, but personalization was unsustainable.Discussion and ImplicationsUnderstanding different participants’ experiences of different technologies will contribute to more effective remote delivery of arts-based programs with options to use technology in various contexts depending on individual and organizational capacities.

Converting threats from COVID-19 in long term care into opportunities for improvement

The effects of the COVID-19 pandemic on long term care (LTC) have been published in the literature and experienced by residents, their support persons and nursing staff. The morbidity and mortality, as well as the threats of isolation and psychosocial distress continue. Both LTC residents and staff experience physiological and psychological impacts. Nurses can use the current threats produced by the pandemic to advocate for alternate models of care and reduced isolation for residents. The pandemic is an opportunity for nursing advocacy in LTC for shared governance and empowerment, involvement in policy development, and oversight in policy implementation. Nurses are presented with the opportunities for advocacy related to resources and reshaping the paradigm of residential care for older adults.

Excess Mortality in Long-Term Care Residents With and Without Personal Contact With Family or Friends During the COVID-19 Pandemic

Excess Mortality in Long-Term Care Residents With and Without Personal Contact With Family or Friends During the COVID-19 Pandemic

Evidence-based Recommendations to Inform Best Practices for LGBTQ Older Adults in Long-term Care Settings

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) older adults are more likely to live alone and have less familial support, which disproportionately contributes to a reliance on long-term care facilities as they age. Best-practice guidelines supported by scholarly literature to care for LGBTQ older adults in long-term care settings do not exist. This review synthesizes literature about LGBTQ older adults in long-term care facilities and provides recommendations for best practice guideline development. Four electronic databases were searched in June 2019 for studies conducted between 2000 – 2019 related to caring for LGBTQ older adults in long-term care settings. An integrative literature review was completed on the twenty eligible studies. Findings showed that LGBTQ participants fear discrimination in long-term care leading to the invisibility of their identities. They recognize a need for increased staff training and the importance of community networks and facility preferences. Long-term care staff have mixed experiences with inclusive practices and complex views of LGBTQ older adults. They experience training deficits and have a need for more expansive training modalities. The recommendations offered by both LGBTQ participants and long-term care staff are to revise policies and forms as well as provide widespread training and education. LGBTQ participants recommend that their unique identities be recognized within long-term care while long-term care staff recommend leadership involvement to change culture and practice. This review provides evidence-based recommendations to promote equitable healthcare to the LGBTQ older adult population and calls to attention the need for long-term care settings to uniformly follow best-practices.

Caring for a Relative With Dementia in Long-Term Care During COVID-19.

ObjectivesThe COVID-19 pandemic created unique stressors for caregivers of persons with dementia living in long-term care (LTC) facilities. The purpose of this qualitative study was to identify the challenges associated with caring for a relative with dementia in LTC during the pandemic, as well as resources, strategies, and practices caregivers found helpful in coping with COVID-19.DesignThis study was conducted within the context of an ongoing randomized controlled trial of a psychosocial intervention to support caregivers. Open-ended survey responses (n = 125) and semistructured interviews with a subset of the sample (n = 20) collected between June 2020 and June 2021 explored caregivers' experiences during COVID-19.Setting and ParticipantsParticipants included 125 family caregivers of persons with dementia living in residential LTC.MethodsThematic analysis was used to identify themes capturing caregivers' experiences.ResultsIn addition to concerns about COVID-19 infection, participants reported key challenges such as the difficulty of maintaining contact with relatives because of visiting restrictions, lack of information about relatives' health and well-being, worries about overburdened LTC staff, impossibility of returning relatives home from the LTC facility, and fears about relatives dying alone. Participants also identified resources, strategies, and practices that they perceived as helpful, including effective infection prevention within the LTC facility, good communication with LTC staff, and creative strategies for connecting with their relatives.Conclusions and ImplicationsThis qualitative analysis informs recommendations for practice within LTC facilities, as well as supports that may help caregivers manage stressful situations in the context of COVID-19. Vaccination and testing protocols should be implemented to maximize family caregivers' opportunities for in-person contact with relatives in LTC, as alternative visiting modalities were often unsatisfactory or unfeasible. Informing caregivers regularly about individual residents' needs and status is crucial. Supports for bereaved caregivers should address complicated grief and feelings of loss.

Research Applying Adaptive Leadership Framework for Chronic Illness Across Settings of Care

The carepartner is an essential member of the team to facilitate and assist in maximizing the independence of the older adult. The four papers in this symposium applies The Adaptive Leadership Framework for Chronic Illness (ALFCI) at the point of design, as well as an analytic framework for literature synthesis, intervention design, and analysis of existing data. In the first paper, a qualitative metasummary of a scoping review synthesizes qualitative findings about fatigue adaptation and challenges for stroke survivors, care partners, and healthcare professionals. The second paper describes the use of the ALFCI in an intervention study to manage symptom challenges in older adults with acute myeloid leukemia. The third paper shares staff’s experiences of providing direct care for older residents with advanced dementia in long-term care facilities. The fourth paper describes use of the carepartner–assisted intervention to improve oral hygiene of older adults with cognitive impairment. The ALFCI is a useful framework for intervention design 1) this framework provides a comprehensive way to examine the context of symptoms/behaviors (not just the symptom/behavior in isolation), 2) the framework guides “collaborative work”, 3) analytically it can help guide development of shared meaning of communication and “collaborative work” of dyads (family caregivers, long-term care staff and older adults), and 4) helps understand process of staff utilizing their strengths and doing adaptive work to facilitate interactions and communication, managing older residents’ behavioral and psychological symptoms of dementia, and improving their care provision and work life.

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.

Burnout, Compassion Satisfaction, and Intent to Quit Among Long-Term Care Nursing Assistants in the Time of COVID-19

The COVID-19 pandemic has greatly exacerbated the stress and burden of those employed in long-term care (LTC) facilities due to staff shortages, increased risks on the job, and ever-changing COVID-19 protocol requirements. This study examines potential differences in pre-COVID-19 and current COVID-19 LTC facility employed nursing assistants on burnout, compassion satisfaction, job satisfaction, and intent to quit. The sample included 81 nursing assistants employed in LTC facilities across the United States, with data collected prior to (n= 42) and during COVID-19 related shutdowns (n= 39). Participants completed the Professional Quality of Life Scale 5 (ProQOL 5), a single-item self-report measure of job satisfaction, and a two-item self-report measure of intent to quit their current employment. Nursing assistants during COVID-19 reported a higher level of burnout and lower level of compassion satisfaction than nursing assistants Pre-COVID-19. However, there were no differences in job satisfaction or intent to quit. The results suggest there may be additional factors that influence an individual’s decision to remain employed above and beyond the impacts of burnout and compassion satisfaction that may be unique to the caring professions. Future research might investigate factors that influence an individual’s decision to remain employed as a nursing assistant during periods of increased stress and burnout. Additionally, the impact of COVID-19 related stress added to the already high levels of stress and burnout on nursing assistants calls for further attention and research devoted to psychological support of LTC staff during crisis and normal times.

Comparison of Embedded Sensor Data for Long-Term Care Residents Before and After Onset of the COVID-19 Pandemic

Older adults have experienced greater isolation and mental health concerns during the COVID-19 pandemic. In long-term care (LTC) settings, residents have been particularly impacted due to strict lockdown policies. Little is known about how these policies have impacted older adults. This study leveraged existing research with embedded sensors installed in LTC settings, and analyzed sensor data of residents (N=30) two months pre/post the onset of the U.S. COVID-19 pandemic (1/13/20 to 3/13/20, 03/14/20 to 5/13/20). Data from three sensors (bed sensors, depth sensors, and motion sensors) were analyzed for each resident using paired t-tests, which generated information on the resident’s pulse, respiration, sleep, gait, and motion in entering/exiting their front door, living rooms, bedrooms, and bathrooms. A 14.4% decrease was observed in front door motion in the two months post-onset of the pandemic, as well as a 2.4% increase in average nighttime respiration, and a 7.6% increase in nighttime bed restlessness. Over half of our sample (68%) had significant differences (p<0.05) in restlessness. These results highlight the potential impact of the COVID-19 pandemic and social distancing policies on older adults living in LTC. While it is not surprising that significant differences were found in the front door motion sensor, the bed sensor data can potentially shed light on how sleep was impacted during this time. As older adults experienced additional mental health concerns during this time, their normal sleep patterns could have been affected. Implications could help inform LTC staff, healthcare providers, and self-management of health approaches among older adults.

Position Statement for Mental Health Care in Long-Term Care During COVID-19.

COVID-19 has disproportionately impacted older adults in long-term care (LTC) facilities in Canada. There are opportunities to learn from this crisis and to improve systems of care in order to ensure that older adults in LTC enjoy their right to the highest attainable standard of health. Measures are needed to ensure the mental health of older adults in LTC during COVID-19. The Canadian Academy of Geriatric Psychiatry (CAGP) and Canadian Coalition for Seniors’ Mental Health (CCSMH) have developed the following position statements to address the mental health needs of older adults in LTC facilities, their family members, and LTC staff. We outlined eight key considerations related to mental health care in LTC during COVID-19 to optimize the mental health of this vulnerable population during the pandemic.

Informal Caregivers' Perspectives on the Mandated No Visitation Policy During COVID-19 Pandemic in Long-Term Care: A Qualitative Study.

The current descriptive qualitative study aimed to explore how informal caregivers of persons residing in long-term care (LTC) facilities are coping with the no visitation policy during the coronavirus disease 2019 (COVID-19) pandemic. Semi-structured interviews were conducted approximately 1 month after the no visitation policy was implemented. Interview questions explored how informal caregivers are feeling, coping, and staying connected and involved with loved ones residing in LTC. Recruitment (N = 14) occurred through social media, email, and word of mouth. To maintain social distance and reduce transmission risk, interviews were conducted by phone. Through systematic data reduction, six themes emerged: (a) Reminiscing About Life Before COVID-19, (b) Feelings Related to Physical Separation, (c) Our Loved Ones Are Lonely and Don't Understand, (d) Creating Ways to Stay Connected, (e) Recognition and Concern for LTC Staff, and (f) Coping During Future No Visitation Mandates. Results of this study may assist LTC administrators and nurses if no visitation policies are required in the future. [Journal of Gerontological Nursing, 47(12), 19-26.].

Nurse Practitioners and The Use of Antipsychotic Medications in Long Term Care in Ontario, Canada

Introduction: Antipsychotic use in Long-Term Care (LTC) in Ontario, Canada continues to pose a challenge in the care of older adult patients living in these institutions. The dangers and patterns of inappropriate prescribing have been documented frequently. Most of the current literature focuses on dementia and behavioral and psychological symptoms of dementia, the role of prescribers, or on interprofessional interventions with person-centered care to address the behavior. Very little discussion has focused on the role of nurse practitioners and other frontline long-term care staff in the assessment and interactions with residents that may result in prescriptions of antipsychotics.&#x0D; Objectives: The purpose of this population based retrospective study of data from all LTC facilities in Ontario, Canada in 2019-2020 was to determine the extent to which antipsychotic medications were used in and the factors associated with this use. Reflections about the NP role are discussed.&#x0D; Results: The results demonstrate that over thirty percent of residents in LTC continue to receive antipsychotics and those with the responsive behaviours are significantly more likely to be prescribed antipsychotics. &#x0D; Conclusions: The findings identify a potential link between over-burdened front-line staff and increased antipsychotic prescriptions, as well as continued use of antipsychotics in attempts to prevent harm to residents and staff at long-term care homes. Recommendations are made that include changes to legislation that will ensure optimal front-line care and time for care, increased training for front line staff and, in particular, how the role of the nurse practitioner in LTC can be utilized to optimize the appropriate use of antipsychotics, and the support of discontinuing or decreasing the dose of antipsychotics when required.

Exploring the attitudes, beliefs, and values of the long-term care workforce towards palliative care: A qualitative evidence synthesis protocol

Background and Aim The long-term care workforce is a significant provider of palliative care. The majority of older people being admitted to long-term care have palliative care needs and many are approaching end of life. The long-term care workforce comprises both registered health care professionals and unlicensed health care workers (UHCW) who provide most direct care. Studies that have examined palliative care competence in long-term care have focused on staff knowledge. However, it is also important to understand staff attitudes, beliefs, and values towards palliative care because these attributes influence behaviours related to care provision. The aim of the qualitative evidence synthesis is to identify and appraise the best available qualitative evidence on the attitudes, beliefs, and values of the long-term care workforce towards palliative care. Inclusion criteria The review will consider original research that reports qualitative findings of long-term care staff and their attitudes, beliefs, and values regarding palliative care for residents of long-term care facilities. Methods The following databases will be searched for eligible papers: CINAHL, EMBASE, PubMed, PsychINFO, and Scopus. Studies that meet the inclusion criteria by addressing all of the phenomena of interest will be reviewed using the Joanna Briggs Institute (JBI) methodology for systematic reviews of qualitative evidence. Two reviewers will independently assess the studies for methodological quality. The data will be extracted using the standardized JBI SUMARI extraction tool. Specific details about authors and publication date, study design, aims, context, population, cultural and linguistic background, location, main findings, limitations, and conclusions will be extracted and a level of credibility assigned. Categories will be developed from the findings. The findings will be presented diagrammatically and accompanied by a narrative to explain categories and synthesised findings. Discussion The review of the literature will synthesis key findings pertaining to the attitudes, beliefs, and values of the workforce providing palliative care to older people in long-term care, beyond what is known about palliative care knowledge in this workforce.

Perspectives of substitute decision-makers and staff about person-centred physical activity in long-term care.

This paper aims to explore the care processes that best exemplify person-centred care during physical activity (PA) for long-term care (LTC) residents with dementia from the perspectives of substitute decision-makers (SDMs) and LTC home staff. Little is known about how person-centred care is reflected during PA for residents with dementia, or the barriers and benefits to enacting person-centred care during PA. Semistructured interviews were used to collect SDMs and LTC home staffs' perspectives on the importance of person-centred care during PA from two LTC homes in Canada. The McCormack and McCance person-centredness framework was used to guide thematic content analysis of responses. SDM (n = 26) and staff (n = 21) identified actions categorized under the sympathetic presence or engagement care processes from the person-centredness framework as most reflecting person-centred care. Benefits of person-centred care during PA were categorized into three themes: functional and physical, behavioural and communication and psychosocial improvements. Barriers to person-centred care during PA identified were lack of time, opportunities for meaningful activity in LTC setting and staff experiences with resident aggression. Understanding the care processes that are most recognized as person-centred care and valued by SDMs and LTC home staff has implications for education and training. Insights into SDMs' care expectations regarding person-centred care can inform staff about which actions should be prioritized to meet care expectations and can foster relationships to the benefit of residents with dementia. Study participants were not involved in the development of research questions, research design or outcome measures of this study.

Leadership for quality in long-term care.

Leadership in long-term care is a burgeoning field of research, particularly that which is focused on enabling point of care staff to provide high-quality and responsive healthcare. In this article, we focus on the relatively important role that leadership plays in enabling the conditions for high-quality long-term care. Our methodological approach involved a rapid in-depth ethnography undertaken by an interdisciplinary team across eight public and non-profit long-term care homes in Canada, where we conducted over 1,000hours of observations and 275 formal and informal interviews with managers, staff, residents, family members and volunteers. Guiding our analysis post hoc is the LEADS in a Caring Environment framework. We mapped key promising leadership practices identified by our analysis and discuss how these can inform the development of leadership standards across staff and management in long-term care.

Older Lesbian, Gay, Bisexual, Transgender, and Queer Adults’ Experiences With Discrimination and Impacts on Expectations for Long-Term Care: Results of a Survey in the Southern United States

The number of older adults in the United States is projected to increase in coming years, including the number of lesbian, gay, bisexual, transgender, queer, or questioning (LGBTQ+) older adults requiring long-term care (LTC) services. We conducted an online survey of older LGBTQ+ adults living in the Southern United States between January and March of 2018 to inquire about their anticipation of discrimination in and willingness to utilize LTC services. We found that 78.6% of respondents (N = 789) anticipated discrimination in LTC. Previous experiences with discrimination, higher educational attainment, and queer/questioning sexual orientation were associated with greater expectation of discrimination. Higher anticipation of discrimination was also associated with a greater preference for utilizing LTC services offered by LGBTQ+ providers or for LGBTQ+ older adults. These findings suggest that LTC staff and researchers may be uniquely positioned to craft outreach and policies to protect LGBTQ+ LTC residents.

There Is No Place Like Home … But Things Could Be Better.

Increasing attention is being placed on the role of the built environment in promoting and sustaining health in long-term care home settings. Work that reconsiders the physical and work designs of the long-term care sector in the future is expected. In light of that, we urge full and reflective consideration of the tensions and complexities that have been brought to light through the pandemic and attending to what is known and knowable about the influences of the built environment on long-term care home residents and staff who provide their care.

A systematic review of long-term care facility characteristics associated with COVID-19 outcomes.

Background/ObjectivesThe coronavirus disease 2019 (COVID‐19) pandemic has taken a disproportionate toll on long‐term care facility residents and staff. Our objective was to review the empirical evidence on facility characteristics associated with COVID‐19 cases and deaths.DesignSystematic review.SettingLong‐term care facilities (nursing homes and assisted living communities).ParticipantsThirty‐six empirical studies of factors associated with COVID‐19 cases and deaths in long‐term care facilities published between January 1, 2020 and June 15, 2021.MeasurementsOutcomes included the probability of at least one case or death (or other defined threshold); numbers of cases and deaths, measured variably.ResultsLarger, more rigorous studies were fairly consistent in their assessment of risk factors for COVID‐19 outcomes in long‐term care facilities. Larger bed size and location in an area with high COVID‐19 prevalence were the strongest and most consistent predictors of facilities having more COVID‐19 cases and deaths. Outcomes varied by facility racial composition, differences that were partially explained by facility size and community COVID‐19 prevalence. More staff members were associated with a higher probability of any outbreak; however, in facilities with known cases, higher staffing was associated with fewer deaths. Other characteristics, such as Nursing Home Compare 5‐star ratings, ownership, and prior infection control citations, did not have consistent associations with COVID‐19 outcomes.ConclusionGiven the importance of community COVID‐19 prevalence and facility size, studies that failed to control for these factors were likely confounded. Better control of community COVID‐19 spread would have been critical for mitigating much of the morbidity and mortality long‐term care residents and staff experienced during the pandemic. Traditional quality measures such as Nursing Home Compare 5‐Star ratings and past deficiencies were not consistent indicators of pandemic preparedness, likely because COVID‐19 presented a novel problem requiring extensive adaptation by both long‐term care providers and policymakers.