Journal of Gerontological Nursing

Feature Article 

Differences in Assisted Living Staff Perceptions, Experiences, and Attitudes

Anna S. Beeber, PhD, RN; Lauren W. Cohen, MA; Sheryl Zimmerman, PhD; Lisa P. Gwyther, MSW; Tiffany Washington, PhD, MSW; John G. Cagle, PhD; David Reed, PhD

Abstract

Research within residential care/assisted living (RC/AL) settings has shown that the attitudes of personal care (PC) staff toward their organization and its residents and families can affect the quality of resident care. This article describes the perceptions, experiences, and attitudes of PC staff and their supervisors, and considers these data in the context of non-hierarchical staffing patterns—a philosophically expected, yet unproven tenet of RC/AL. Using data collected from 18 RC/AL communities, these analyses compared the characteristics, perceptions, experiences, and attitudes of PC staff (N = 250) and supervisors (N = 30). Compared to supervisors, PC staff reported greater burden, frustration, depersonalization, hassles, and feeling significantly more controlling of, and less in partnership with, families (p < 0.05). Because the PC staff experience is crucial for resident outcomes, more work is needed to create an environment where PC staff are less burdened and have better attitudes toward work and families. [Journal of Gerontological Nursing, 40(1), 41–49.]

Dr. Beeber is Assistant Professor, School of Nursing, Research Fellow, Cecil G. Sheps Center for Health Services Research, Robert Wood Johnson Nurse Faculty Scholar, University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, North Carolina; Ms. Cohen is Associate Director, Collaborative Studies of Long-term Care, Research Associate, Program on Aging, Disability, and Long-term Care, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Dr. Zimmerman is Mary Lily Kenan Flagler Bingham Distinguished Professor and Associate Dean, Doctoral Education, School of Social Work, Co-Director and Senior Research Scientist, Program on Aging, Disability and Long-Term Care, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Ms. Gwyther is Director, Duke Center for the Study of Aging and Human Development, Durham, North Carolina; Dr. Washington is Assistant Professor, School of Social Work, University of Georgia, Athens, Georgia; Dr. Cagle is Assistant Professor, School of Social Work, University of Maryland, Baltimore, Maryland; and Dr. Reed is Research Associate, Analyst, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This work was supported by a grant from the National Institutes of Health (R01AG025443), the Building Interdisciplinary Research Careers in Women’s Health, Institutional K12 Program at the University of North Carolina at Chapel Hill (NICHHD 5K12HD001441), and the Robert Wood Johnson Nurse Faculty Scholars Program. The authors are grateful for the time and effort of the staff, residents, and families participating in the Collaborative Studies of Long-Term Care. They also appreciate the support of administration of Brookdale Senior Living; Kindred Health-care; Therapeutic Alternatives, Inc.; Brookshire, Inc.; and Meridian Senior Living.

Address correspondence to Anna S. Beeber, PhD, RN, Assistant Professor, School of Nursing, Research Fellow, Cecil G. Sheps Center for Health Services Research, Robert Wood Johnson Nurse Faculty Scholar, University of North Carolina at Chapel Hill, School of Nursing, Carrington Hall CB #7460, Chapel Hill, NC 27599-7460; e-mail: asbeeber@email.unc.edu.

Received: November 26, 2012
Accepted: March 22, 2013
Posted Online: August 16, 2013

Abstract

Research within residential care/assisted living (RC/AL) settings has shown that the attitudes of personal care (PC) staff toward their organization and its residents and families can affect the quality of resident care. This article describes the perceptions, experiences, and attitudes of PC staff and their supervisors, and considers these data in the context of non-hierarchical staffing patterns—a philosophically expected, yet unproven tenet of RC/AL. Using data collected from 18 RC/AL communities, these analyses compared the characteristics, perceptions, experiences, and attitudes of PC staff (N = 250) and supervisors (N = 30). Compared to supervisors, PC staff reported greater burden, frustration, depersonalization, hassles, and feeling significantly more controlling of, and less in partnership with, families (p < 0.05). Because the PC staff experience is crucial for resident outcomes, more work is needed to create an environment where PC staff are less burdened and have better attitudes toward work and families. [Journal of Gerontological Nursing, 40(1), 41–49.]

Dr. Beeber is Assistant Professor, School of Nursing, Research Fellow, Cecil G. Sheps Center for Health Services Research, Robert Wood Johnson Nurse Faculty Scholar, University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, North Carolina; Ms. Cohen is Associate Director, Collaborative Studies of Long-term Care, Research Associate, Program on Aging, Disability, and Long-term Care, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Dr. Zimmerman is Mary Lily Kenan Flagler Bingham Distinguished Professor and Associate Dean, Doctoral Education, School of Social Work, Co-Director and Senior Research Scientist, Program on Aging, Disability and Long-Term Care, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Ms. Gwyther is Director, Duke Center for the Study of Aging and Human Development, Durham, North Carolina; Dr. Washington is Assistant Professor, School of Social Work, University of Georgia, Athens, Georgia; Dr. Cagle is Assistant Professor, School of Social Work, University of Maryland, Baltimore, Maryland; and Dr. Reed is Research Associate, Analyst, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

The authors have disclosed no potential conflicts of interest, financial or otherwise. This work was supported by a grant from the National Institutes of Health (R01AG025443), the Building Interdisciplinary Research Careers in Women’s Health, Institutional K12 Program at the University of North Carolina at Chapel Hill (NICHHD 5K12HD001441), and the Robert Wood Johnson Nurse Faculty Scholars Program. The authors are grateful for the time and effort of the staff, residents, and families participating in the Collaborative Studies of Long-Term Care. They also appreciate the support of administration of Brookdale Senior Living; Kindred Health-care; Therapeutic Alternatives, Inc.; Brookshire, Inc.; and Meridian Senior Living.

Address correspondence to Anna S. Beeber, PhD, RN, Assistant Professor, School of Nursing, Research Fellow, Cecil G. Sheps Center for Health Services Research, Robert Wood Johnson Nurse Faculty Scholar, University of North Carolina at Chapel Hill, School of Nursing, Carrington Hall CB #7460, Chapel Hill, NC 27599-7460; e-mail: asbeeber@email.unc.edu.

Received: November 26, 2012
Accepted: March 22, 2013
Posted Online: August 16, 2013

Residential care/assisted living (RC/AL) is a long-term care option that provides housing and services for close to 1 million older adults in the United States (Park-Lee et al., 2011), and next to nursing homes, is the largest provider of residential long-term care (Polzer, 2010). RC/AL is an attractive alternative to nursing homes because it is designed to be more home-like and emphasize the resident as an individual who deserves autonomy, privacy, independence, and consistent engagement with staff empowered to provide for resident needs (Center for Excellence in Assisted Living, 2010; Fazio, 2008; Talerico, O’Brien, & Swafford, 2003).

In RC/AL settings, personal care (PC) staff typically take care of residents’ daily needs, including personal hygiene, housekeeping, meals, and assisting with medication administration (Chou & Robert, 2008). The retention of PC staff is one of the biggest challenges to quality of care in long-term care, in that turnover disrupts continuity of resident care, creates burden for other staff, and incurs costs in hiring and training new staff (Sikorska-Simmons, 2005). Given these consequences, a number of studies—conducted primarily in nursing homes—have examined factors that contribute to staff retention and staff turnover (Angelelli, Gifford, Shah, & Mor, 2001; Castle, 2001, 2005; Castle & Engberg, 2005; Castle & Lin, 2010; Fitzpatrick, 2002). Staff relationships with families affect not only the quality of resident care provided but also job satisfaction and turnover (Lerner, Resnick, Galik, & Flynn, 2011). PC staff attitudes (e.g., burden, work stress, hassles) can also cause staff to be less satisfied with their jobs, and thus more likely to leave. Protective factors, such as knowing a resident well, being better trained, maintaining a resident’s independence, and having a family member follow recommendations, help staff deal with day-to-day challenges and are associated with higher rates of staff satisfaction and staff reporting that they intend to stay in their position (Devereux, Hastings, Noone, Firth, & Totsika, 2009; Lerner et al., 2011; Zimmerman et al., 2005). Although more limited in scope and quantity, research conducted within RC/AL settings has yielded similar findings as the work done in nursing homes; PC staff attitudes toward their organization, the residents they care for, and residents’ families can affect the quality of the care they provide to residents (Aud & Rantz, 2004; Maas & Buckwalter, 2006).

The attitudes of supervisors, and especially those toward their care and management duties, affect the care PC staff provide and residents’ outcomes (Anderson, Issel, & McDaniel, 2003; Barry, Brannon, & Mor, 2005). Previous work in nursing homes has shown that supervisors who are flexible, responsive, and collaborative engender work environments characterized by high teamwork and shared decision making among all staff types (Tellis-Nayak, 2007). Not surprisingly, other work has found that nursing homes with low teamwork have less interaction among staff and more animosity between supervisors and PC staff (Scott-Cawiezell et al., 2004; Tyler & Parker, 2011). Thus, it seems that both the structure and function of the nursing home team are crucial to a high functioning work environment.

In addition to the quality of the team, the quality of the relationship between supervisors and PC staff can also affect staff and resident outcomes. For example, in settings where supervisors are empathetic, reliable, and focus on connecting with staff, PC staff have lower job stress and higher job satisfaction (Chou & Robert, 2008; McGilton, Hall, Wodchis, & Petroz, 2007). Similarly, in settings where staff share similar attitudes, including a common understanding of the work they do, mutual respect, and shared goals, staff report better job satisfaction and residents report better quality of life (Gittell, Weinberg, Pfefferle, & Bishop, 2008) and greater satisfaction with care (Sikorska-Simmons, 2006). Similarly, nursing homes with a flattened staffing hierarchy that includes open communication, shared decision making, and relationship-oriented leadership have lower rates of restraint use, and residents exhibit fewer aggressive and disruptive behaviors and complications from immobility (Anderson et al., 2003). Evidence suggests that a more equitable working environment provides the opportunity for better relationships among staff and residents and family. In a study of the long-term care work environment, staff working in organizations with a more person-centered management approach had more positive attitudes toward management and these attitudes correlated with families having higher ratings of satisfaction and care quality (Tellis-Nayak, 2007). These findings suggest that if this structure has been effectively translated into practice, one would expect PC staff and supervisors have similar perceptions about work, experiences of burden and stress, and attitudes toward families and their coworkers (Barry et al., 2005; Stone et al., 2002).

This article explores the experiences, perceptions, and attitudes of staff in RC/AL communities, comparing those held by PC staff to their supervisors. The unique contribution of this study is that it examines staff perceptions, experiences, and attitudes (both toward their work and toward families) in RC/AL communities, a setting that has been understudied. This article concludes with a discussion of the implications of this work on future research, RC/AL organizational and care practices, and gerontological nursing.

Method

The data for these analyses were derived from RC/AL staff members who participated in Families Matter, a group randomized controlled trial conducted in North Carolina. This trial involved data collection at both baseline and 6-month follow up; the data for these analyses are based only on those collected at baseline. Data were obtained from 18 RC/AL communities, which each received monetary reimbursement for participation so as to defray the cost of staff time incurred by study procedures. The Institutional Review Boards of the participating universities reviewed and approved all study materials and procedures.

Sample

The Families Matter study consisted of a sample of approximately 20 residents from each long-term care setting and the staff members who were most familiar with the selected residents. In addition to being familiar with a participating resident, eligible staff members were at least 18 years old, worked at least 20 hours per week, and were employed by the setting for at least 1 month prior to the study. All eligible staff members were approached in person, provided details about the study and its requirements, and asked to provide written informed consent prior to participation. Participation comprised a 20-minute in-person interview. As part of this interview, staff participants reported their job title and position, which were categorized as supervisory or PC during analyses. Job titles and positions categorized as supervisors included administrators, business managers, activity directors, life enrichment coordinators, health and wellness coordinators, licensed practical nurses (LPNs), and other supervisors. Job titles and positions categorized as PC staff included certified nursing assistants (CNAs), medication technicians, and unlicensed care assistants. Of note, in North Carolina, RC/AL settings are not required to have an RN on-site, and thus there were few to recruit for this study. Further, when RNs are on-site, they typically act in supervisory rather than direct care roles. Because this study was primarily targeted at direct caregivers who interact with families and residents, in most cases, the inclusion of RNs was inappropriate. However, two RNs were enrolled in the study; but because they numbered too few, they were excluded from analyses.

Measures

Administrators from the participating RC/AL communities provided information about the community characteristics including profit status, years in operation, number of beds, occupancy rate, number of administrators in the past 3 years, staffing, monthly charges, affiliation, and percentage of residents with dementia, of minority race, and receiving Medicaid.

Staff Characteristics. Staff participants provided information about their own demographic characteristics, health status, perceptions about and attitudes toward the caregiving role, families, and residents, and experiences. To measure overall health, staff were asked “In general, would you say your health is: excellent, very good, good, fair, or poor?” To assess depression, the 10-item Center for Epidemiologic Studies Depression Scale was used to identify the absence or presence of depressive symptoms in the past month (Radloff, 1977). Work history included the number of years working in that setting, years of long-term care experience, hours worked in a typical week, and whether the work role included personal care or other functions (e.g., supervisor, coordinator, director, administrator).

Staff Perceptions, Experiences, and Attitudes. Staff perceptions were evaluated using the Staff Perception of the Caregiving Role Instrument, a 78-item self-report measure with four subscale measures of task burden (alpha = 0.61 to 0.84), frustration (alpha = 0.70 to 0.82), dominion (control in relation to family members; alpha = 0.64 to 0.71), and exclusion of families (alpha = 0.70) (Maas & Buckwalter, 1990; Maas et al., 2004; Specht et al., 2005). Staff perceptions were also examined using the Family Behaviors and Family Empathy Scales (alpha = 0.55), which ask staff their perceptions of how families behave toward them, how well family members understand their job, and if they are sensitive to their feelings (Pillemer et al., 2003).

Staff experiences were measured using the 22-item self-report Maslach Burnout Inventory, which includes three subscales measuring emotional exhaustion (alpha = 0.90), depersonalization (alpha = 0.79), and lack of personal accomplishment (alpha = 0.71) (Maslach, Jackson, & Leiter, 1996); hassles and uplifts measured by the Hassles and Uplifts Scale (Elder, Wollin, Härtel, Spencer, & Sanderson, 2003); work stressors measured by the Work Stress Inventory subscale related to caring for residents (alpha = 0.82) (Schaefer & Moos, 1993, 1996); and interpersonal conflict measured using the Interpersonal Conflict Scale (alpha = 0.79), which asks how frequently staff have conflict with family members regarding resident care tasks (Pillemer et al., 2003). Staff attitudes toward their jobs and residents’ families were assessed with the 16-item self-report Attitudes Towards Family Checklist (alpha = 0.70 to 0.91), which includes three subscales: families cause disruption (alpha = 0.56 to 0.64), partnership with family (alpha = 0.58 to 0.63), and family relevance (alpha = 0.61) (Maas & Buckwalter, 1990; Maas et al., 2004). The Staff Perceptions of Caregiving Role and the Attitudes Towards Families Checklist were developed for use with staff from special care units for individuals with dementia, rather than RC/AL. However, because the majority of RC/AL residents have some cognitive impairment, it is likely that the staff share similar experiences and the measures are similarly valid (Magsi & Malloy, 2005).

Analyses

Descriptive statistics related to RC/AL communities (means, standard deviations, frequency counts, and percentages) were generated using SPSS version 16.0. Because of the clustering of staff within communities, linear and nonlinear mixed models were used in analyses of differences between staff types, as appropriate to the measure. The mixed models specified a random effect for setting and a fixed effect for staff type. Models were also run adjusting for staff race and educational level. All mixed models analyses were completed using SAS software version 9.2.

Results

Table 1 presents the characteristics of the 18 RC/AL communities participating in this study. All are for profit, have been in operation for a mean 8.3 years, have an average bed size of 81.7, have an occupancy rate of 83.3%, and an average monthly charge of $3,095. Eight (44%) communities reported having three or more administrators in the past 3 years. Three (17%) communities are affiliated with a continuing care retirement community, 12 (67%) are affiliated with another RC/AL community, and 2 (11%) are affiliated with a nursing home. Approximately half of the residents have a diagnosis of dementia (48.4%) and 22.6% are of racial minorities.

Characteristics of Residential Care/Assisted Living (RC/AL) Communities (N = 18)

Table 1:

Characteristics of Residential Care/Assisted Living (RC/AL) Communities (N = 18)

A total of 280 staff (250 categorized as PC staff and 30 categorized as supervisors) provided data for these analyses. Table 2 describes and compares the PC staff and supervisors. Regardless of classification, the sample was overwhelmingly female (96% PC staff, 93% supervisors), but differed in age (PC staff: 37.6 years; supervisors: 43.7 years; p = 0.013), race (74% of PC staff and 27% of supervisors were of racial minorities; p < 0.001), and educational level (8% of PC staff and 30% of supervisors held a bachelor’s degree or higher; p < 0.001). PC staff worked in the setting an average of 2.7 years versus 4 years for supervisors (p = 0.032), but the two groups did not differ in overall years of long-term care experience (PC staff 6.9 years versus supervisors 7.4 years). PC staff worked fewer hours each week than supervisors (36.8 versus 40.2; p = 0.005).

Characteristics, Perceptions, Experiences, and Attitudes of Personal Care Staff and SupervisorsCharacteristics, Perceptions, Experiences, and Attitudes of Personal Care Staff and Supervisors

Table 2:

Characteristics, Perceptions, Experiences, and Attitudes of Personal Care Staff and Supervisors

Table 2 also presents the unadjusted and adjusted differences between PC staff and supervisors on perceptions, experiences, and attitudes. The completeness of these measures was high, with no single item of any of the measures having more than one missing response. In adjusted analyses, PC staff reported being significantly more burdened (p = 0.002) and controlling in relation to families (dominion, p = 0.004) than supervisors. They also reported more burnout related to depersonalization (p = 0.038) and accomplishment (p = 0.048). Finally, PC staff reported significantly lower scores on the attitude scales than supervisors, including partnership with families (p = 0.028), families cause disruption (p = 0.014), and family relevance (p = 0.025). Additional adjustments for the setting characteristics of percentage of residents with dementia, staff-to-resident ratio, size (total beds), and percentage of residents receiving Medicaid/public assistance had no substantive effect on the results of the analyses.

Discussion

The purpose of the current study was to compare RC/AL PC staff and supervisors in terms of their perceptions, experiences, and attitudes. Not unexpectedly, PC staff and supervisors differed by demographic characteristics including age, race, and educational level. PC staff were more likely to be younger, racial minorities, and less educated. These differences reflect the nature of the long-term care setting and work-force—supervisors tend to be higher educated and non-minorities, whereas PC staff are primarily middle-aged, minority women with at least a high school education (Bureau of Labor Statistics, 2010).

Even after adjusting for differences in race and educational attainment, there were numerous differences between PC staff and supervisors. Overall, PC staff had poorer perceptions, experiences, and attitudes toward their jobs. PC staff perceived their work as being more burdensome and were less willing to grant families control over resident care. At the same time, when compared to supervisors, PC staff reported that they experienced more depersonalization and felt less accomplished. These findings suggest that the PC staff may benefit from a more supportive environment that emphasizes teamwork and allows for participation in decision making. Research examining staff-supportive cultures suggests that RC/AL communities that value teamwork, PC staff empowerment, and shared decision making have more organizational commitment, less turnover, and better quality of care (Sikorska-Simmons, 2008). Future work focused on identifying and relieving the specific burdens PC staff experience may improve staff attitudes toward their work and also their relationships with families.

Although the relationship between residents’ families and PC staff is a key interface essential for day-to-day RC/AL resident care (Gaugler & Ewen, 2005), PC staff had more negative attitudes toward families than supervisors. PC staff had poorer scores on the three Attitudes Towards Families subscales (partnership with family, families cause disruption, and families relevant subscales). A potential explanation for this difference may be the nature of the PC staff work, meaning that while providing hands-on care to residents, they—more so than supervisors—come into contact with families or are more often aware when families are not present. These situations may engender conflict, either in their own right or because PC staff are not comfortable interacting with families, or perhaps because families are not as supportive as desired. Our study and the existing literature suggest that the attitudes of PC staff toward families warrants more detailed investigation to examine not only staff attitudes, but factors that may influence these attitudes (e.g., organizational culture, supervisory support, the relationship between RC/AL residents and families) (Gaugler & Ewen, 2005; Maas & Buckwalter, 2006; McGilton et al., 2007; Sikorska-Simmons, 2005). Understanding the factors that influence PC staff attitudes could help focus efforts aimed at improving PC staff satisfaction with their work.

RC/AL is often viewed as preferable to nursing homes because it provides a home-like environment, presumably emphasizing choice, independence, and connection to a larger community (Center for Excellence in Assisted Living, 2010; Fazio, 2008; Talerico et al., 2003). The RC/AL setting is further presumed to empower PC staff to focus on individual resident needs and thereby achieve more of an equal partnership between supervisors and PC staff than evidenced in traditional nursing homes (Center for Excellence in Assisted Living, 2010). In the current study, PC staff reported significantly poorer attitudes on the burden, dominion, burnout, and attitudes toward family scales. The differences observed between PC staff and supervisors are inconsistent with what would be expected from a less hierarchical structure where perceptions, experiences, and attitudes should be more similar. On the other hand, it must also be considered that these findings may in fact be consistent with what would be expected in a setting wherein PC staff have control and are empowered to make decisions, but there are poor relations with families nonetheless or even in consequence. Thus, this finding suggests a need for further research examining the leadership structure in place and the relationships among supervisors, PC staff, and families. Future research observing contextual factors (e.g., enactment of the philosophy, mission of care) may provide insight into the factors that may influence these relationship including the organizational structure (whether they have a person-centered or hierarchical focus), staff attitudes, and resident/family/staff outcomes.

This analysis was limited because the cross-sectional nature of the data did not examine the consequences of staff perceptions, experiences, and attitudes (e.g., staff turnover, residents’ care outcomes). The analyses for this study were derived from baseline data from an intervention study and did not focus on collecting data about the flattened or hierarchical nature of the organizational structure itself. Regardless of these limitations, the findings have implications for future research efforts and gerontological nursing practice. Overall, PC staff had more negative perceptions of their work, were more burdened, and had more negative attitudes toward residents’ families than supervisors. This highlights a need for a more concentrated effort to create an environment that decreases the stresses and burdens experienced by PC staff. Prior work aimed at improving the work environment in nursing homes has found that efforts such as consistent assignment, improving employee benefits, and interventions to improve communication between staff and family can affect staff work stress and staff retention (Advancing Excellence in America’s Nursing Homes, 2009; Pillemer et al., 2003). Adapting these intervention efforts for staff in RC/AL settings may provide positive outcomes. In particular, focusing policy and management efforts on providing routine assessment of PC staff perceptions, experiences, and attitudes may inform programs to improve PC staff stress and burden, as well as PC staff and family relationships.

Clinical Implications and Conclusion

Currently, there is a wide array of roles a nurse can enact in RC/AL settings. Although less than 50% of states currently require a nurse to be involved in RC/AL care, between 47% and 70% of these settings employ an RN or LPN (Maas & Buckwalter, 2006; Mitty et al., 2010). RNs may oversee care at a single RC/AL site, or may oversee care for multiple settings, whereas LPNs may coordinate clinical care as health care supervisor or case manager (Mitty et al., 2010). For settings that do not employ nurses, nurses who provide care to RC/AL residents may be employed by outside agencies such as home health or hospice (Park-Lee et al., 2011; Stearns et al., 2007; Zimmerman et al., 2003). Given the various roles nurses can have in overseeing the care provided to RC/AL residents, it is important that they critically examine the care that is provided to these residents and understand the factors that may influence resident outcomes, such as staff relationships with residents and families. Nurses employed in RC/AL settings may be in the position to implement interventions to improve staff attitudes and experiences. For nurses who provide care to RC/AL residents but may not necessarily be employed by the setting, it is important to understand the staff experiences and attitudes that may be facilitators or barriers to providing high quality care.

References

  • Advancing Excellence in America’s Nursing Homes. (2009). Interventions table: Staff retention. Retrieved from http://www.nhquali-tycampaign.org/files/interventions/Interven-tions_Table_Staff_Retention.pdf
  • Anderson, R.A., Issel, L.M. & McDaniel, R.R. Jr.. (2003). Nursing homes as complex adaptive systems: Relationship between management practice and resident outcomes. Nursing Research, 52, 12–21. doi:10.1097/00006199-200301000-00003 [CrossRef]
  • Angelelli, J., Gifford, D., Shah, A. & Mor, V. (2001). External threats and nursing home administrator turnover. Health Care Management Review, 26, 52–62. doi:10.1097/00004010-200107000-00006 [CrossRef]
  • Aud, M.A. & Rantz, M.J. (2004). Quality concerns in assisted living facilities. Journal of Nursing Care Quality, 19, 8–9. doi:10.1097/00001786-200401000-00003 [CrossRef]
  • Barry, T.T., Brannon, D. & Mor, V. (2005). Nurse aide empowerment strategies and staff stability: Effects on nursing home resident outcomes. The Gerontologist, 45, 309–317. doi:10.1093/geront/45.3.309 [CrossRef]
  • Bureau of Labor Statistics, U.S. Department of Labor. (2010). Occupational outlook handbook, 2010–11 edition. Retrieved from http://www.bls.gov/oco/cg/cgs035.htm
  • Castle, N.G. (2001). Administrator turnover and quality of care in nursing homes. The Gerontologist, 41, 757–767. doi:10.1093/geront/41.6.757 [CrossRef]
  • Castle, N.G. (2005). Turnover begets turnover. The Gerontologist, 45, 186–195. doi:10.1093/geront/45.2.186 [CrossRef]
  • Castle, N.G. & Engberg, J. (2005). Staff turnover and quality of care in nursing homes. Medical Care, 43, 616–626. doi:10.1097/01.mlr.0000163661.67170.b9 [CrossRef]
  • Castle, N.G. & Lin, M. (2010). Top management turnover and quality in nursing homes. Health Care Management Review, 35, 161–174. doi:10.1097/HMR.0b013e3181c22bcb [CrossRef]
  • Center for Excellence in Assisted Living. (2010). Person-centered care in assisted living: An informational guide. Retrieved from http://www.theceal.org/assets/PDF/Person-Centered%20Care%20in%20Assisted%20Living.pdf
  • Chou, R.J. & Robert, S.A. (2008). Workplace support, role overload, and job satisfaction of direct care workers in assisted living. Journal of Health and Social Behavior, 49, 208–222. doi:10.1177/002214650804900207 [CrossRef]
  • Devereux, J.M., Hastings, R.P., Noone, S.J., Firth, A. & Totsika, V. (2009). Social support and coping as mediators or moderators of the impact of work stressors on burnout in intellectual disability support staff. Research in Development Disabilities, 30, 367–377. doi:10.1016/j.ridd.2008.07.002 [CrossRef]
  • Elder, R., Wollin, J., Härtel, C., Spencer, N. & Sanderson, W. (2003). Hassles and uplifts associated with caring for people with cognitive impairment in community settings. International Journal of Mental Health Nursing, 12, 271–278. doi:10.1046/j.1447-0349.2003.t01-5-.x [CrossRef]
  • Fazio, S. (2008).Person-centered care in residential settings. Alzheimer’s Care Today, 9, 155–161. doi:10.1097/01.ALCAT.0000317200.58816.a3 [CrossRef]
  • Fitzpatrick, P.G. (2002). Turnover of certified nursing assistants: A major problem in long-term care facilities. Hospital Topics, 80, 21–25. doi:10.1080/00185860209597991 [CrossRef]
  • Gaugler, J.E. & Ewen, H.H. (2005). Building relationships in residential long-term care: Determinants of staff attitudes toward family members. Journal of Gerontological Nursing, 31(9), 19–26.
  • Gittell, J.H., Weinberg, D., Pfefferle, S. & Bishop, C. (2008). Impact of relational coordination on job satisfaction and quality outcomes: A study of nursing homes. Human Resource Management Journal, 18, 154–170. doi:10.1111/j.1748-8583.2007.00063.x [CrossRef]
  • Lerner, N., Resnick, B., Galik, E. & Flynn, L. (2011). Job satisfaction of nursing assistants. Journal of Nursing Administration, 41, 473–478. doi:10.1097/NNA.0b013e3182346e7a [CrossRef]
  • Maas, M.L. & Buckwalter, K. (1990). Final report: Phase II nursing evaluation research: Alzheimer’s care unit (R01 NR01689-NCNR). Rockville, MD: National Institutes of Health.
  • Maas, M.L. & Buckwalter, K.C. (2006). Providing quality care in assisted living facilities: Recommendations for enhanced staffing and staff training. Journal of Gerontological Nursing, 32(11), 14–22.
  • Maas, M.L., Reed, D., Park, M., Specht, J.P., Schutte, D., Kelley, L.S. & Buckwalter, K.C. (2004). Outcomes of family involvement in care intervention for caregivers of individuals with dementia. Nursing Research, 53, 76–86. doi:10.1097/00006199-200403000-00003 [CrossRef]
  • Magsi, H. & Malloy, T. (2005). Underrecognition of cognitive impairment in assisted living facilities. Journal of the American Geriatrics Society, 53, 295–298. doi:10.1111/j.1532-5415.2005.53117.x [CrossRef]
  • Maslach, C., Jackson, S.E. & Leiter, M.P. (1996). Maslach Burnout Inventory manual. Palo Alto, CA: Consulting Psychologists Press.
  • McGilton, K.S., Hall, L.M., Wodchis, W.P. & Petroz, U. (2007). Supervisory support, job stress, and job satisfaction among long-term care nursing staff. Journal of Nursing Administration, 37, 366–372. doi:10.1097/01.NNA.0000285115.60689.4b [CrossRef]
  • Mitty, E., Resnick, B., Allen, J., Bakerjian, D., Hertz, J., Gardner, W. & Mezey, M. (2010). Nursing delegation and medication administration in assisted living. Nursing Administration Quarterly, 34, 162–171. doi:10.1097/NAQ.0b013e3181d9183f [CrossRef]
  • Park-Lee, E., Caffrey, C., Sengupta, M., Moss, A.J., Rosenoff, E. & Harris-Kojetin, L.D. (2011). Residential care facilities: A key sector in the spectrum of long-term care providers in the United States (NCHS Data brief No. 78). Retrieved from http://www.cdc.gov/nchs/data/databriefs/db78.pdf
  • Pillemer, K., Suitor, J.J., Henderson, C.R. Jr.. , Meador, R., Schultz, L., Robison, J. & Hegeman, C. (2003). A cooperative communication intervention for nursing home staff and family members of residents. The Gerontologist, 43, 96–106. doi:10.1093/geront/43.suppl_2.96 [CrossRef]
  • Polzer, K. (2010). Assisted living state regulatory review 2010. Retrieved from http://www.ahcancal.org/ncal/resources/Documents/2010AssistedLivingRegulatoryReview.pdf
  • Radloff, L.S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401. doi:10.1177/014662167700100306 [CrossRef]
  • Schaefer, J.A. & Moos, R.H. (1993). Relationship, task, and system stressors in the health care workplace. Journal of Community and Applied Social Psychology, 3, 285–298. doi:10.1002/casp.2450030406 [CrossRef]
  • Schaefer, J.A. & Moos, R.H. (1996). Effects of work stressors and work climate on long-term care staff’s job morale and functioning. Research in Nursing and Health, 19, 63–73. doi:10.1002/(SICI)1098-240X(199602)19:1<63::AID-NUR7>3.0.CO;2-J [CrossRef]
  • Scott-Cawiezell, J., Schenkman, M., Moore, L., Vojir, C., Connolly, R.P., Pratt, M. & Palmer, L. (2004). Exploring nursing home staff’s perceptions of communication and leadership to facilitate quality improvement. Journal of Nursing Care Quality, 19, 242–252. doi:10.1097/00001786-200407000-00011 [CrossRef]
  • Sikorska-Simmons, E. (2005). Predictors of organizational commitment among staff in assisted living. The Gerontologist, 45, 196–205. doi:10.1093/geront/45.2.196 [CrossRef]
  • Sikorska-Simmons, E. (2006). Linking resident satisfaction to staff perceptions of the work environment in assisted living: A multilevel analysis. The Gerontologist, 46, 590–598. doi:10.1093/geront/46.5.590 [CrossRef]
  • Sikorska-Simmons, E. (2008). Predictors of staff-supportive organizational culture in assisted living. Journal of Gerontological Nursing, 34(3), 15–23. doi:10.3928/00989134-20080301-09 [CrossRef]
  • Specht, J.K., Park, M., Maas, M.L., Reed, D., Swanson, E. & Buckwalter, K.C. (2005). Interventions for residents with dementia and their family and staff caregivers: Evaluating the effectiveness of measures of outcomes in long-term care. Journal of Gerontological Nursing, 31(6), 6–14.
  • Stearns, S.C., Park, J., Zimmerman, S., Gruber-Baldini, A.L., Konrad, T.R. & Sloane, P.D. (2007). Determinants and effects of nurse staffing intensity and skill mix in residential care/assisted living settings. The Gerontologist, 47, 662–671. doi:10.1093/geront/47.5.662 [CrossRef]
  • Stone, R.I., Reinhard, S.C., Bowers, B., Zimmerman, D., Phillips, C.D., Hawes, C. & Jacobson, N. (2002). Evaluation of the Wellspring Model for improving nursing home quality. Retrieved from http://www.commonwealth-fund.org/Publications/Fund-Reports/2002/Aug/Evaluation-of-the-Wellspring-Model-for-Improving-Nursing-Home-Quality.aspx
  • Talerico, K.A., O’Brien, J.A. & Swafford, K.L. (2003). Person-centered care. An important approach for 21st century health care. Journal of Psychosocial Nursing and Mental Health Services, 41(11), 12–16.
  • Tellis-Nayak, V. (2007). A person-centered work-place: The foundation for person-centered caregiving in long-term care. Journal of the American Medical Directors Association, 8, 46–54. doi:10.1016/j.jamda.2006.09.009 [CrossRef]
  • Tyler, D.A. & Parker, V.A. (2011). Staff team-work in long-term care facilities: The influence of management styles, training, and feedback. Research in Gerontological Nursing, 4, 135–146. doi:10.3928/19404921-20100706-01 [CrossRef]
  • Zimmerman, S., Gruber-Baldini, A.L., Sloane, P.D., Eckert, J.K., Hebel, J.R., Morgan, L.A. & Konrad, T.R. (2003). Assisted living and nursing homes: Apples and oranges?The Gerontologist, 43, 107–117. doi:10.1093/geront/43.suppl_2.107 [CrossRef]
  • Zimmerman, S., Williams, C.S., Reed, P.S., Boustani, M., Preisser, J.S., Heck, E. & Sloane, P.D. (2005). Attitudes, stress, and satisfaction of staff caring for residents with dementia. The Gerontologist, 45, 96–105. doi:10.1093/geront/45.suppl_1.96 [CrossRef]

Characteristics of Residential Care/Assisted Living (RC/AL) Communities (N = 18)

Characteristic n (%)
For-profit 18 (100)
Three or more administrators in past 3 years 8 (44)
Affiliated with a continuing care retirement community 3 (17)
Affiliated with another RC/AL living community 12 (67)
Affiliated with a nursing home 2 (11)
Mean (SD)
Years in operation 8.3 (4.7)
Number of beds 81.7 (26.8)
Occupancy rate (%) 83.3 (14.7)
Average monthly charge $3,095 ($722)
Residents with dementia diagnosis (%) 48.4 (31.8)
Residents of minority race (%) 22.6 (27.9)

Characteristics, Perceptions, Experiences, and Attitudes of Personal Care Staff and Supervisors

Personal Care Staff (N = 250) Supervisors (N = 30)
Characteristic n (%) p Value
Gender (% female) 240 (96) 28 (93) 0.65
Marital status (% married) 100 (40) 14 (47) 0.50
Race (% minority) 184 (74) 8 (27) <0.001
Hispanic 6 (2) 0 (0) 0.73
Educational level
  High school or less 118 (47) 6 (20)
  Some college or associate’s degree 113 (45) 15(50)
  Bachelor’s degree or higher 19 (8) 9 (30) <0.001
  Excellent health 47 (19) 10 (33) 0.07
Mean (SD)
Age (years) 37.6 (13.2) 43.7 (12.1) 0.013
Depressiona (0 to 10) 2.6 (2.1) 2.5 (2.0) 0.80
Years working in that setting 2.7 (3.3) 4.0 (3.3) 0.032
Years of long-term care experience 6.9 (6.7) 7.4 (7.0) 0.69
Hours worked in typical week 36.8 (6.0) 40.2 (7.3) 0.005
Mean (SD) p Value Unadjusted p Value Adjustedb
Perceptions
  Caregiving rolec
    Burden (1 to 5) 2.2 (0.5) 1.9 (0.5) <0.001 0.002
    Frustration (1 to 5) 3.7 (0.5) 3.4 (0.5) 0.05 0.07
    Dominion (1 to 5) 3.2 (0.5) 2.7 (0.5) <0.001 0.004
    Exclusion (1 to 5) 2.1 (0.4) 2.1 (0.4) 0.63 0.88
  Family empathy toward staffd (3 to 15) 8.5 (2.4) 9.2 (1.8) 0.15 0.14
Experiences
  Burnoute
    Emotional exhaustion (0 to 54) 13.3 (11.4) 10.9 (8.9) 0.31 0.26
    Depersonalization (0 to 30) 2.1 (3.1) 0.8 (1.4) 0.035 0.038
    Lack of personal accomplishment (0 to 48) 39.9 (7.6) 42.5 (4.9) 0.09 0.048
  Work Stress Inventoryf, caring for residents (4 to 20) 11.0 (3.6) 11.1 (3.3) 0.73 0.85
  Hasslesg (17 to 85) 45.4 (9.7) 42.9 (7.2) 0.09 0.06
  Upliftsg (20 to 100) 87.1 (10.2) 86.7 (9.5) 0.64 0.71
  Interpersonal conflict – disagreementsh (7 to 35) 11.9 (5.6) 10.7 (4.3) 0.23 0.08
Personal Care Staff (N = 250) Supervisors (N = 30) p Value Unadjusted p Value Adjustedb
Mean (SD)
Attitudesi
  Toward job (1 to 4) 3.3 (0.8) 3.6 (0.6) 0.11 0.18
  Toward families – partnership with family (1 to 5) 3.9 (0.5) 4.1 (0.3) 0.013 0.028
  Toward families – families cause disruption (1 to 5) 3.4 (0.5) 3.8 (0.4) 0.002 0.014
  Toward families – family relevance (1 to 5) 3.0 (0.6) 3.3 (0.5) 0.024 0.025

Keypoints

Beeber, A.S., Cohen, L.W., Zimmerman, S., Gwyther, L.P., Washington, T., Cagle, J.G. & Reed, D. (2014). Differences in Assisted Living Staff Perceptions, Experiences, and Attitudes. Journal of Gerontological Nursing, 40(1), 41–49.

  1. Staff attitudes toward their organization, the residents they care for, and families can affect quality of care.

  2. Although the relationship between residents’ families and personal care (PC) staff are a key interface essential for day-to-day resident care, PC staff had more negative attitudes toward their work and families than supervisors.

  3. This study highlights a need for a more concentrated effort to create an environment that decreases the stresses and burdens experienced by PC staff.

10.3928/00989134-20130731-03

Sign up to receive

Journal E-contents