Reimagining Family Involvement in Residential Long-Term Care

Engagement of Relatives in End-of-life Care of Residents in Long-Term Care Facilities: A Cross-Sectional Study in 5 EU Countries

OBJECTIVE

To determine the extent and factors associated with relatives' engagement in end-of-life care for residents of long-term care facilities (LTCFs) during the last week before the resident's death.

DESIGN

A cross-sectional retrospective survey.

SETTING AND PARTICIPANTS

A total of 814 relatives of deceased LTCF residents in a representative sample of 229 LTCFs in Belgium, Finland, Italy, the Netherlands, and Poland.

METHODS

LTCFs reported all residents' deaths in the past 3 months. In each case, standardized questionnaires were sent to the LTCF manager, nurse, physician, and relative most involved in care. A multivariable logistic regression model was applied to assess which factors and characteristics of the relative and deceased resident were associated with more time spent with the resident in the last week of life.

RESULTS

Compared with Poland, relatives from the Netherlands [odds ratio (OR), 14.22; 95% CI, 6.56-30.82], Belgium (OR, 10.24; 95% CI 4.87-24.52), and Finland (OR, 2.57; 95% CI, 1.18-5.58) had higher odds of spending more than 14 hours with residents in the last week of life. Female relatives, who were their partners or spouses, and who provided more than 11 hours of care weekly before the resident's admission to the LTCF (OR, 2.96; 95% CI 1.55-5.65) were more likely to visit the dying resident during the last week of life. Residents placed in the LTCF due to their behavioral problems or dependency in activities of daily living (ADL) were less frequently visited by their relatives in the last week of life (OR, 0.34; 95% CI, 0.16-0.71 and OR, 0.54; 95% CI, 0.36-0.82, respectively).

CONCLUSIONS AND IMPLICATIONS

Resident's behavioral problems and dependency in ADLs at the time of admission to the LTCF were associated with their relative's lower engagement in end-of-life care. We also found substantial differences in relatives' engagement among countries. Further research is required to identify the causes of these discrepancies and to develop culture-specific support for relatives.

Variations in caregiving patterns of spouses/partners and adult children of long-term care home residents in Ontario, Canada

Family involvement in care often continues after an individual moves into a long-term care (LTC) home. This cross-sectional study delves into the dynamics of family caregiving for LTC residents. Spouses/partners (n = 32, mean age 76) primarily focused on tasks such as mealtimes (53 %) and direct care like feeding, whereas adult children (n = 159, mean age 62) showed a preference for non-mealtime visits (64 %) and managing indirect care activities such as finances. These distinct caregiving patterns underscore the varied contributions of different care partners within LTC settings. Drawing from a survey conducted between April and June 2021 among 191 spouses/partners and adult children, who provide care to LTC residents, our findings offer valuable insights into the diverse roles of care partners, including tasks related to health (feeding, physical health, medication), instrumental activities (transportation, legal affairs, shopping), and social-emotional support. The implications of this research extend to redefining essential care partner roles within LTC homes.

"Families are a resource, not the enemy": Canadian family caregivers' experiences of COVID-19 pandemic visitor restrictions

Canadian long-term care homes implemented strict visitor restrictions at the onset of the COVID-19 pandemic to control the spread of the virus among residents. These restrictions extended to family caregivers, a significant provider of in-person physical and social care, preventing them from entering long-term care homes. The purpose of the current study was to explore the experiences and observations of family caregivers during the prolonged visitor restrictions. Fifteen semi-structured, one-on-one interviews were conducted with family caregivers of persons living in long-term care and analysed using a codebook thematic approach. Four themes were identified: a) pandemic policies dismissed family relationships; b) prolonged separation traumatised families; c) family caregivers were resourceful in fulfilling their roles; and d) family caregivers are calling for collaborative change. Our findings reflect how long-term care policies and standards that lacked a family-centred lens resulted in barriers to care and led to serious concerns about the quality of life of residents and serious distress among family caregivers.

Exploring the Relationship Between Nursing Staff and Family Members' Appraisal of Resident Care in Nursing Homes: The Role of Facility Ownership

Background/Objectives: To address long-standing staffing challenges and elevating care standards in the United States, new legislation will require a minimum of 0.55 h per resident day (HPRD) of registered nurse (RN) care, 2.45 HPRD of certified nursing aide (CNA) care, and a combined total of 3.48 HPRD across any combination of nursing staff. We examine differences in family members' views of care quality between facilities meeting the minimum staffing requirements and those that do not and whether there is any difference in those associations by facility ownership. Methods: This cross-sectional study utilized public data from 218 Medicare and Medicaid-certified nursing facilities in Maryland, collected in 2023. We used regression analyses to examine the association between staffing requirements and quality of care ratings, considering facility ownership status as a potential moderator. Results: Compared to facilities with CNA staffing levels below the cut off, facilities that met the CNA staffing requirement were rated more favorably by family members in overall quality and across the subdomains of staffing, care, activities, and security. In contrast, meeting the RN 0.55 cut off was not associated with family ratings across any quality domain. A facility for-profit status did not moderate the relationship between staffing and family ratings. Conclusions: These results suggest that CNA staff time is a significant driver of care quality and that non-profit facilities may already be closer to meeting new federal requirements. These findings highlight the need for regulations that support the minimum nursing staffing requirements to enhance care quality. Future research should identify the specific factors contributing to higher quality care in non-profit facilities and explore ways to implement these practices in for-profit settings.

Exploring the Experiences of LTCF Staff in Implementing Visitation Policies in England During the COVID-19 Pandemic

Background: Restrictions on family visitation to long-term care facilities (LTCFs) during the COVID-19 pandemic remain an area of contention for residents, family members and staff members. Current research has explored the experience of family members; however, fewer studies have explored the impact of visitation restrictions from the perspective of LTCF staff members. We examined the experiences of LTCF staff members in implementing visitation restrictions, including maintaining contact with families, in England over the course of the COVID-19 pandemic. Method: A sample of twenty-four LTCF staff members employed at eight LTCFs in one region of England was recruited. Qualitative, in-depth interviews were conducted with staff members to explore their experiences of implementing government policies during the COVID-19 pandemic. Thematic analysis was used to analyse data on maintaining contact and visitation with relatives. Results: Five broad themes were identified from the data. These were: (i) engaging with family members on visitation, (ii) facilitating visitation with family members, (iii) maintaining remote contact with family members, (iv) managing visitation restrictions with residents and (v) navigating equitable access for residents and family members. While some staff welcomed the introduction of national guidance on restrictions as a source to refer family members to for justification of the LTCFs' decisions to restrict access, others reflected on the negative effect of limited social contact on resident wellbeing and difficulties in implementing the guidance. At times, LTCFs felt conflicted in their responsibility for supporting family members in visiting at the same time as communicating, enforcing and policing visitation restrictions. Guidance on facilitating remote contact required substantial time and resources required to support it. Discussion: The extent to which restricting visitation was a proportionate response to reducing the spread of COVID-19, within the wider context of negative impacts on relatives and family members, is an ongoing debate. This study identified some of the challenges experiences by LTCF staff in implementing such guidance, and calls into question the practicality of restricting visitation. Further research is needed on how social contact can be maintained between relatives and their families during pandemics, which is both equitable and achievable.

Changes in Long-term Services and Supports Among Adults With and Without Dementia During the First Year of the COVID-19 Pandemic

Background and Objectives

This study draws upon local coronavirus disease 2019 (COVID-19) mortality rates as a proxy for pandemic severity to determine if the COVID-19 pandemic disrupted long-term services and supports (LTSS) for adults with dementia, relative to adults with care needs unrelated to dementia.

Research Design and Methods

We used the Health and Retirement Study to estimate associations between local COVID-19 mortality rates from March 2020 through April 2021 and LTSS outcomes (receiving paid and unpaid help, monthly hours of paid and unpaid help, number of paid and unpaid helpers, living in a residential care setting, or living with adult children). We compared 2 groups of adults ages 51 and older: those with dementia (n = 522) and those without dementia but having difficulty with at least one activity of daily living (n = 2,036).

Results

We found that higher local COVID-19 mortality rates were associated with a reduction in paid care and living in residential care settings for both groups of adults with care needs. In addition, higher local COVID-19 mortality rates were associated with a greater likelihood of living with adult children among those without dementia and greater hours of unpaid help among those with dementia.

Discussion and Implications

Although we did not find differences in disruptions of LTSS between persons with and without dementia, observed declines in paid LTSS and increases in unpaid care in the first year of the pandemic may nevertheless have different implications for persons with dementia. Future research should investigate if COVID-19 related disruptions in LTSS led to differential changes in health and unmet needs among adults with dementia, increased strain for their caregivers, and the equitable availability of high-quality paid care.

Caregivers' Experiences of Nursing Home Restrictions During the COVID-19 Pandemic

BACKGROUND

Pandemic-related restrictions in nursing homes have undermined the critical role that family and friend caregivers play in enhancing resident quality of life.

OBJECTIVE

We examined how family caregiver access restrictions in nursing homes were implemented and how they impacted the mutual well-being of and relationships between residents and their caregivers over time. Methods Between March 2021 and march 2022, 24 'designated caregivers' in Atlantic Canada were interviewed three times.

FINDINGS

We identified changes in family relationships and activities over time, constricted support networks, the increasing need for advocacy and monitoring, and the generally negative cumulative impacts of restrictions, especially during residents' end-of-life. Subsequent adaptations to access restrictions allowed caregivers to contribute to essential monitoring, care relationships, and advocacy roles.

DISCUSSION

We argue that the role of designated caregivers in nursing homes must be maintained during public health emergencies to ensure resident's supportive family relationships and general well-being.

Care partner experience with telepresence robots in long-term care during COVID-19 pandemic

Objective

As people living with dementia move into long-term care (LTC), their care partners face a difficult role change from primary caregiver to visitor, losing a significant degree of control and direct care involvement. The COVID-19 pandemic exacerbated these challenges with health risks, changing care home protocols, and government policies. To help address these challenges, this study aimed to investigate the experiences of care partners who used telepresence robots to maintain contact with and care for their loved ones during the pandemic.

Methods

This study was guided by the Collaborative Action Research (CAR) approach. Along with interdisciplinary researchers and trainees, our team included patient and family partners as co-researchers throughout the project. We conducted semi-structured interviews with 20 care partners who used the robots in five urban Canadian LTC homes between May 2021 and August 2023.

Results

Thematic analysis identified four key themes characterizing their experiences using the robot: (a) decreases care partner burden, (b) facilitates care partner-staff relationship, (c) creates relational autonomy, and (d) expands the scope of what is possible.

Conclusion

The results of the study suggest that telepresence robots can play a useful role in enhancing the caregiving experience for informal care partners in multifaceted ways. Care partners reported positive benefits of having the robot assist their virtual visits. However, further research is needed to determine the sustainability of robot implementation among diverse geographic regions and care home compositions.

Patient Profile and Cost Savings of Long-Term Care in a Spanish Hospital: Retrospective Observational Study

BACKGROUND

Long-term care hospitals have been considered an efficient response to the health care needs of an increasingly aging population. These centers are expected to contribute to better hospital bed management and more personalized care for patients needing continuous care. The evaluation of their outcomes is necessary after a sufficient period to assess their impact. Hospitals for Acute and Chronic Long-Term Extended Stay (HACLES) emerged in Spain in the late 20th century as a response to the aging population and the increase in chronic diseases.

OBJECTIVE

This study aimed to analyze the profile of patients treated in a HACLES, particularly analyzing gender differences, and evaluate the cost savings associated with using these centers.

METHODS

A retrospective study was conducted based on data from patients 65 years old or older admitted to a HACLES between 2022 and 2023. Gender, age, household cohabitation data, diagnosis and comorbidity, daily medication intake, and degree of dependency were obtained to describe the profile of patients who attended the HACLES. Data coded in SIA-Abucasis (version 37.00.03; Consellería Sanitat, Generalitat Valenciana; a digital medical record system used in the Valencian region) were reviewed, and descriptive statistics and comparison tests were used. The direct cost savings of HACLES admissions were calculated by comparing the daily cost of a general hospital bed with that of a HACLES bed.

RESULTS

Data from 123 patients with a mean age of 77 years were analyzed. Most (n=81, 65.9%) had a cohabiting family member as their primary caregiver. Palliative care was the most frequent reason for admission (n=75, 61%). The mortality rate (odds ratio [OR] 61.8, 95% CI 53.2-70.5) was similar between men and women (OR 54.1, 95% CI 47.8-71.5 vs OR 59.7, 95% CI 42.2-66.0; P=.23). The cognitive assessment, using the Pfeiffer scale, improved at discharge (mean 3.2, SD 3.2 vs mean 2.5, SD 3.1; P=.003). The length of stay was significantly larger for patients who returned home compared with patients discharged to other facilities (mean 89.8, SD 58.2 versus mean 33.1, SD 43.1 days; P<.001). The direct cost savings were estimated at US $42,614,846 per 1000 admissions.

CONCLUSIONS

Patients typically treated in HACLES are older, with a high level of cognitive impairment and physical dependency, and a significant proportion are in palliative care, highlighting the importance of adapting care to the individual needs of the admitted patients. The HACLES model contributes to the sustainability of the public health system.

Family Involvement in the Care of Nursing Home Residents With Dementia: A Scoping Review

Family members are involved in the lives of older adults with dementia in complex ways. This scoping review synthesizes existing research on family involvement in the care of nursing home residents with advanced dementia. Using the Arksey and O'Malley scoping review framework, electronic searches of PubMed, EBSCO's CINAHL Complete, and APA PsychInfo on the Ovid platform were conducted. Twenty-eight studies met inclusion criteria. Emergent themes and definitions of involvement were obtained through thematic analysis, including: (1) contact (through visitation, calling, or writing letters); (2) engagement in care activities (instrumental/activities of daily living); (3) planning and monitoring care (being aware of health and treatment changes, partnership with care staff, ensuring adequate care, and decision-making); and (4) supporting the resident (advocacy, socioemotional support, and financial support). Moreover, limited psychometrically sound instruments exist to measure family involvement. These limitations stall the progression of research targeting family involvement.

Addressing unnecessary and avoidable transfers from residential aged care to emergency departments and hospitals

Purpose The purpose of this article is to examine and discuss the literature regarding emergency department (ED) transfers from residential aged care with a focus on reducing potentially avoidable transfers to enhance care experiences, safety, and outcomes. Design Researchers experienced in evidence synthesis and policy research in the aged care space reviewed the literature about residential aged care transfers to EDs, including factors underlying transfers and interventions to reduce transfers. Findings Transfers to EDs from aged care are common. They can be harmful, distressing, costly, and have a variety of negative impacts on residents, staff, and the aged care and health system. High rates of potentially avoidable or unwarranted transfers suggests the presence of systemic issues, including the lack of sufficient staffing levels and skills mix with the requisite knowledge, training, resources, and support. Reforms are required to improve staffing levels and skills mix, enhance access to on-site and in-reach clinical expertise, provide access to quality improvement initiatives, and engage consumers to ensure shared decision-making. Further research is also required to help determine the best approach to reducing unnecessary hospital transfers from aged care considering the specific scopes of practice of aged care workers. Conclusion While some transfers from residential aged care to EDs are necessary, many do not represent safe, dignified care for older people. Unwarranted transfers are burdensome and risky and should be minimised through the provision of a range of reforms including sufficient staffing, resources, and support, that allow for the delivery of care in place where appropriate.

Psychosocial Distress Among Certified Nursing Assistants in Long-Term Care During the COVID-19 Pandemic: A Social Ecological Model Informed Scoping Review

OBJECTIVES

This scoping review maps the literature on psychosocial distress and coping among nursing assistants (CNAs) in long-term care facilities (LTC) during the COVID-19 pandemic onto the Social Ecological Model (SEM) of Occupational Stress.

METHODS

Searches yielded 862 unique studies. Inclusion criteria were sample CNAs or equivalent in LTC; includes psychosocial variable; and collect data from February 2020-. A multi-phasic, meta-synthesis was used to synthesize qualitative data.

RESULTS

We identified 20 studies (13 quantitative, 7 qualitative) conducted between March 2020 and December 2021 from 14 countries. Prevalence rates were reported for perceived stress (31-33%; n = 1 study), post-traumatic stress (42%; n = 1), anxiety (53%; n = 1), depression (15-59%; n = 2), suicidal thoughts (11-15%; n = 1), and everyday emotional burnout (28%; n = 1). Qualitative studies identified factors contributing to psychosocial distress and coping at each SEM level (i.e. individual, microsystem, organization, and peri-/extra-organizational). Quantitative studies primarily measured factors relating to psychosocial distress and coping at the individual and organizational levels.

CONCLUSIONS & CLINICAL IMPLICATIONS

This review identifies specific targets for intervention for psychosocial distress among CNAs in LTC at multiple levels, including job clarity; workload; facility culture; community relations; and policy. These intervention targets remain relevant to the LTC industry beyond the context of the COVID-19 pandemic.

Examining Care Network Characteristics in Older Adults' Relocation to Residential Care Settings

Background and Objectives

When older adults face increasing care needs or limited support, remaining safely and comfortably at home becomes challenging. Extant research has primarily concentrated on characteristics of the older adult or their primary caregiver on nursing home admission. This study examines the risk of older adults transitioning to residential care (e.g., assisted living, nursing home), focusing on the influence of their care network or involvement of multiple helpers.

Research Design and Methods

Using the National Health and Aging Trends Study, we conducted competing risk regression models that account for mortality, following 7,085 initially community-dwelling older adults across Rounds 1-9 (2011-2019). We assessed network composition, size, shared tasks, and the number of in-network specialists or generalists while controlling for individual sociodemographic and health factors.

Results

Individuals with care networks that shared medical tasks had the highest risk of moving to a residential care setting, followed by those sharing household tasks. Conversely, shared mobility or self-care and transportation responsibilities were associated with lower risks. Having more generalists, but not specialists, increased the risk. Larger networks were associated with heightened risk, although having close family members like a spouse was protective.

Discussion and Implications

The findings underscore that care network characteristics are critical to older adults' ability to age in place. Specifically, older adults with larger networks, lacking a spouse or child, and providing complex care are at greater risk for relocating. Understanding care networks can guide interventions related to care network coordination and resource allocation to help avoid or postpone a residential care move.

The Involvement of Caregivers in the End-of-life Care of an Older Adult Living in a Long-term Care Home: A Qualitative Case Study with Nurses and Relatives

BACKGROUND

A key role of nurses working in long-term care homes (LTCHs) is to promote the involvement of care partners in end-of-life (EOL) care. However, studies on the involvement of care partners in EOL care in LTCHs have focused on care planning and decision-making. While care partners can participate in other ways, it's unclear how they are currently involved in EOL care by staff.

PURPOSE

We aimed to explore the involvement of care partners in the EOL care of an older adult living in a LTCH.

METHODS

A qualitative case study was conducted. Data was collected from a sample of four nurses and three care partners, using sociodemographic questionnaires, individual semi-structured interviews, documents pertaining to the LTCH's philosophy for EOL care, and a field diary.

RESULTS

The results of a thematic analysis showed the broad scope of care partners' possible involvement, including contributing to care, obtaining information, and being present. As there was some variation in care partners' desire to be involved, nurses seemed to rely on them to convey their wishes. To promote this involvement, some strategies aimed at health professionals and managers were suggested.

CONCLUSIONS

These results can guide improvement in clinical practices and raise awareness on the EOL care experiences of care partners.

Family Involvement among Oregon Adult Foster Home Residents, 2018-2023

OBJECTIVES

To track the changes that occurred in family involvement among Oregon Adult Foster Home (AFH) residents following the COVID-19 pandemic and to examine the associations between home and resident characteristics and family involvement.

DESIGN

Retrospective analysis of repeated cross-sectional data.

SETTING AND PARTICIPANTS

A total of 2027 responses from AFH providers that replied to a mailed questionnaire from a sample of eligible licensed Oregon AFH selected to participate annually between 2018 and 2023 (6 waves).

METHODS

AFH providers filled out a questionnaire containing questions about family involvement (residents who received 6 types of support from family members or friends, such as help with personal care or social visit) and resident characteristics (activities of daily living needs, payer mix, age, gender, dementia status). Additional contextual data (size, rural/urban) were obtained from state agencies. Associations among family involvement and home and resident characteristics were examined using multivariable linear regression models.

RESULTS

Bivariate analyses showed statistically significant declines in social visits and outings and help getting to medical appointments during the first 2 years (2021 and 2022) of the COVID-19 pandemic, but little change in help with personal care or taking medications or phone calls. By 2023, social visits had recovered to pre-pandemic levels but remained significantly lower for help getting to medical appointments and going on outings. Multiple regression models that included controls showed that rural AFH and those with higher Medicaid use reported significantly lower family involvement in social visits, outings, and help getting to medical appointments.

CONCLUSIONS AND IMPLICATIONS

The continued decline in assistance for medical appointments and outings portends potential challenges in resident socioemotional well-being and accessing health care services in this setting. Understanding the long-term impacts of the pandemic on quality of life and quality of care for residents living in community-based care settings may require a multifaceted approach to measuring family involvement.

Efficacy of the residential care transition module: A telehealth intervention for dementia family caregivers of relatives living in residential long-term care settings

The purpose of this study was to evaluate the efficacy of the Residential Care Transition Module, a six-session, psychosocial, and psychoeducational telehealth intervention for family caregivers of cognitively impaired relatives living in a residential long-term care setting. Eligible participants (including care recipients, regardless of time since admission) were randomized to treatment or usual care control conditions. Survey data were collected at baseline, 4 months, 8 months, and 12 months (N = 240). Primary analytic outcomes included caregiver subjective stress (a stress process mechanism) and depressive symptoms (a measure of global well-being). Secondary analytic outcomes included secondary role strains, residential care stress, caregiver sense of competence, and self-efficacy (additional mechanisms of action). General linear models tested for the main effects of the intervention at 4 months, and longitudinal mixed models examined the 12-month effects of the intervention. Post hoc analyses also examined the influence of moderators. No significant differences between the treatment and control groups for any primary analytic outcome were apparent. Caregivers in the treatment group whose relatives were admitted to residential long-term care in the prior 3 months were more likely to indicate reductions in depressive symptoms over the first 4 months of participation. Over the 12-month study period, caregivers in the treatment group who were employed reported increased self-efficacy over time. The heterogeneity of dementia care requires a broader consideration of key contextual factors that may influence the efficacy of nonpharmacological interventions. Aligning measures with the preferences, goals, and values of dementia caregivers may further demonstrate the direct benefits of interventions such as the Residential Care Transition Module. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Suffering while resigning to an unacceptable violation of dignity

BACKGROUND

The interaction of health personnel with relatives is linked to the quality of care results in nursing homes. However, there is limited knowledge of how relatives perceive being an integral part of the nursing home context. This secondary analysis has its starting point in an ethical concern about relatives' experiences in a previous study.

AIM

To critically discuss relatives' experiences of suffering when their next of kin live in a nursing home in a rural arctic context.

RESEARCH DESIGN, PARTICIPANTS AND CONTEXT

The critical hermeneutic stance is informed by Habermas. The secondary analysis is conducted on original data from five semi-structured focus groups with 18 relatives of residents of two nursing homes in a rural part of Norway. The theoretical framework concerning dignity, well-being, and suffering, as developed by Galvin and Todres, contrasts the analysis.

ETHICAL CONSIDERATIONS

The study followed the principles of the Helsinki Declaration. It was approved by the Norwegian Center for Research Data (NSD) (reg. no. 993360).

FINDINGS

The main theme of this study is: suffering while resigning to an unacceptable violation of dignity. This theme is deepened by two subthemes: (a) suffering while adapting to a relationship of dependence and (b) suffering while accepting the unacceptable.

CONCLUSIONS

Relatives experience suffering as a cross-pressure in their struggle to interact responsibly with health personnel in nursing homes. This may have a negative outcome, where relatives end up adapting to being silent witnesses to missed care and a violation of dignity.

Addressing loneliness and social isolation through the involvement of primary and secondary informal caregivers in nursing homes: a scoping review

OBJECTIVES

To clarify the mechanisms of interventions addressing loneliness and social isolation in older adults living in nursing homes through the involvement of primary and secondary informal caregivers.

METHODS

This scoping review was performed by two independent reviewers, covering the period between 2011 and 2022 and the databases MEDLINE, CINAHL, PsycINFO and Scopus. It included terms related to (A) informal caregivers, (B) nursing homes, (C) psychosocial interventions, (D) involvement and (E) social isolation or loneliness.

RESULTS

Thirty-three studies met the inclusion criteria. Although there were various definitions and assessment tools related to social isolation and loneliness, the studies referred to three dimensions of these concepts in nursing home residents: the quantity of social interactions, the perception of these encounters and biographical changes in social relationships. Most studies did not explicate the mechanisms of these interventions. The review uncovered the following aspects of intervention mechanisms: increasing opportunities for social contact, creating meaningful encounters, maintaining existing relationships with primary informal caregivers and establishing new ones with secondary informal caregivers.

CONCLUSION

Studies reporting on interventions addressing loneliness and social isolation in nursing home residents need to clarify and detail their intervention mechanisms in order to foster more targeted interventions. In addition, there is a need for further research on large-scale programs or care philosophies in this field and the development of intervention designs, which allow for tailored intervention formats in order to respond to the individual perception of social relationships.

Informal care provided in US nursing homes: Reduced from 2010 to 2021 and lower for Medicaid residents

BACKGROUND

Little is known about the trend of informal care (unpaid care provided by family or other caregivers) provided to nursing home residents before or during the COVID-19 pandemic. This study assessed this trend during 2010-2021, for all and Medicaid versus non-Medicaid residents.

METHODS

Using data from the RAND Health and Retirement Study longitudinal file, our study sample included a total of 2025 resident-years (860 for Medicaid and 1165 for non-Medicaid residents). We fit two-part regression models to determine adjusted trends in average amount of informal care over time, and difference by resident Medicaid status.

RESULTS

Informal care received by residents reduced substantially over time, from an average of 39.2 h in the past month of interview in 2010-11 to 23.2 h in 2018-19, and then to 11.2 h in the COVID-19 pandemic (2020-21). The reduced hours were due to both reduced percentages of nursing home residents who received any informal care and reduced hours of care among those who did receive it over time. Multivariable analyses confirmed this trend and similar downward trends for Medicaid versus non-Medicaid residents. Medicaid residents on average received 10.02 fewer hours of informal care per month (95% confidence interval -17.16, -2.87; p = 0.006) than non-Medicaid residents after adjustment for resident characteristics and time trends.

CONCLUSION

Informal care provided to nursing home residents during 2010-2021 reduced over time, especially during the COVID-19 pandemic (2020-21). Medicaid residents tended to receive less informal care than non-Medicaid residents.

Public Health Response to SARS-CoV-2 in Assisted Living Facilities in New York State: March 2020-December 2022

CONTEXT

Assisted living facility (ALF) residents are especially vulnerable to SARS-CoV-2 infection due to the age and comorbidities of the resident population and the social nature of these facilities.

OBJECTIVE

To collate all New York State Department of Health guidance and regulations to control transmission of SARS-CoV-2 infection within ALFs from March 2020 through December 2022 and to include US Food and Drug Administration COVID-19 testing and vaccine authorizations.

DESIGN

A narrative chronological review of all New York State Department of Health guidance.

RESULTS

Documents and associated guidance and regulations are divided into 4 sections: (1) lockdown until COVID-19 vaccine emergency use authorization; (2) COVID-19 vaccine authorization until phased reopening; (3) phased reopening, vaccination requirements, and booster vaccination; (4) the period of the bivalent booster.

CONCLUSION

Controlling the spread of SARS-CoV-2 within ALFs required a multifactorial approach that included stringent infection control measures, testing, and vaccination and careful attention to the social structure and support systems within ALFs. The SARS-CoV-2 pandemic highlighted the complexity of controlling spread of an easily transmissible respiratory pathogen in assisted living communities and the need to structure infection control programs within the diverse ALFs that provide care for our aging population.

Ready or Not: A Conceptual Model of Organizational Readiness for Embedded Pragmatic Dementia Research

The National Institute on Aging Alzheimer's Disease/Alzheimer's Disease and Related Dementias Research Implementation Milestones emphasize the need for implementation research that maximizes up-take and scale-up of evidence-based dementia care practices across settings, diverse populations, and disease trajectories. Organizational readiness for implementation is a salient consideration when planning and conducting embedded pragmatic trials, in which interventions are implemented by provider staff. The current article examines the conceptual and theoretical underpinnings of organizational readiness for implementation and the operationalization of this construct. We offer a preliminary conceptual model for explicating and measuring organizational readiness and describe the unique characteristics and demands of implementing evidence-based interventions targeting persons with dementia and/or their care partners. [Research in Gerontological Nursing, 17(3), 149-160.].

Amant O, Ward-Griffin C, Anderson S. Double-duty caregivers enduring COVID-19 pandemic to endemic: "It's just wearing me down"

The COVID-19 pandemic has considerably strained health care providers and family caregivers. Double-duty caregivers give unpaid care at home and are employed as care providers. This sequential mixed-method study, a survey followed by qualitative interviews, aimed to comprehensively understand the experiences of these Canadian double-duty caregivers amidst the pandemic and the transition to the endemic phase. The multi-section survey included standardized assessments such as the Double-duty Caregiver Scale and the State Anxiety Scale, along with demographic, employment-related, and care work questions. Data analysis employed descriptive and linear regression modeling statistics, and content analysis of the qualitative data. Out of the 415 respondents, the majority were female (92.5%) and married (77.3%), with 54.9% aged 35 to 54 years and 29.2% 55 to 64 years. 68.9% reported mental health decline over the past year, while 60.7% noted physical health deteriorated. 75.9% of participants self-rated their anxiety as moderate to high. The final regression model explained 36.8% of the variance in participants' anxiety levels. Factors contributing to lower anxiety included more personal supports, awareness of limits, younger age, and fewer weekly employment hours. Increased anxiety was linked to poorer self-rated health, and both perceptions and consequences of blurred boundaries. The eighteen interviewees highlighted the stress of managing additional work and home care during the pandemic. They highlighted the difficulty navigating systems and coordinating care. Double-duty caregivers form a significant portion of the healthcare workforce. Despite the spotlight on care and caregiving during the COVID-19 pandemic, the vital contributions and well-being of double-duty caregivers and family caregivers have remained unnoticed. Prioritizing their welfare is crucial for health systems as they make up the largest care workforce, particularly evident during the ongoing healthcare workforce shortage.

"You're the only thing he comes out [of his room] for": A qualitative study of engagement between Laughter Care Specialists and families of people with dementia in long-term care

OBJECTIVES

Family involvement in the lives of people who have dementia and live in long-term care is important, but family members may face challenges communicating and connecting with their loved one as dementia progresses. A type of therapeutic humor (Laughter Care) delivered by trained specialists aims to engage people with dementia who reside in long-term care through creative play and laughter. This study aimed to explore the perceptions of Laughter Care Specialists (LCSs) regarding families' engagement with the program.

METHODS

Semi-structured interviews were conducted with LCSs (n = 8) and analyzed inductively using thematic analysis.

RESULTS

Family members were reported to initially have varied degrees of openness toward Laughter Care, but often become more accepting after observing positive engagement with the person with dementia. Family members were perceived to benefit from the program through witnessing the person with dementia enjoy joyous and light interactions, learn new ways of communicating and connecting with the person with dementia, and engage in positive interactions at end of life.

SIGNIFICANCE OF RESULTS

Laughter Care may provide family members with novel ways of communicating and connecting with people who have dementia at end of life as well as comfort into bereavement.

Filling In: Family Member Support for Nonrelative Residents in Long-Term Care Homes

BACKGROUND AND OBJECTIVES

Past research about family involvement in long-term care (LTC) homes mainly focuses on family members' involvement with their own relative, interactions with staff, and collective activities such as Family Councils. Our research provides novel insights into family member's involvement in the care of residents who are not their relatives, an area that has not previously been explored.

RESEARCH DESIGN AND METHODS

This critical ethnographic study examined ways that family members negotiate and navigate their roles within LTC homes. Data collection and analysis took place at 3 LTC homes in British Columbia, Canada, between 2014 and 2018. Data were collected through participant observation and semistructured interviews. Eleven family member participants shared experiences of caring for residents who were not their relatives.

RESULTS

The umbrella theme was "filling in," which takes place in a care environment that is understaffed and underresourced. The subthemes reflect the various ways that families are "filling in": responding to resident's needs, supporting staff to respond to resident needs, and filling in for residents' families.

DISCUSSION AND IMPLICATIONS

Caring for residents who are not their relatives is facet of family involvement in LTC homes that has not been previously explored. Many family members have expertise in providing person-centered care and they extend this expertise to residents who are not their relatives. Policies and legislation are needed to formalize family involvement in caring for nonrelative residents as it is a component of quality of care for all residents.

Towards equitable representation in long-term residential care: widening the circle to ensure "essential voices" in research teams

The COVID-19 pandemic exposed long-standing inequities in Canada's long-term residential care (LTRC) sector with life-threatening consequences. People from marginalized groups are overrepresented among those who live in, and work in LTRC facilities, yet their voices are generally silenced in LTRC research. Concerns about these silenced voices have sparked debate around ways to change LTRC policy to better address long-standing inequities and enhance the conditions that foster dignity for those who live and work in LTRC. Weaving an analysis of historical and cultural attitudes about LTRC, and promising strategies for engaging people with lived experience, we argue that the voices of people with lived experience of life and work (paid and unpaid) in LTRC are essential for ethically and effectively shifting long-standing inequities. Lessons from a 4-year, national, multi-disciplinary research study, known as the Seniors Adding Life to Years (SALTY) project, suggest that resident-determined quality of life can be prioritized by centring the perspectives of residents, their family/friends, direct care workers, volunteers, and people living with dementia in the research process. Accordingly, we highlight strategies to include these voices so that meaningful and impactful system change can be realized.

Social Connectedness Between Family Caregivers and Older Adults Living in Long-Term Care Homes in the Context of COVID-19

The coronavirus disease (COVID-19) pandemic and resulting restrictions on physical access to long-term care homes culminated in health declines for older adults living there and their families. Knowledge gaps exist regarding maintaining social connectedness when physically separated. The study aimed to explore family members' perceptions of the impact that restrictions on physical access to long-term care homes had on the experience of social connectedness between family members and older adults living in long-term care. The method used was a qualitative description, using in-depth semi-structured interviews. Themes arising from inductive qualitative content analysis of 21 interviews with family members included: (a) lack of connection threatening mental, emotional health, and physical health; (b) navigating trust in the unknown; (c) feelings of stress and anxiety for family members; and (d) technology - an asset, but not for everyone. Study findings suggest more emphasis should be placed on supporting social connections between older adults and their families in the context of long-term care beyond COVID-19.

Family Involvement Training for Staff and Family Caregivers: Case Report on Program Design and Mixed Methods Evaluation

The COVID-19 pandemic underscored the imperative for meaningful family involvement in long-term care, aligning with policy and safety standards while enhancing outcomes for caregivers, residents, and staff. The objectives of this article are as follows: (1) a case study report on implementing a family involvement intervention designed to facilitate the formal and safe engagement of family caregivers in resident care and (2) the pilot evaluation of the intervention. We used Knapp's six-step implementation science model to guide and describe intervention development to provide insight for others planning family involvement projects. We employed sequential mixed methods, including surveys with quantitative and qualitative questions before and after program implementation for providers, and surveys and interviews with family caregivers a year after. We used the Mann-Whitney U test (p < 0.05) to assess differences in health providers' perceptions pre- and post-education. Families and staff perceived that the Family Involvement Program was important for improving the quality of care, residents' quality of life and family/staff relationships. Providers' perceptions of the program's positive impact on residents' quality of life (p = 0.020) and quality of care (p = 0.010), along with their satisfaction with working relationships with families (p = 0.039), improved significantly after the program. Qualitative data confirmed improvements in family-staff relationships. In conclusion, we documented the design of this family involvement initiative to encourage family caregivers and staff to work together in residents' care. Youville's Family Involvement Program gives families and family caregivers an explicit role as partners in long-term care. The mixed methods pilot evaluation documented improvements in staff and family relationships.

What about the fundamentals of nursing-its interventions and its continuity among older people in need of home- or facility-based care: a scoping review

AIM

This scoping review investigated and descriptively summarised previous research about fundamental nursing, its focus (what care needs are described, how is it described and by whom is it described), continuity of care (is it described in relation to fundamental nursing) and possible nursing interventions or activities targeting older people's fundamentals of care needs in home- or facility-based care.

METHODS

This scoping review was carried out following the steps of Arksey and O'Malley's methodology and PRISMA-ScR reporting guidelines. Searches were conducted in PubMed via NIH, CINAHL via EBSCO and PsycInfo via ProQuest for the time period between January 2002 and May 2023.

RESULTS

Forty-two studies were included where the majority had been conducted in a facility-based care context. Nutrition-or rather nutritional care activities targeting eating and drinking-was the most frequently described fundamental care needs addressed. After this came personal care such as cleansing, dressing, oral care, skin, and foot care. Few studies addressed more than one fundamental care need at the time. The nursing staff described fundamental nursing as complex, comprehensive, and demanding. Older people and relatives described a gap between the fundamental nursing provided and their perceived need for support. Less attention was given to older peoples relational and psychosocial needs. Identified nursing interventions mainly targeted physical care needs. Our findings also implied that interventions focusing on fundamental nursing were described as feasible in practice with favourable or moderate results, while long-term effects were difficult to detect. No studies were identified focusing on fundamental nursing in relation to outcomes such as continuity of care.

CONCLUSION

Fundamental nursing was mainly described in relation to physical care needs, which were essentially conducted within facility-based care contexts. Interventions and activities primarily focused on one fundamental need at the time, mainly within the physical domain. No nursing interventions were identified focusing on relational and psychosocial needs where continuity of care can be viewed as a relevant outcome. Such limited focus are especially concerning as research has highlighted the importance of that older people with complex care needs can benefit from a holistic and person-centred approach i.e. fundamental nursing.

TRIAL REGISTRATION

Open Science Framework https://doi.org/10.17605/OSF.IO/XJ39E Protocol: http://dx.doi.org/10.1136/bmjopen-2022-069798.

Do Residential Long-Term Care Policies Support Family Involvement in Residents' Quality of Life in Four Canadian Provinces?

Family members are essential contributors to the quality of life (QoL) of persons living in residential long-term care (RLTC). This paper analyzes how the system enables or inhibits family involvement with residents in RLTC. Our analysis of 21 policies that regulate long-term care in four Canadian Provinces reveal differences in their portrayal of residents' families. Family roles are characterized procedurally (task-oriented) or relationally (interactive). Operational standards linked to licensing of RLTC homes employ more formal terminology, while RLTC program guidelines, use facilitative language to engage families and build relationships. Examples of orientation procedures, care protocols, living at risk, and end-of-life care reveal inter-provincial variations. We argue that there are opportunities to further engage families within the current regulatory framework and improve their continued contributions in the post-pandemic era.

Promoting activity and mobility in long-term care environments: A photo-elicitation study with older adults and nurses

AIM(S)

The aim of this research study is to collaboratively generate insights in the current institutional long-term care environment for activity and mobility of older adults, and of solutions that could be used to increase the activity and improve the mobility of the older adults.

DESIGN

This research constitutes a qualitative study with a critical approach.

METHODS

Data were collected using photo-elicitation in four long-term care units in Finland during the spring of 2022. Older adults participated in individual data collection sessions which combined photographing and discussion. Staff members individually took photographs and later participated in a group discussion based on the photographs. Reflexive thematic analysis was used to analyse all data together.

RESULTS

Ten older adults and 12 staff members participated in the research study. Four themes were identified: (1) facilities should be designed and equipped for their users, (2) moving in the institutional environment, (3) passivity as a norm, and (4) nurses should act differently and have the resources to do so.

CONCLUSION

To increase the activity and improve the mobility of older adults, improvements are needed in terms of the design of facilities, opportunities for freedom of movement, outdoor activity, daily life activities, exercise, nurses' role in activating older adults and resources.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Increased attention to the support of activity and mobility could benefit older adults in institutional long-term care. Physical activity promotion should be incorporated as an integral part of nursing practice.

PATIENT OR PUBLIC CONTRIBUTION

Directors of units were consulted when planning the study. Older adults and nurses contributed to the data collection and interpretation of data.

IMPACT

(ADDRESSING): What problem did the study address? ○Older adults have recurrently been reported as living inactive lives in institutional long-term care. ○There is evidence of the relationship between the environment and the activity and mobility of older adults, but there seems to be a research-practice gap in terms of implementing activity- and mobility-promoting environments. ○Older adults and staff members are important in developing practice and change-oriented knowledge that can be used to increase the activity and improve the mobility of older adults in institutional long-term care. What were the main findings? ○Various environmental improvements are recommended to increase the activity and improve the mobility of older adults in institutional long-term care settings. ○Improvements for the design of facilities, opportunities for freedom of movement, outdoor activity, daily life activities, exercise, nurses' role in activating older adults and resources for activity support would benefit older adults' activity and mobility. Where and on whom will the research have an impact? ○Increasing the activity of older adults requires better activity promotion and mobility support by nurses in institutional care. Sufficient education and resources should be organized for activity promotion, in addition to a care and organizational culture that values activity. ○Environmental aspects to promote activity and mobility need to be considered already at the planning, building and renovating phases of facilities. ○Policymakers and care organizers should consider evidence of the harms and benefits of different institutional living environments when making decisions on organizing care.

REPORTING METHOD

The study is reported using the Consolidated Criteria for Reporting Qualitative Research (COREQ).

Residential Environments for Older Persons: A Comprehensive Literature Review (2005-2022)

BACKGROUND

Independent noninstitutional and institutional residential long-term care environments for older persons have been the subject of significant empirical and qualitative research in the 2005-2022 period. A comprehensive review of this literature is reported, summarizing recent advancements in this rapidly expanding body of knowledge.

PURPOSE AND AIM

This comprehensive review conceptually structures the recent literature on environment and aging to provide conceptual clarity and identify current and future trends.

METHOD AND RESULT

Each source reviewed was classified as one of the five types-opinion piece/essay, cross-sectional empirical investigation, nonrandomized comparative investigation, randomized study, and policy review essay-within eight content categories: community-based aging in place; residentialism; nature, landscape, and biophilia; dementia special care units; voluntary/involuntary relocation; infection control/COVID-19, safety/environmental stress; ecological and cost-effective best practices; and recent design trends and prognostications.

CONCLUSIONS

Among the findings embodied in the 204 literature sources reviewed, all-private room long-term care residential units are generally safer and provide greater privacy and personal autonomy to residents, the deleterious impacts of involuntary relocation continue, family engagement in policy making and daily routines has increased, multigenerational independent living alternatives are increasing, the therapeutic role of nature and landscape is increasingly well-documented, ecological sustainability has increased in priority, and infection control measures are of high priority in the wake of the coronavirus pandemic. Discussion of the results of this comprehensive review sets the stage for further research and design advancements on this subject in light of the rapid aging of societies around the globe.

Caregiver Involvement and Concerns with Care of Residents of Assisted Living before and during the COVID-19 Pandemic

INTRODUCTION

Family/friend caregivers play an essential role in promoting the physical and mental health of older adults in need of care - especially during the COVID-19 pandemic and especially in assisted living (AL) homes, where resident care needs are similarly complex as in long-term care homes but fewer staffing resources and services are available. However, little research is available on caregiver involvement and concerns with care of AL residents prior to and during waves 1 and 2 of the COVID-19 pandemic. This study addressed this important knowledge gap.

METHODS

This prospective cohort study used baseline and follow-up online surveys with primary caregivers to AL residents in Western Canada who were 65 years or older and had lived in the AL home for at least 3 months before Mar 1, 2020. Surveys assessed the following outcomes in the 3 months prior to and during waves 1 and 2 of the pandemic: sociodemographics, 5 ways of visiting or communicating with residents, involvement in 16 care tasks, concerns with 9 resident physical/mental health conditions, perceived lack of resident access to 7 care services, and whether caregivers felt well informed and involved with resident care.

RESULTS

Based on 386 caregiver responses, in-person visits dropped significantly in wave 1 of the pandemic and so did caregiver involvement in nearly all care tasks. While these rates increased in wave 2, most did not return to pre-pandemic levels. Correspondingly, caregiver concerns (already high before the pandemic) substantially increased in wave 1 and stayed high in wave 2. These were particularly elevated among caregivers who did not feel well informed/involved with resident care.

CONCLUSIONS

Restricted in-person visiting disrupted resident care and was associated with worse perceptions of resident health and well-being. Continued caregiver involvement in resident care and communication with caregivers even during lockdowns is key to mitigating these issues.

Coping Behaviors and Health Status during the COVID-19 Pandemic among Caregivers of Assisted Living Residents in Western Canada

OBJECTIVES

To examine the prevalence of coping behaviors during the first 2 waves of the COVID-19 pandemic among caregivers of assisted living residents and variation in these behaviors by caregiver gender and mental health.

DESIGN

Cross-sectional and longitudinal survey.

SETTING AND PARTICIPANTS

Family/friend caregivers of assisted living residents in Alberta and British Columbia.

METHODS

A web-based survey, conducted twice (October 28, 2020 to March 31, 2021 and July 12, 2021 to September 7, 2021) on the same cohort obtained data on caregiver sociodemographic characteristics, anxiety and depressive symptoms, and coping behaviors [seeking counselling, starting a psychotropic drug (sedative, anxiolytic, antidepressant), starting or increasing alcohol, tobacco and/or cannabis consumption] during pandemic waves 1 and 2. Descriptive analyses and multivariable (modified) Poisson regression models identified caregiver correlates of each coping behavior.

RESULTS

Among the 673 caregivers surveyed at baseline, most were women (77%), White (90%) and age ≥55 years (81%). Alcohol (16.5%) and psychotropic drug (13.3%) use were the most prevalent coping behaviors reported during the initial wave, followed by smoking and/or cannabis use (8.0%), and counseling (7.4%). Among the longitudinal sample (n = 386), only alcohol use showed a significantly lower prevalence during the second wave (11.7% vs 15.1%, P = .02). During both waves, coping behaviors did not vary significantly by gender, however, psychotropic drug and substance use were significantly more prevalent among caregivers with baseline anxiety and depressive symptoms, including in models adjusted for confounders [eg, anxiety: adjusted risk ratio = 3.87 (95% CI 2.50-6.00] for psychotropic use, 1.87 (1.28-2.73) for alcohol use, 2.21 (1.26-3.88) for smoking/cannabis use).

CONCLUSIONS AND IMPLICATIONS

Assisted living caregivers experiencing anxiety or depressive symptoms during the pandemic were more likely to engage in drug and substance use, potentially maladaptive responses. Public health and assisted living home initiatives that identify caregiver mental health needs and provide targeted support during crises are required to mitigate declines in their health.

Three Perspectives on the Experience of Support for Family Caregivers in First Nations Communities

There is a dearth of research on how family caregivers are supported in First Nations. We interviewed family caregivers, health and community providers, and leaders in two Alberta First Nations Communities about their experiences of care and support for the family caregivers in their communities. We employed a qualitative, collaborative participatory action research methodology. We drew on Etuaptmumk, the Mi’kmaw understanding of being in the world is the gift of multiple perspectives. Participants in this research included family caregivers (n = 6), health and community providers (n = 14), and healthcare and community leaders (n = 6). The overarching caregiving theme is the “Hierarchy of challenge”. Six themes capture the challenges faced by family caregivers: (one) “Caregiving is a demanding job”: yet “No one in a sense is taking care of them”; (two) difficult navigation: “I am unable to access that”; (three) delayed assessments and treatment “And I don’t know how they’re being missed”; (four) disconnected health records: “It’s kind of on you to follow up”; (five) racism, “It’s treated differently”; and, (six) social determinants of health, “A lot of these factors have been developing for the longest time”. This study provides evidence that family caregivers’ need to care for and to maintain their own wellbeing is not top of mind in policy or programs in these First Nations communities. As we advocate for support for Canadian family caregivers, we need to ensure that Indigenous family caregivers are also recognized in policy and programs.

Hogan D, Gruneir A, A. Chamberlain S, Corbett K, E. Griffith L, McGrail KM, E. Amuah J, E. Lane N, J. Maxwell C. Caregivers' Concerns About Assisted Living Residents' Mental Health During the COVID-19 Pandemic: A Cross-Sectional Survey Study

Family or friend caregivers' concerns about assisted living (AL) residents' mental health are reflective of poor resident and caregiver mental health. COVID-19-related visiting restrictions increased caregiver concerns, but research on these issues in AL is limited. Using web-based surveys with 673 caregivers of AL residents in Western Canada, we assessed the prevalence and correlates of moderate to severe caregiver concerns about residents' depressed mood, loneliness, and anxiety in the 3 months before and after the start of the COVID-19 pandemic. Caregiver concerns doubled after the start of the pandemic (resident depressed mood: 23%-50%, loneliness: 29%-62%, anxiety: 24%-47%). Generalized linear mixed models identified various modifiable risk factors for caregiver concerns (e.g., caregivers' perception that residents lacked access to counseling services or not feeling well informed about and involved in resident care). These modifiable factors can be targeted in efforts to prevent or mitigate caregiver concerns and resident mental health issues.

Trust as a key measure of quality and safety after the restriction of family contact in Canadian long-term care settings during the COVID-19 pandemic

Family caregivers in Canadian long-term care homes are estimated to provide 10 h per week of direct care to approximately 30% of residents through roles including mobility support, mealtime assistance, personal care, social interaction, psychological care, care coordination, and advocacy. Despite these contributions, they continue to be viewed as visitors rather than as key participants in the interdependent relationships that support the long-term care sector. Their marginalization was evident during the COVID-19 pandemic, as Canadian public health policy focused on preventing them from entering long-term care, rather than supporting personal risk management, symptom screening, personal protective equipment, and other mechanisms for safe involvement in care. Several iatrogenic resident outcomes have been attributed to this, including decreased cognitive function, decreased mobility, increased incontinence, weight loss, increased depression and anxiety, increased responsive behaviours amongst those living with dementia, and increased delirium. In this commentary article, we argue that family caregiver presence was conflated as a risk when instead, it contributed to unintended harm. We identify nine well-known human social cognitive predispositions that may have contributed to this. We then examine their implications for trust in long-term care, and consider how quality and safety can be further fostered in long-term care by working in partnership with family caregivers to rebuild trust through enquiry and collaboration. We advocate incorporating trust as an essential measure of quality health service.

Disruptions in Relational Continuity: The Impact of Pandemic Public Health Measures on Families in Long-Term Care

Although the value of family caregivers' involvement with relatives in long-term care (LTC) is well recognized, tensions remain regarding their role. Such tensions were exacerbated during the COVID-19 pandemic as strict public health measures restricted family access to LTC homes. Using interpretive description, we examined the impact of visitation restrictions on family caregivers' experiences caring for a relative in LTC between March 2020 and June 2021. In-depth interviews were conducted with 14 family caregivers (five spouses and nine adult daughters) and two key themes were identified. The first theme, "seeking to maintain relational continuity," illustrates how caregivers sought to sustain connections with residents prior to and during the pandemic. The second theme, "disrupted relational continuity," highlights the impact of severed relational connections on caregivers' sense of self and ongoing feelings of loss and anger. Findings call for a trauma-informed approach that recognizes the pervasiveness of trauma for family caregivers and the avoidance of re-traumatization.

A Fresh Look at the Nursing Home Workforce Crisis: Transforming Nursing Care Delivery Models

The current State of the Science Commentary focuses on workforce challenges in the nursing home (NH) setting that lie within the purview of professional nursing-what professional nurses can do to promote high-quality person-centered care within a context of existing resources-individually and broadly across the collective profession. Historically, three models of care delivery have characterized the way in which nursing care is organized and delivered in different settings: primary nursing, functional nursing, and team nursing. Based on the existing evidence, we call for scientific leadership in the redesign, testing, and implementation of a nursing care delivery model that operationalizes relationship-centered team nursing. This integrative model incorporates successful evidence-based approaches that have the potential to improve quality of care, resident quality of life, and staff quality of work life: clear communication, staff empowerment, coaching styles of supervision, and family/care partner involvement in care processes. In addition to the needed evidence base for NH care delivery models, it is imperative that educational programs incorporate content and clinical experiences that will enable the future nursing workforce to fill the leadership gap in NH care delivery. [Research in Gerontological Nursing, 16(1), 5-13.].

A Qualitative Analysis of Mechanisms of Benefit in the Residential Care Transition Module: A Telehealth Intervention for Caregivers of Relatives With Dementia Living in Residential Long-Term Care

This study sought to determine the perceived benefits of the Residential Care Transition Module (RCTM), a novel multi-component, psychoeducational/psychosocial, telehealth intervention for caregivers of cognitively impaired relatives living in residential long-term care (RLTC). Few support programs exist for these caregivers. Determining the intervention's mechanisms of benefit will provide actionable clinical and research information regarding which key features aspects RLTC and public health agencies should offer their families. We conducted semi-structured interviews with 30 purposively selected participants randomly assigned to receive the RCTM. Additionally, an open-ended survey question solicited feedback at 4 (n = 90), 8 (n = 79), and 12 months (n = 77). Available qualitative data were analyzed for thematic content. Participants endorsed 9 mechanisms of benefit. Six mechanisms were related to RCTM content: education dementia progression and dementia behavior management, personalized resource provision, strategies for communication and engagement with the care recipient (CR) and others, management of multiple roles, and relaxation exercises. Three mechanisms were related to coaching: emotional support, knowledgeability, and being a neutral third party. Common benefits attributed to RCTM included improvement in mood, caregiving confidence, and communication and interactions with CR and others. Using qualitative data and analyses, we discovered the most valued aspects of the RCTM intervention. These mechanisms of benefit have not been described in the literature. Notably, we were unable to detect mechanisms of benefit in a separate analysis utilizing quantitative data. Findings emphasize the importance of including qualitative measures in intervention research and selecting quantitative measures that reflect the intervention's real effects, if any.

Nurse-Led Virtual Delivery of PIECES in Canadian Long-Term Care Homes to Support the Care of Older Adults Experiencing Responsive Behaviors During COVID-19: Qualitative Descriptive Study

BACKGROUND

Worldwide, the COVID-19 pandemic has resulted in profound loss of life among older adults living in long-term care (LTC) homes. As a pandemic response, LTC homes enforced infection control processes, including isolating older adults in their rooms, canceling therapeutic programs, and restricting family member visits. Social isolation negatively impacts older adults in LTC, which may result in increased rates of anxiety, depression, physical and cognitive decline, disorientation, fear, apathy, and premature death. Isolation of older adults can also cause an increase in responsive behaviors (eg, yelling, hitting, calling out) to express frustration, fear, restricted movement, and boredom. To respond to the challenges in LTC and support frontline staff, older adults, and family members, a novel registered practical nurse (RPN)-led delivery of the PIECES approach for addressing responsive behaviors among older adults with dementia using virtual training/mentoring was implemented in Canadian LTC homes. PIECES employs a person- and family/care partner-centered collaborative team-based approach to provide education and capacity-building for nurses; engages families as active participants in care; and embeds evidence-informed practices to provide person- and family-centered care to older adults with complex needs, including dementia.

OBJECTIVE

The aim of this study was to describe the experiences of LTC staff, family/care partners, and older adult research partners with implementation of a novel RPN-led virtual adaptation of the PIECES care-planning approach for responsive behaviors in two Canadian LTC homes during the COVID-19 pandemic.

METHODS

Using a qualitative descriptive design, two focus groups were held with three to four staff members (eg, RPNs, managers) per LTC home in Ontario. A third focus group was held with three PIECES mentors. Individual semistructured interviews were conducted with RPN champions, family/care partners, and older adult research partners. Research team meeting notes provided an additional source of data. Content analysis was performed.

RESULTS

A total of 22 participants took part in a focus group (n=11) or an in-depth individual interview (n=11). Participant experiences suggest that implementation of RPN-led virtual PIECES fostered individualized care, included family as partners in care, increased interdisciplinary collaboration, and improved staff practices. However, virtual PIECES, as delivered, lacked opportunities for family member feedback on older adult outcomes. Implementation facilitators included the provision of mentorship and leadership at all levels of implementation and suitable technological infrastructure. Barriers were related to availability and use of virtual communication technology (family members) and older adults became upset due to lack of comprehension during virtual care conferences.

CONCLUSIONS

These findings offer promising support to adopting virtual PIECES, a team approach to gather valuable family input and engagement to address residents' unmet needs and responsive behaviors in LTC. Future research should investigate a hybridized communication format to foster sustainable person- and family-centered care-planning practices to include active collaboration of families in individualized care plans.

Prevalence and correlates of anxiety and depression in caregivers to assisted living residents during COVID-19: a cross-sectional study

BACKGROUND

Family and friend caregivers play significant roles in advocating for and ensuring quality health and social care of residents in Assisted Living (AL) homes. However, little is known about how the COVID-19 pandemic and related visitor restrictions affected their health and mental well-being. We examined the prevalence and correlates of anxiety and depressive symptoms among caregivers of AL residents during the initial wave of COVID-19 in two Canadian provinces.

METHODS

A cross-sectional web-based survey was conducted among family/friend caregivers of AL residents in Alberta and British Columbia (Oct 28, 2020-Mar 31, 2021) to collect data on their sociodemographic, health and caregiving characteristics, as well as concerns about residents' health and social care before and during the first wave of the pandemic. A clinically significant anxiety disorder and depressive symptoms were assessed with the GAD-7 and CES-D10 instruments, respectively. Separate multivariable (modified) Poisson regression models identified caregiver correlates of each mental health condition.

RESULTS

Among the 673 caregivers completing the survey (81% for Alberta residents), most were women (77%), white (90%) and aged ≥ 55 years (81%). Clinically significant anxiety and depression were present in 28.6% and 38.8% of caregivers respectively. Both personal stressors (comorbidity level, income reduction, low social support) and caregiving stressors exacerbated by the pandemic were independently associated with caregiver anxiety and depression. The latter included increased concern about the care recipients' depression (adjusted risk ratio [adjRR] = 1.84, 95% confidence interval [CI] 1.19-2.85 for caregiver anxiety and adjRR = 1.75, 95% CI 1.26-2.44 for caregiver depressive symptoms) and reported intention to withdraw the resident from AL because of COVID-19 (adjRR = 1.24, 95%CI 0.95-1.63 for caregiver anxiety and adjRR = 1.37, 95%CI 1.13-1.67 for caregiver depressive symptoms).

CONCLUSIONS

Caregivers of residents in AL homes reported significant personal and caregiving-related stressors during the initial wave of COVID-19 that were independently associated with an increased likelihood of experiencing clinically significant anxiety and depressive symptoms. Healthcare providers and AL staff should be aware of the prevalence and varied correlates of caregivers' mental health during public health crises so that appropriate screening and support may identified and implemented.

Nursing Home Palliative Care during the Pandemic: Directions for the Future

Background and Objectives

Palliative care addresses physical, emotional, psychological, and spiritual suffering that accompanies serious illness. Emphasis on symptom management and goals of care is especially valuable for seriously ill nursing home residents. We investigated barriers to nursing home palliative care provision highlighted by the coronavirus disease 2019 (COVID-19) pandemic and the solutions nursing home staff used to provide care in the face of those barriers.

Research Design and Methods

For this descriptive qualitative study, seven Massachusetts nursing home directors of nursing were interviewed remotely about palliative care provision before and during the COVID-19 pandemic. Interview data were analyzed using thematic analysis.

Results

Before the pandemic, palliative care was delivered primarily by nursing home staff depending on formal and informal consultations from palliative care specialists affiliated with hospice providers. When COVID-19 lockdowns precluded these consultations, nursing staff did their best to provide palliative care, but were often overwhelmed by shortfalls in resources, resident decline brought on by isolation and COVID-19 itself, and a sense that their expertise was lacking. Advance care planning conversations focused on hospitalization decisions and options for care given resource constraints. Nevertheless, nursing staff discovered previously untapped capacity to provide palliative care on-site as part of standard care, building trust of residents and families.

Discussion and Implications

Nursing staff rose to the palliative care challenge during the COVID-19 pandemic, albeit with great effort. Consistent with prepandemic analysis, we conclude that nursing home payment and quality standards should support development of in-house staff capacity to deliver palliative care while expanding access to the formal consultations and family involvement that were restricted by the pandemic. Future research should be directed to evaluating initiatives that pursue these aims.