Deeply Discrediting: A Systematic Review Examining the Conceptualizations and Consequences of the Stigma of Working in Aged Care

Bridging Educational Grant in Nursing (BEGIN) students' intentions for retention in long-term, home and community care: A survey protocol

INTRODUCTION

Retention of nurses in long-term care (LTC) and home and community care (HCC) settings is a growing concern. Previous evidence underscores factors which contribute to nurses' intentions for retention in these sectors. However, perspectives of nursing students preparing to enter the workforce, and their intentions for short-term and long-term retention, remain unknown. This study aims to explore relationships between short-term and long-term intentions for retention with psychological empowerment, work engagement, career commitment, burnout, prosocial motivation, self-care and personal resilience among students enrolled in nursing educational bridging programs supported by the Bridging Educational Grant in Nursing (BEGIN) program in Ontario, Canada.

METHODS AND ANALYSIS

This cross-sectional design study will use an open online survey to investigate perspectives of current nursing students enrolled in educational bridging programs on factors relating to psychological empowerment, work engagement, career commitment, resilience, burnout, prosocial motivation, self-care and intentions for retention. Additionally, the survey will collect demographic information, including age, gender, ethnicity, citizenship, income, family status, nursing role, and years of employment and/or education. Open-ended questions will elicit participants' perspectives on financial considerations for career planning and other factors impacting intentions for retention. Descriptive data will be presented for contextualisation of participants' demographic characteristics to enhance generalisability of the cohort. Descriptive statistics will be used to summarise participants' scores on various assessment measures, as well as their short-term and long-term intentions for retention in LTC and HCC after completion of BEGIN. A Pearson's product moment r correlation will determine relationships between intentions for retention and other measures, and linear regression will determine whether any potential correlations can be explained by regression.

ETHICS AND DISSEMINATION

This research protocol received ethical approval from a research-intensive university research ethics board (#123211). Findings will be disseminated to nursing knowledge users in LTC and HCC through publications, conferences, social media and newsletters.

2024 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including prevalence and incidence, mortality and morbidity, use and costs of care and the ramifications of AD for family caregivers, the dementia workforce and society. The Special Report discusses the larger health care system for older adults with cognitive issues, focusing on the role of caregivers and non-physician health care professionals. An estimated 6.9 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060, barring the development of medical breakthroughs to prevent or cure AD. Official AD death certificates recorded 119,399 deaths from AD in 2021. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death in the United States. Official counts for more recent years are still being compiled. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2021, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 140%. More than 11 million family members and other unpaid caregivers provided an estimated 18.4 billion hours of care to people with Alzheimer's or other dementias in 2023. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $346.6 billion in 2023. Its costs, however, extend to unpaid caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Members of the paid health care and broader community-based workforce are involved in diagnosing, treating and caring for people with dementia. However, the United States faces growing shortages across different segments of the dementia care workforce due to a combination of factors, including the absolute increase in the number of people living with dementia. Therefore, targeted programs and care delivery models will be needed to attract, better train and effectively deploy health care and community-based workers to provide dementia care. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2024 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $360 billion. The Special Report investigates how caregivers of older adults with cognitive issues interact with the health care system and examines the role non-physician health care professionals play in facilitating clinical care and access to community-based services and supports. It includes surveys of caregivers and health care workers, focusing on their experiences, challenges, awareness and perceptions of dementia care navigation.

The development and validation of tour guides internalized occupational stigma scale (TIOSS)

BACKGROUND

Tour guides' identification and internalization of occupational stigma may exacerbate their career development, perceived professional reputation and status, and mental health. The current study aimed to develop and verify the Tour guides Internalized Occupational Stigma Scale (TIOSS) to provide an effective tool for relevant quantitative research.

METHODS

The study developed an initial questionnaire through literature analysis, expert review, and semi-structured surveys. We conducted item analyses and exploratory factor analyses among 326 tour guides, and confirmatory factor analysis and reliability and validity tests among 315 tour guides.

RESULTS

The TIOSS consists of 21 items and is formed in three dimensions referring to Stigma Perception (SP), Status Loss (SL), and Career Denial (CD). The correlation coefficient values of the TIOSS total scale and dimension scores with the criterion instruments ranged from 0.17 to 0.68. In addition, the Cronbach's α coefficients for the TIOSS and its dimensions ranged from 0.837 to 0.928, and the split-half reliability coefficients ranged from 0.843 to 0.916. The study also revealed that the TIOSS was consistent across genders.

CONCLUSION

The TIOSS performed favorable reliability and validity to be a valid instrument to assess tour guides' internalized occupational stigma.

"I haven't really gone through things like this": Young long-term care workers' experiences of working during the COVID-19 pandemic

BACKGROUND

Long-term care (LTC) facilities were hard hit by the COVID-19 pandemic in Canada. Using life course theory concepts, we looked for conditions that led to worker moral distress -i.e. pain or anguish over not being able to take right action - and how life stage may influence experiences.

OBJECTIVE

To illuminate the experiences of adults under the age of 30 who stepped into, and/or persevered in, working in LTC during the pandemic, recognizing that this emerging workforce represents the future of LTC in Canada.

METHODS

This secondary analysis uses interview data from a sub-sample of 16 young workers between 18 and 29 years of age who had been working in Canadian LTC facilities for between 8 months and 7 years.

RESULTS

Young workers expressed feeling guilt about mourning the loss of socially significant milestones as these milestones paled by comparison to the loss of life and consequences of resident isolation they witnessed at work. To manage feelings of moral distress, young workers attempted to maintain high standards of care for LTC residents and engaged in self-care activities. For some workers, this was insufficient and leaving the field of LTC was their strategy to respond to their mental health needs.

CONCLUSION

The life stage of young LTC workers influenced their experiences of working during the COVID-19 pandemic. Interventions are needed to support young workers' wellbeing and job retention.

Post-Acute and Long-Term Care Leaders' Perspectives on Leading During COVID-19

Post-acute and long-term care (PALTC) delivery is complex, and the COVID-19 pandemic created additional complexities. This qualitative study investigates how PALTC administrators responded to the pandemic, factors that impacted their leadership role and decision-making. Participants from North Carolina (N = 15) and Pennsylvania (N = 6) were interviewed using an interview guide containing open-ended questions. The results revealed three themes: (1) critical knowledge and competencies; (2) resources, supports and essential actions taken; and (3) psychosocial impact. The findings suggest communication and relationship building were the most useful competencies. Lack of staff was a primary stress point during and after the pandemic.

2023 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease, including prevalence and incidence, mortality and morbidity, use and costs of care, and the overall impact on family caregivers, the dementia workforce and society. The Special Report examines the patient journey from awareness of cognitive changes to potential treatment with drugs that change the underlying biology of Alzheimer's. An estimated 6.7 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, and Alzheimer's disease was officially listed as the sixth-leading cause of death in the United States. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. This trajectory of deaths from AD was likely exacerbated by the COVID-19 pandemic in 2020 and 2021. More than 11 million family members and other unpaid caregivers provided an estimated 18 billion hours of care to people with Alzheimer's or other dementias in 2022. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $339.5 billion in 2022. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Members of the paid health care workforce are involved in diagnosing, treating and caring for people with dementia. In recent years, however, a shortage of such workers has developed in the United States. This shortage - brought about, in part, by COVID-19 - has occurred at a time when more members of the dementia care workforce are needed. Therefore, programs will be needed to attract workers and better train health care teams. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2023 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $345 billion. The Special Report examines whether there will be sufficient numbers of physician specialists to provide Alzheimer's care and treatment now that two drugs are available that change the underlying biology of Alzheimer's disease.

The precarious resilience of aged care employees enrolled in an Australian online dementia course: A cross-sectional study of occupational health and well-being

OBJECTIVE

Australian aged care workforce surveys offer limited information about those who engage in online dementia education regarding their occupational health and well-being. A salutogenic approach was applied to an aged care context to quantitatively assess both positive and negative aspects of health at work to inform the development of workplace interventions tailored to those interested in self-development.

METHODS

Physical, psychological and occupational health were measured in an online cross-sectional survey of general health, chronic conditions, psychological distress, positive and negative affect, job satisfaction, access to workplace amenities and turnover intentions of aged care workers undertaking an online dementia course in October 2014.

RESULTS

Participants (N = 662) rated their general physical health as good and a minority experienced chronic conditions such as obesity. Overall, workers had average levels of positive and negative affect and low distress. However, 25% were likely to have a mental health condition. While most were employed on a permanent basis (80%) and reported moderate job satisfaction, 18% were likely to leave their job. There were some gaps in workplace amenities to support health and well-being: for example, 13% reported no access to lunch break areas.

CONCLUSIONS

Results suggest precarious resilience in aged care workers enrolled in an Australian online dementia course. Workplace interventions that focus on preventative health strategies are required to address the health risks associated with higher than national averages of obesity and mental health, and reduce exposure of workers to physical and psychological harms.

"The Stigma is what you do": Examining the Relationship Between Occupational Stigma and Worker Outcomes in the Aged Care Context

Negative social evaluations about aged-care work continue to discredit those who perform this type of work. Drawing on 'dirty work' literature from the field of management and stigma theory from the field of psychology, this study examines occupational stigma in the context of aged-care work and its relationship with negative outcomes for people who work in aged care. Findings from a path analysis revealed that aged-care workers (n = 185) who ascribe occupational taints and poor occupational conditions with aged-care work perceive aged-care work as being stigmatized, and in turn, are more likely to internalize this stigma. Through this process of perceiving and internalizing occupational stigma, aged-care workers experience greater psychological distress, job dissatisfaction, and turnover intentions. This research fills a void within the gerontology literature regarding the psychological processes underlying how occupational stigma may come to negatively impact this workforce. Findings offer practical implications for policy reform and managerial training.

Development of the Chinese Version of the Physician Internalized Occupational Stigma Scale (PIOSS)

BACKGROUND/OBJECTIVE

Internalized occupational stigma may develop in physicians as a result of their identification with the public negative labels and stereotypes about them, and then internalization of them as a part of their self-concept. This study aims to develop the Physician Internalized Occupational Stigma Scale (PIOSS) and to examine its reliability and validity.

METHODS

In study 1, the initial scale was used to investigate 356 physicians. While in study 2, a total of 346 physicians were investigated with the survey tools named the PIOSS, the Career Commitment Scale (CCS), the Workplace Well-Being Scale (WWBS), the Scale for the Doctor with Patient-doctor Relationship (DDPRQ-10), the Intent to Leave Scale (ILS) and the Occupational Disidentification Scale (ODS).

RESULTS

The PIOSS includes 19 items divided into 3 dimensions: label identification, status loss, and career denial. The results of confirmatory factor analysis (CFA) reveal that the three-factor model fitted well (χ 2/df=2.574, RMSEA= 0.068, CFI= 0.931, IFI= 0.931, TLI= 0.919, PNFI= 0.762, PCFI= 0.795). The PIOSS total and each dimension scores were significantly negatively correlated with the CCS and the WWBS scores and remarkably positively associated with the DDPRQ-10, the ILS, and the ODS scores. Cronbach's α coefficients for the PIOSS total scale and dimensions ranged from 0.775 to 0.914, and split-half reliability coefficients ranged from 0.801 to 0.931. In addition, the PIOSS exhibited cross-gender invariance.

CONCLUSION

Having good reliability and validity, the PIOSS can serve as a valid tool for the assessment of physician internalized occupational stigma.

Does context count? The association between quality of care and job characteristics in residential aged care and hospital settings: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Within residential aged care settings, reduced quality of care (QOC), abuse, and neglect have been global phenomena which require urgent intervention. As the reported rate of these problems is much higher in aged care compared to hospital settings, we investigated whether differing job design characteristics between the two settings might explain the difference.

RESEARCH DESIGN AND METHODS

We used a meta-analysis to compare differences in the relationships between high job demands, low job resources, and job strain with QOC and counter-productive work behaviors (CWBs) across aged care and hospital settings.

RESULTS

Data was extracted from 42 studies (n=55 effects). QOC was negatively correlated with high job demands (ρ̅ =-.22, 95% CI: -.29:-.15, k=7), low job resources (ρ̅ = -.40, 95% CI:-.47:-.32, k=15), and job strain (ρ̅ =-.32, 95% CI: -.38:.-.25, k=22), CWBs had a positive relationship with job demands (ρ̅ =.35, 95%CI: .10:.59, k=3) and job strain (ρ̅ =.34, 95% CI: .13:.56, k=6). The association between poor QOC and low job resources was stronger in aged care (r=-.46, 95% CI:-.55:-36, k=8) than in hospital settings (r= -.30, 95% CI:-.41:-.18, k=7).

DISCUSSION AND IMPLICATIONS

Our findings suggest that relationships between low job resources and poor quality of care are exacerbated in residential aged care contexts. To improve care outcomes, stakeholders should improve job resources such as skill discretion, supervisory supports, and increased training and staffing levels in residential aged care.

The Social Construction of Stigma in Aged-Care Work: Implications for Health Professionals' Work Intentions

Background and Objectives

Although society has cultivated a deeper appreciation for essential health services, societal discourses reinforce a stigma of working in aged care. Drawing on dirty work and Stigma Theory, this study aims to investigate stigma in the context of recruiting health professionals.

Research Design and Methods

We employed a mixed-methods design to examine the nature and implications of the stigma of working in aged care. A path analysis was used to test whether health professionals’ (n = 159) negative perceptions of aged-care work would negatively predict their willingness to work in aged care. A linguistic analysis was conducted to understand how health professionals’ (n = 168) use of language positions themselves toward or away from engaging in aged-care work.

Results

Quantitative findings revealed that perceptions of physical taint directly predicted lower willingness to perform aged-care work. Perceptions of social taint, moral taint, and poor occupational conditions negatively predicted willingness to work in institutional aged care, indirectly via social devaluation. Findings from the linguistic analysis demonstrated that health professionals (re)produce stigma through aligning themselves with devaluing discourses about aged-care workers, work, and institutions.

Discussion and Implications

This study provides insight about the role that stigma plays in the aged-care recruitment crisis, with implications for aged-care institutions. Societal discourse may obstruct the employment of health professionals in aged care because it can (re)produce the stigma of working in aged care. Recommendations for ways to reduce the impact of this stigma include public messaging and training.

Exploring evolving caring relationship experiences among nursing home residents and nurse aides in Shanghai: a dyadic perspective

Although research has shown that older nursing home residents can benefit from caring relationships with nurse aides, few studies have explored their dyadic, evolving relationship dynamics. Using a dyadic perspective, this study simultaneously explores caring relationships among older residents and nurse aides in Shanghai. In a government-sponsored nursing home in Shanghai, 20 matched resident–nurse aide dyads participated in semi-structured, in-depth interviews (N = 40). We performed thematic analysis to interpret and conceptualise the evolving caring relationships within dyads. Four types emerged during the evolution of caring relationships across the 20 dyads: (a) sharing strong rapport, (b) respecting each other, (c) hesitant responding, and (d) keeping emotional distance. Upon placement, all the residents kept emotional distance from nurse aides, and their assigned nurse aides provided care-giving by following nursing home regulations. As time passed, nurse aides began to create a family environment and tried to interact with residents on an emotional level; however, residents’ attitudes varied. The caring relationships in some dyads evolved as rapport and respect emerged, while others remained hesitant and distant. This suggests that residents and nurse aides prioritised caring relationships differently in terms of autonomy preservation and safety protection, respectively. This study sheds light on nursing home practice to facilitate building caring relationships between residents and nurse aides.

Organizational learning during COVID-19: A qualitative study of nurses' experiences

Aim

The aim of this study is to test the validity of the Organizational Learning in Hospitals model in the context of the COVID‐19 pandemic.

Background

Organizational learning is especially crucial in circumstances of intense, complex, enduring change, as with the COVID‐19 pandemic. Nurse managers need additional guidance for fostering organizational learning under such circumstances. The Organizational Learning in Hospitals model may be a helpful resource but requires additional validation.

Methods

Semi‐structured interviews were conducted to gather 19 nurses' first‐hand experiences of organizational learning during the COVID‐19 pandemic. Data were analysed using deductive thematic analysis.

Results

Nurses' experiences of organizational learning generally aligned with the tenets of the model. Specifically, effective organizational learning occurred when the contextual factors and mechanisms portrayed in the model converged. Model and contrary cases illustrate this phenomenon.

Conclusions

This study validates and adds context to the model. It offers practical examples of the contextual factors and mechanisms of organizational learning. Leaders can use the model to guide their efforts to foster organizational learning.

Implications for Nursing Management

This study reaffirms the importance of nurse leaders' central role in organizational learning. Nurse leaders can use the Organizational Learning in Hospitals model, and the practical examples provided, to foster organizational learning during challenging times.