ORGANIZATIONAL AND POLICY FACTORS INFLUENCING FEEDING IN RESIDENTS WITH DEMENTIA: NURSING ASSISTANTS’ EXPERIENCES

Abstract In the United States, Certified Nursing Assistants (CNAs) are critical in providing direct care to nursing home residents with dementia, which includes the challenging task of feeding residents. Guided by the Social Ecological Model (SEM), this qualitative study aimed to gain an in-depth understanding of organizational and policy constructs that CNAs encounter when feeding residents with dementia. Using purposive sampling, nine semi-structured focus groups were conducted with 53 CNAs. Each participant had at least one year of experience working as a CNA with older adults. Focus groups were audio recorded and transcribed verbatim. Data were analyzed using the directed content analysis. Factors that emerged were organized into organizational and policy categories within the SEM levels. CNAs identified organizational barriers such as exclusion from the interdisciplinary team, inability to meet resident needs and wants due to budgetary constraints, and inadequate staffing to function efficiently. Organizational facilitators included teamwork, interdisciplinary assistance, and varying dining styles and meal times to accommodate resident needs. Policy-related barriers included funding concerns, staffing ratios, and frustration with unrealistic regulations and state inspections. These results suggest that organizational and policy factors have a large influence on the ease of feeding nursing home residents with dementia. Involving CNAs in interdisciplinary collaboration, resident-centered accommodations, and subtler state inspection behaviors could improve the mealtime experience for both residents and CNAs. Careful attention to these factors may enhance facilitators and minimize barriers to improve the feeding experience of CNAs and residents with dementia.

In some cases, AL staff are able to successfully address those behaviors and in other cases they are not. This study explores behavioral expressions of persons with dementia residing in AL, strategies used to address those behaviors, and residents' behavioral results, as reported by 251 AL healthcare supervisors across seven states. We also examine what differentiates situations deemed successful from situations that were not successful. Methods: Qualitative interviews conducted with healthcare supervisors revealed cases of successful and unsuccessful strategies for addressing severe/disruptive behavioral expressions of persons with dementia residing in AL. During initial analysis, a data-driven conceptual model was developed to identify common structural domains within and across responses, which ranged from recognizing antecedents to final discharge from the AL community. Additionally, content analysis was applied to identify themes. Results: A minority (<5%) of reports indicated that staff recognized antecedents to behaviors, or noted including residents' families in addressing behaviors. The majority of both successful and unsuccessful cases referenced the use of medications to address behaviors, and a notable proportion (10%) referenced professional psychiatric assessment. Discussion: Findings suggest the benefit of helping staff identify antecedents of behavioral expressions, and the important role of psychiatric assessment for AL residents who experience agitation, aggression, and similar behaviors. Purpose: This study tracks the growing number of direct care workers (DCWs) employed by private households and describes the differences between this often ignored labor force and DCWs employed by agencies. Design and Methods: Data were from the 1% Public Use Microdata Sample (PUMS) of the 2000 and 2017 American Community Survey (ACS). Logistic regression was used to compare demographic and employment characteristics of DCWs employed by private households and DCWs employed by agencies, which include outpatient care centers, home health care services, and individual and family services. Results: Between 2000 and 2017, the number of DCWs employed by private households in the U.S. increased 32% and the majority of this growth was since 2007. Compared to DCWs employed by agencies, DCWs employed by private households were more likely to be over age 65, white, unmarried, have higher educational attainment, be more likely to be in poverty, receive health insurance from Medicare or direct-pay. DCWs employed by private households were less likely to be under age 25, nonwhite, Hispanic, speak a language other than English, work year-round and full-time, receive health insurance from an employer or through Medicaid, and have a disability. Implications: DCWs employed by private households represent a small, but growing proportion of the long-term care (LTC) workforce in the U.S. Further, these workers are distinct within the LTC workforce. This has important implications both for DCWs and for families, particularly those with limited LTC options due to location, financial resources, family support, or other factors.

STAFFING AND CARE QUALITY OF NURSING HOMES IN KOREA
Hee Seung Lee 1 , 1. National Health Insurance Service, Health Insurance Policy Research Institute, Wonju, Korea,

Republic of
Staffing has been regarded as the most important factor for the quality of care service in nursing homes. Korea introduced Long-Term Care Insurance (LTCI) in 2008. The payment system of LTCI has incentivized LTC facilities based on the staffing level of LTC facilities. This study aims to investigate whether staffing is associated with quality of care. The effect of staffing on care quality was assessed using ordered logit analysis. Staffing data in 2015 were retrieved from claim data in the National Health Insurance Service. The publicly reported care service quality grade in 2015 was used as a proxy for care quality. Staffing of registered nurses (RN) and social workers were strongly associated with the care quality. As the number of RNs per residents additionally increased, the LTC facilities were more likely to receive better grades (OR=16851.54, p<0.000). The effect of social workers' staffing was significant for the care service quality, even though the effect size of smaller than that of RNs (OR=345.87, p<0.000). However, staffing in other professions such as nurse assistants (NA) and personal care workers (PCW) was insignificantly associated with care quality. The effect of staffing on service quality might not be profession-neutral. RN staffing affects most in care quality in Korea. Still, the possibility remains that PCWs or NAs could serve for indirect care services such as cooking or cleaning because of short staffing in indirect care services. This finding could be considered when designing financial incentives for nursing homes in Korea as well as other countries. In the United States, Certified Nursing Assistants (CNAs) are critical in providing direct care to nursing home residents with dementia, which includes the challenging task of feeding residents. Guided by the Social Ecological Model (SEM), this qualitative study aimed to gain an in-depth understanding of organizational and policy constructs that CNAs encounter when feeding residents with dementia. Using purposive sampling, nine semi-structured focus groups were conducted with 53 CNAs. Each participant had at least one year of experience working as a CNA with older adults. Focus groups were audio recorded and transcribed verbatim. Data were analyzed using the directed content analysis. Factors that emerged were organized into organizational and policy categories within the SEM levels. CNAs identified organizational barriers such as exclusion from the interdisciplinary team, inability to meet resident needs and wants due to budgetary constraints, and inadequate staffing to function efficiently. Organizational facilitators included teamwork, interdisciplinary assistance, and varying dining styles and meal times to accommodate resident needs. Policy-related barriers included funding concerns, staffing ratios, and frustration with unrealistic regulations and state inspections. These results suggest that organizational and policy factors have a large influence on the ease of feeding nursing home residents with dementia. Involving CNAs in interdisciplinary collaboration, resident-centered accommodations, and subtler state inspection behaviors could improve the mealtime experience for both residents and CNAs. Careful attention to these factors may enhance facilitators and minimize barriers to improve the feeding experience of CNAs and residents with dementia.

OLDER ITALIANS' VIEWS OF AND EXPERIENCES WITH IMMIGRANT CAREWORKERS
Katia Vecchione, 1 and Anne Barrett 2 , 1. University of Trento,Trento,Italy,2. Florida State University,Tallahassee,Florida,United States Population aging has led, in many countries, to new care arrangements to meet the growing need. In Italy, with the second oldest population in the world, family members, especially women, provide the majority of care; however, paid immigrants are increasingly filling in where families cannot. Known as "badanti," most of these careworkers are middle-aged women from Eastern Europe. Although some research examines this phenomenon, it focuses exclusively on careworkers -not those receiving their care. Addressing this gap, my paper examines older Italians' attitudes toward and experiences with immigrant careworkers, using interviews with 20 nursing home residents and 20 senior center participants. Analyses reveal polarized views of "badanti, with more positive views found among those with personal experience receiving their care. I find that negative attitudes are shaped by three broader cultural discourses about aging, as well as immigration. Attitudes are influenced by views of independence and autonomy --core values perceived to be threatened by badanti. Relatedly, attitudes are influenced by the centrality of space and home, which again are viewed as challenged by badanti's presence. Negative views of badanti also are shaped by dominant discourses regarding immigrants, who are viewed as threats to security, particularly regarding one's belongings. Such beliefs and values influence older adults' willingness to accept help from careworkers and its effectiveness --knowledge of which can help create better care scenarios. Marlene Steinheiser 1 ,1. Infusion Nurses Society,Norwood,Massachusetts,United States The purpose of this hermeneutic interpretive phenomenology study was to describe the shared meaning of compassion fatigue (CF) among registered nurses (RNs) who work in skilled nursing facilities (SNFs). The specific aims were to describe: 1) contributors (triggers, situation, or patient characteristics) that cause symptoms of compassion fatigue, 2) associated physical and emotional symptoms, and 3) the short-term outcomes of unresolved compassion fatigue impacting nurses and patient care. CF can negatively impact patient outcomes, is associated with decreased quality of patient care, and can be a reason why nurses leave the profession. Eight participants were interviewed three times each, while concurrent data analysis helped to formulate mutual understanding of the phenomenon and informed subsequent interviews. Self-reflection, journaling, record keeping, and use of direct quotes enhanced trustworthiness. Four shared meanings were abstracted:1) I feel conflicted and that causes my CF; 2) physical and emotional manifestations of CF; 3) CF is infused in every aspect of my life; 4) we are trying to cope with CF. The participants shared their central desire to make a difference in the lives of their patients, which was of paramount importance. When participants felt they were unable to make the desired difference, they began to develop symptoms of CF. Symptoms were compounded when they experienced frequent patient deaths. A resiliency program specifically addressing the needs of SNF nurses, incorporating individuals and their organizations, could positively impact the nurses' professional quality of life. Future research is needed to better understand CF and interventions specific to SNF nurses.

CARING RELATIONSHIP DEVELOPMENT IN THE NURSING HOME IN SHANGHAI: A DYADIC QUALITATIVE STUDY
Lin Chen, 1 Minzhi Ye, 2 and Qiang Zhu 3 , 1. Fudan University, Shanghai, China, 2. Benjamin Rose Institute on Aging,Cleveland,Ohio,United States,3. Fudan University,Shanghai,China,China Caring relationships between older residents and nurse aides are fundamental in terms of service delivery in nursing homes. However, little is known for the nuanced dynamics of this relationship in China. The purpose of this study is to explore how caring relationships develop between older residents and nurse aides in the nursing home setting in urban China. Informed by the dyadic perspective, this study illustrates the development process and relational nuances by simultaneously eliciting residents' and nurse aides' perceptions. This qualitative study purposively sampled 20 matched resident-nurse aide dyads (N= 40) in a government-sponsored nursing home in Shanghai. Participants participated in semistructured, in-depth interviews from January to June 2017. Thematic analysis was performed. The findings reveal that the caring relationship began with nursing home assignment