Organizational Factors Associated With Retention of Certified Nursing Assistants and Direct Care Workers

Abstract Low retention of certified nursing assistants (CNAs) and direct care workers (DCWs) continues to be an unresolved problem for nursing homes (NH) and assisted living (AL) settings. While numerous studies have examined predictors of CNA retention in NHs, little attention has been paid to differences between settings of long-term care. To inform practice and policy related to growth in the AL industry, this study compares the predictors of CNA and DCW retention rates. The 2017 Ohio Biennial Survey of Long-Term Care Facilities provides facility-level information from 968 NHs (91% response rate) and 708 ALs (88% response rate). Using regression analysis, we compare the factors that predict retention rates among providers with complete data on retention and controls. The same covariates relating to structural and financial characteristics, as well as staffing, management, and a number of retention best practices are used. Average DCW and CNA retention rates were 66% and 61% in ALs and NHs, respectively, with some settings reporting very low (and even 0%) retention over a year. AL and NH providers rated the problem’s severity highest (6 out of 10) compared to retaining other licensed nurses. Similar and different predictors were found across financial, environmental, and managerial practices supporting retention. CNA and DCW retention strategies may not be equivalently meaningful between settings, given differing working environments, resources, and regulations. Aging services managers should be attuned to practices supporting retention in their industry.


NURSING HOME STAFF'S PERCEPTIONS OF HEALTHCARE DECISION MAKING FOR UNBEFRIENDED RESIDENTS
Hyejin Kim, 1 Molly Perkins, 2 Thaddeus Pope, 3 Patricia Comer, 2 and Mi-Kyung Song, 5 1. Seoul,Republic of Korea,2. Emory University,Atlanta,Georgia,United States,3. Mitchell Hamline School of Law,Saint Paul,Minnesota,United States,4. A.G. Rhodes Health & Rehab,Atlanta,United States 'Unbefriended' adults are those who lack decision-making capacity and have no surrogates or advance care plans. Little data exist on nursing homes (NHs)' healthcare decision-making practices for unbefriended residents. This study aimed to describe NH staff's perceptions of healthcare decision making on behalf of unbefriended residents. Sixty-six staff including administrators, physicians, nurses, and social workers from three NHs in one geographic area of Georgia, USA participated in a 31-item survey. Their responses were analyzed using descriptive statistics and conventional content analysis. Of 66 participants, eleven had been involved in healthcare decision-making for unbefriended residents. The most common decision was do-not-resuscitate orders. Decisions primarily were made by relying on the resident's primary care physician and/or discussing within a facility interdisciplinary team. Key considerations in the decision-making process included "evidence that the resident would not have wanted further treatment" and the perception that "further treatment would not be in the resident's best interest". Compared with decision making for residents with surrogates, participants perceived decision making for unbefriended residents to be equally-more difficult. Key barriers to making decisions included uncertainty regarding what the resident would have wanted in the given situation and concerns regarding the ethically and legally right course of action. Facilitators (reported by 52 participants) included some information/knowledge about the resident, an understanding regarding decision-making-related law/policy, and facility-level support. The findings highlight the complexity and difficulty of healthcare decision making for unbefriended residents and suggest more discussions among all key stakeholders to develop practical strategies to support decision-making practices in NHs.

ORGANIZATIONAL FACTORS ASSOCIATED WITH RETENTION OF CERTIFIED NURSING ASSISTANTS AND DIRECT CARE WORKERS
Katherine Kennedy, Robert Applebaum, John Bowblis, and Jane Straker, Miami University, Oxford, Ohio, United States Low retention of certified nursing assistants (CNAs) and direct care workers (DCWs) continues to be an unresolved problem for nursing homes (NH) and assisted living (AL) settings. While numerous studies have examined predictors of CNA retention in NHs, little attention has been paid to differences between settings of long-term care. To inform practice and policy related to growth in the AL industry, this study compares the predictors of CNA and DCW retention rates. The 2017 Ohio Biennial Survey of Long-Term Care Facilities provides facility-level information from 968 NHs (91% response rate) and 708 ALs (88% response rate). Using regression analysis, we compare the factors that predict retention rates among providers with complete data on retention and controls. The same covariates relating to structural and financial characteristics, as well as staffing, management, and a number of retention best practices are used. Average DCW and CNA retention rates were 66% and 61% in ALs and NHs, respectively, with some settings reporting very low (and even 0%) retention over a year. AL and NH providers rated the problem's severity highest (6 out of 10) compared to retaining other licensed nurses. Similar and different predictors were found across financial, environmental, and managerial practices supporting retention. CNA and DCW retention strategies may not be equivalently meaningful between settings, given differing working environments, resources, and regulations. Aging services managers should be attuned to practices supporting retention in their industry. Depressive symptoms are common among nursing home (NH) residents. Important predictors of depression to tease apart include demographic characteristics, physical status, functional ability, and chronic pain. A challenge to addressing depression is that a majority of NH residents have some level of dementia. Nonpharmacological management of depression in the NH is a recommended first line of treatment including: personalized activities, music therapy, repositioning, and attention to personal care needs (toileting, resting, and hydration). A holistic approach to the well-being of NH residents is the adoption of person directed (PDC) care models. In this study, predictors of decreased depression over time was examined in residents (N=144) living in two communities featuring PDC models, and those living in traditional care communities within the same NH. Care in the two PDC communities focused on provision of comfort care for persons with advancing dementia at-risk of not having their care needs met largely due to their inability to clearly communicate these needs. Care practices focused on knowing each elder deeply, and anticipating their needs. Care practices also included an emphasis on staff empowerment and meaningful life activities for residents. Traditional communities are those where PDC practices had not yet been incorporated. Data on demographic characteristics, cognitive status, physical and functional status, behavioral symptoms, and pain were extracted from the MDS. Results showed that being in the PDC group, less time in the nursing home, having less pain, and fewer behavioral symptoms were significant predictors of decreased depressive symptoms over a sixmonth period.

PSYCHOSOCIAL REACTIONS TO RELOCATION TO NURSING HOMES IN CHINESE OLDER ADULTS
Xiuyan Lan, 1 Huimin Xiao, 2 and Ying Chen, 2 1. Fujian Provincial Hospital,Fuzhou,China,2. Fujian Medical University,Fuzhou,China This study aimed to elicit psychosocial reactions to relocation to nursing homes from older adults' perspectives with a qualitative interview design. Narratives from 23 Chinese nursing home residents from Fuzhou, China in a life review program were recorded, transcribed into sentences, and analyzed with the qualitative content analysis. It revealed five stages of psychosocial reactions to relocation to nursing homes as fear, struggle, compromise, acceptance, and contribution. The first stage resulted from negative labels attached to nursing homes, disconnection to the society, difficulties in establishing new relationships, and being abandoned by their families. The second stage described the behaviors of struggle: complain about family members, think of going back home, pray to have a change, and take action to leave. The third stage described the keys to compromise: choices between maintaining the harmony in family relation and companionship of relatives, choices between professional care and family care, and choices between costs and effects of family care and nursing home care. The fourth stage described how they accept nursing home life: accept the life and yet with worries, affirm benefits of living in nursing homes, and embrace the nursing home life. The last stage resulted from sense of ownership and giving full play to self-worth. This study generated new insights into the knowledge on psychosocial reactions to relocation to nursing homes and provided both family members and nursing home staff with a direction for how to promote a smoother relocation process.

SENSE OF BELONGING, RELIGIOUS ACTIVITY, AND WELL-BEING IN LONG-TERM CARE RESIDENTS Kelly Shryock, and Suzanne Meeks, University of Louisville, Louisville, Kentucky, United States
Residence in a long-term care (LTC) facility poses numerous challenges to psychological well-being and rates of depression are high. Sense of belonging (SoB) has been linked with measures of well-being in all age groups and interventions focused on improving SoB have been successful with college-age adults. It is unclear if SoB improves in LTC residents as they adjust to living in this environment or what factors predict poor SoB in this population. As part of a larger study of care preferences in LTC residents, participants (n= 76) completed measures of SoB, well-being, religious activity, and demographic information. SoB did not vary significantly based on duration of stay, age, gender, ethnicity, marital status, number of children, education, facility, cognitive functioning, or physical health. SoB was found to be significantly and positively correlated with participation in religious activities (r= .388, N=76, p=.001), private religious practices (r= .275, N=71, p=.020), and spirituality (r= .263, N=70, p=.028). There was also a significant positive correlation between SoB and positive affect (r= .450, N=74, p<.001) and SoB and life satisfaction (r= .393, N=74, p=.001). These results suggest that connections formed before admission to a LTC facility, including religious networks, are important to SoB and well-being and that individuals without or with low religious involvement may benefit most from interventions focusing on improving SoB in LTC residents.

ASSOCIATIONS BETWEEN THE FIVE FACTOR MODEL OF PERSONALITY AND DEMENTIA-RELATED ANXIETY
Stacy Yun, 1 Lisa Stone, 1 Evan Furr, 1 and Molly Maxfield, 2 1. University of Colorado Colorado Springs,Colorado Springs,Colorado,United States,2. Arizona State University,Phoenix,Arizona,United States The Five Factor Model (FFM) of normative personality is predictive of long-term outcomes, including well-being