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The care-related research base continues to grow and demonstrate effective approaches to organizing and providing care in long-term care settings to achieve optimal resident outcomes. This issue of Alzheimer's Care Today begins to report the findings of a new study looking explicitly at the process and results of staff training to improve dementia care. In addition, over the past year, several new peer-reviewed studies have published their results focusing on various facets of care within both nursing homes and residential care/assisted living. Several themes emerge across these studies that both validate existing knowledge and foster new understanding of the experience of staff, their motivations, and ways to improve the care they deliver. It is clear that direct care staff (certified nursing assistants and personal care aides) need to feel supported and that their perceptions of support relate to the supervision that they receive; thus, positive organizational leadership is essential. In addition, relationships are central to staff being able to offer high-quality care, including relationships between staff and residents, staff and their supervisors, and staff and resident families.


This department highlights 2 articles that report results from recent studies focusing on these issues. Collectively, the articles outline research with direct implications for practitioners interested in better supporting direct care staff and improving resident experiences both in nursing homes and residential care/assisted living.


Bishop CE, Squillace MR, Meagher J, Anderson WL, Wiener JM. Nursing home work practices and nursing assistant's job satisfaction.Gerontologist. 2009;49(5):611-622.


Many factors are associated with job satisfaction among nursing assistants. In the first national survey to examine nursing assistant job satisfaction as related to work practices, Bishop and colleagues highlight the importance of supervisors in shaping the experience of the direct care staff members to influence their job satisfaction, and in fact say that


Fostering a culture of respect for nursing assistant work at the level of the organization and through public policy may be both the simplest and the most difficult recommendation to be underscored by this national study of nursing assistant job satisfaction.


They used the 2004 National Nursing Assistant Survey, the first national survey of nursing home nursing assistants, to create a nationally representative sample of 2252 nursing assistants actively working in nursing homes at the time of the interview. Their first finding was that the majority (52%) of nursing assistants were "somewhat satisfied" in their jobs, with 30% being "extremely satisfied," 14% being "somewhat dissatisfied," and only 4% being "extremely dissatisfied." Examining what was associated with job satisfaction, they found that in addition to compensation (more money and paid personal days/sick leave) and job demands (working more hours), the manner in which supervisors interact with their staff relates to job satisfaction. Specifically, the relationship between staff and their supervisors was key, with much lower dissatisfaction among staff who stated that their supervisor was a reason to stay on the job. Furthermore, the study demonstrated a positive relationship with satisfaction when staff engage as a team to offer care to residents, and for those who felt respected, rewarded, and valued. On the other hand, the ability to work independently and to participate in care planning were not associated with satisfaction, which the authors suggest may relate to the fact that they are not rewarded for these practices. Permanent staffing was also not related to satisfaction, which may be because the central issue therein is not permanent staffing per se, but the actual amount of time a staff member spends with a resident.


These findings hold immediate implications for leadership in long-term care in terms of fostering positive interactions between staff and enhancing supportive relationships in working teams. Bishop and her colleagues are clear in their discussions, stating that "Nursing homes can increase job satisfaction by supporting good relationships between nursing assistants and supervisors." Doing so might be accomplished by training supervisors to serve as mentors and supporters and to constructively encourage staff to work together to improve resident care. In this context, supervisors are not simply "bosses," they are coaches and leaders. A team of direct care staff that is supportively coached by its supervisor is afforded an opportunity for the individual members to collaborate and develop innovative solutions to care challenges and to support each other when their hours, pay, or benefits are not optimal. Dementia care in particular is very challenging, and it is not always immediately clear how to best approach any given resident. Effective supervision creates an environment of ongoing learning in which team members work together to deliver high-quality care.


Before closing, it is important to note that the study by Bishop and colleagues was cross-sectional in design, meaning that all of the information was obtained at one point in time. Therefore, it cannot be said that supervisory style causes nursing assistant satisfaction any more than it can be said that satisfaction causes styles of supervision-which is conceivable in that more satisfied workers may well stimulate their supervisors to be more supportive. In this way, we can understand that the supervisor-nursing assistant relationship is indeed a 2-way street, with both having a role in its success.


Kemp CL, Ball MM, Perkins MM, Hollingsworth C, Lepore MJ. "I get along with most of them": direct care workers' relationships with residents' families in assisted living.Gerontologist. 2009;49(2):224-235.


In addition to fostering positive relationships between supervisors and staff to achieve better care, long-term care organizations need to consider the role of residents' families. In their recent study of 41 direct care staff members and 43 administrators from 45 residential care/assisted living settings in Georgia, Kemp and colleagues outline a number of features of the relationship between staff and residents' families, organizing them under the concepts of (1) respectfulness, (2) partnership in caregiving, and (3) affirmation of the caregiving role. With these goals for a positive relationship described, the question remains of how these may be realized in the challenging environment of residential care/assisted living. Although the authors describe individual- and community-level factors of importance (such as commonality of culture and urban/rural setting), they also describe organizational influences on relationships that have direct implications for supervisors and organizational leaders. Specifically, Kemp and colleagues identify the importance of organizational policy related to staff-family relationships, with some staff encouraged to avoid getting "personal" and ensure "professionalism," whereas other staff are encouraged to openly engage and communicate with family. To effectively establish mutual respect and include family members as a part of the care team (not only to take advantage of families' rich knowledge of the resident but also to partner with them to resolve care challenges), there must exist at a minimum a positive relationship. Certainly, different organizations have different cultures and approaches to interacting with families, yet based on their results, the authors invite organizations, in shaping their policies and procedures, to consider ways they can create an environment in which families and staff will hold empathy for one another, recognizing the challenges of the caregiving role and establishing a respectful partnership.


Involving families in care has been discussed for years and was noted in the 1992 Alzheimer's Association publication, "Guidelines for Dignity: Goals of Specialized Alzheimer/Dementia Care in Residential Settings." The guidelines spoke to providing therapeutic activities that involved families. As evidenced in the study by Kemp and colleagues, this same topic continues to require attention today, a full 18 years after that publication. Hopefully this work, and that being conducted by others, will further these efforts.