Long-Term Care Workforce Issues: Practice Principles for Quality Dementia Care

Long-Term Care Workforce Issues: Practice Principles for Quality Dementia Care Abstract Purpose This article is one in a series of articles in this supplement addressing best practice for quality dementia care. The Alzheimer’s Association, in revising their Dementia Care Practice Recommendations for 2017 has identified staff across the long-term care spectrum as a distinct and important determinant of quality dementia care. The purpose of this article is to highlight areas for developing and supporting a dementia-capable workforce. Methods The Alzheimer’s Association Principles For Advocacy To Assure Quality Dementia Care Across Settings provide a framework to examine interventions to support the dementia care workforce in long-term care settings. Evidence-based approaches that represent these principles are discussed: (a) staffing, (b) staff training, (c) compensation, (d) supportive work environments, (e) career growth and retention, and (f) engagement with family. Results Although not all settings currently require attention to the principles described, this article proposes these principles as best practice recommendations. Recommendations and future research considerations to further improve the lives of those who live and work in nursing homes, assisted living, hospice, and home care, are proposed. Additional areas to improve the quality of a dementia care workforce person-centered care information, communication and interdepartmental teamwork, and ongoing evaluation are discussed. Dementia, Person-centered care, Long-term care, Home- and community-based care and services Direct care providers (DCPs) play a vital role in the provision of long-term care (Graf, Cignacco, Zimmermann, & Zuniga, 2016) and dramatically shape the daily lives of persons with dementia (Squires et al., 2015). For the purpose of this article, the term long-term care will be used to encompass nursing homes, assisted living, residential care, hospice, and home health environments. DCPs are the “hands-on” workers in long-term care and are identified specifically as the nurses, nursing assistants or nurse’s aides, medication aides/technicians, personal care, home health, and hospice aides. DCPs assist with all aspects of physical care, offer meaningful activities, and hold in their hands the quality of care and quality of life of individuals with dementia. Through their close contact with persons with dementia, DCPs gain a knowledge of the individual with dementia, preferences, behaviors, and functioning, and are often the first to notice physical changes, signs of illness, pain, or decline (Jansen et al., 2017). Each person who works in a long-term care organization, through their interactions can influence the long-term care experience and quality of life of individuals with dementia and their families. The DCPs collaborate with other staff who are important to the lives of the individuals with dementia and include those who work in dietary, housekeeping, activities, social services, therapy, admissions, and other departments (Gilster, 2006; Hunter, Hadjistavropoulos, Thorp, Lix, & Malloy, 2016). Demand for Dementia Care Providers There are 47 million people worldwide diagnosed with dementia and 9.9 million new cases each year (World Health Organization Media Center, 2017). Currently, there are an estimated 5.5 million Americans with Alzheimer’s disease and dementia and the incidence is expected to increase to 7.1 million in 2025 as the number of people 65 and older surges. More than 80% of the care of individuals with dementia is provided by unpaid care providers (Alzheimer’s Association, 2017a). However, the ratio of the number of family caregivers to recipients is decreasing. In 2010, there were seven caregivers for every older person needing assistance and the number is expected to drop to 4:1 in 2030. The number of unpaid caregivers is not sufficient to meet the increasing number of older adults in need of care, creating an even greater demand for paid DCPs (Redfoot, Feinberg, & Houser, 2013). Increasing numbers of people with dementia will require more caregivers, both family caregivers as well as long-term care providers. The need for paid care providers will continue to increase from 3.27 million in 2014 to 4.56 million in 2024. At the same time the number of those who comprise the bulk of the care providers, women between the ages of 25 and 64 is anticipated to remain the same (Gao, Tilse, Wilson, Tuckett, & Newcombe, 2015). The growing demand and ability to retain care providers continues to challenge the long-term care industry. Turnover is widespread, in home care, hospice, and residential care environments and ranges from 40% to well over 100% (Banaszak-Holl, Castle, Lin, Srivastava, & Spreitzer, 2015). Unless significant changes are made in long-term care the future looks bleak as the demand for DCPs will outpace the supply. Methods: A Framework for a Quality Dementia Workforce The Alzheimer’s Association (AA) posited that the “single most important determinant of quality dementia care across all care settings is direct care staff,” (Alzheimer’s Association, 2017b). The Alzheimer’s Association Principles For Advocacy To Assure Quality Dementia Care Across Settings provide a framework to examine interventions to support the dementia care workforce in long-term care settings (Table 1). Search terms included “dementia” OR “Alzheimer’s” AND “staff” and each of the following terms: (a) levels (OR deployment OR numbers); (b) training (OR education OR teaching); (c) compensation (OR salary OR benefits); (d) work environments (OR practice environment); (e) career growth (OR advancement); (f) family engagement (OR family and partnership); and (g) hiring. Interventional research focused on direct care workers, and published between 2000 and the present were included, representing nursing home, assisted living, residential care, home care and hospice settings. Table 1. Long-Term Care Workforce Issues: Principles for Advocacy to Assure Quality Dementia Care Across Setting Staffing levels should be adequate to allow for proper care at all times—day and night. Staff should be sufficiently trained in all aspects of care, including dementia care. Staff should be adequately compensated for their valuable work. Staff should work in a supportive atmosphere that appreciates their contributions to overall quality care. Improved working environments will result in reduced turnover in all care settings. Staff should have the opportunity for career growth. Staff should work with families in both residential care settings and home health agencies.   Staffing levels should be adequate to allow for proper care at all times—day and night. Staff should be sufficiently trained in all aspects of care, including dementia care. Staff should be adequately compensated for their valuable work. Staff should work in a supportive atmosphere that appreciates their contributions to overall quality care. Improved working environments will result in reduced turnover in all care settings. Staff should have the opportunity for career growth. Staff should work with families in both residential care settings and home health agencies.   Note: Adapted from Alzheimer’s Association (2017b). View Large Results Staffing Levels Staffing requirements for DCPs in long-term care environments providing dementia care vary by the setting, state, and country. Federal mandatory staffing requirements exist for registered nurses and licensed practical nurses in nursing homes, yet there is no minimum requirement for state tested/certified nursing assistants, though many states have established additional staffing requirements for these facilities (Harrington, 2010). Residential care, including assisted living facilities (RC/AL) are licensed by the respective state agencies, though most states do not specify minimum staffing levels or ratios in dementia care (Carder, 2017). Beyond meeting any mandatory DCP staffing numbers required in organizations serving persons with dementia, there is a growing awareness of the need to deploy DCPs in a manner that aligns with resident routines and needs (Cohen-Mansfield & Bester, 2006). Nursing assistants have reported the important role that flexible schedules have in contributing to individualized care (Curry, Porter, Michalski, & Gruman, 2000). Further, flexible schedules may be useful in decreasing turnover and therefore in avoiding the costs associated with frequent hiring and training (Weale, Wells, & Oakman, 2017). For example, the Adards Nursing Home in Tasmania, Australia promotes flexibility as a central management principle in working with both residents and staff members. Flexibility in regard to residents is manifested in their ability to control the time they get up, eat, go outdoors, and go to sleep, with access to multiple opportunities for activities that are common to people who live in the outside community (Cohen-Mansfield & Bester, 2006). The routines of staff members are flexible in that they are encouraged to eat meals with residents, converse and spend time walking with them, or engage in other activities with them. Flexible staff schedules, including shorter hours, support this approach. The flexibility and part-time assignments have positively impacted turnover, staff recruitment, absenteeism, and sick leave. Since the facility opened in 1991, the average tenure of staff members is 7.2 years, and the average turnover rate for those years has been 10% (Cohen-Mansfield & Bester, 2006). This is in marked contrast to the turnover rates of 50%–100% reported in the United States (Castle, 2005; Mukamel et al., 2009). Staff Training Unlike other illnesses, the unique characteristics of dementia, such as impaired communication, disorientation, confusion, and behavioral changes demand training for DCPs to increase understanding and strategies for caregiving (Alzheimer’s Association, 2017a). Care providers working with persons with dementia have identified the need for sufficient training (Pitfield, Shahriyarmolki, & Livingston, 2011). Several literature reviews have described the benefits of dementia training, including a positive approach to dementia and less work-related stress (Barbosa, Nolan, Sousa, & Figueiredo, 2017; Islam, Baker, Huxley, Russell, & Dennis, 2017). Training can be categorized based on three types of targeted outcomes: staff outcomes, patient outcomes, and organizational outcomes. Further, DCPs and staff require an understanding of the concept of person-centered care in an effort to deliver high quality care for individuals with dementia (Kim & Park, 2017). The fundamentals of person-centered care, best practice, and approaches to care are discussed within this supplement in the article on person-centered care, outlining the essential components for care and training (Fazio, Pace, Flinner, & Kallmyer, 2018). Recognizing the person with dementia as a unique individual, with a distinctive life story assists the care providers to view people with dementia as a whole person, not simply a task or person with a disease (Gronhdal, Persenius, Baath, & Helgesen, 2017). Training and Staff Outcomes Spector, Revolta, and Orrell (2016) conducted a systematic review that examined the effect of staff dementia (Type 1) training upon staff outcomes in care homes, nursing homes and assisted living. They found that most training programs incorporated person-centered principles and aimed to improve communication between care staff and residents. Staff outcomes included knowledge, attitude, self-efficacy, burnout, and job satisfaction. In these studies which varied in methodological quality, knowledge showed the greatest increase. Stress and burnout showed more variation as outcomes. There was no association between training intensity and outcomes. Recent studies have examined innovative training approaches. A Norwegian study examined the effectiveness of the Dementia ABC educational program (Rokstad et al., 2017). In addition to written materials, the intervention includes multidisciplinary reflection groups and workshops. The positive impact was evident in scores of patient-centeredness and job satisfaction. The Ladder to the Moon Culture Change Studio Engagement Program (CCSEP) is a staff training approach based on the Positive Psychology framework that uses theatre- and film-based activities. In qualitative responses staff reported an improved sense of teamwork, more positive attitudes towards residents, as well as some concerns about using theatrical intervention (Guzmán, Wenborn, Ledgerd, & Orrell, 2017a). Quantitative responses revealed an increase in positive interactions post intervention, and a significant increase in the building relationship techniques in the care setting. Survey responses also indicated that the intervention did not significantly affect the happiness or job satisfaction of care home staff (Guzmán, Wenborn, Swinson, & Orrell, 2017b). Training and Resident/Patient Outcomes In a review of 19 studies, McCabe, Davison, and George (2007) found no effect of staff training upon outcomes in residents with dementia. However, in a later systematic review of 20 studies that focused specifically on training interventions to reduce behavioral and psychological symptoms of dementia (BPSD), Spector, Orrell, and Goyde (2013) found evidence that training had some positive impact upon BPSD and improved the interaction between staff and residents. Training was also found to impact the way staff behaved towards residents (Spector et al., 2013). No links were found between the theoretical orientation of training programs and their effectiveness. However, studies did demonstrate that training that incorporated the support of management was more likely to be effective (Spector et al., 2013). For example, Burgio and colleagues (2002) supplemented four weeks of behavior management training of nursing assistants, which included hands-on training, with formal staff management (FSM) implemented by nursing supervisors (a Type III intervention). The components of the FSM system included (a) a clear and specific description of behavioral skills, (b) CNA self-monitoring, (c) LPN monitoring of CNA skill performance, (d) verbal and written performance feedback to CNAs, and (e) CNA incentives for achieving established performance criteria. The behavior management skills training program improved CNAs’ ability to interact with nursing home residents who experienced BPSD, and the residents showed sustained reductions in agitation. Also, the FSM system was more effective for maintaining communication skills 6 months after training (Burgio et al., 2002). The STAR intervention, a Type IV intervention, consists of two 4-h workshops augmented by four individualized on-site consultations and three leadership sessions. The intervention reported improved resident outcomes in assisted living (Teri, Huda, Gibbons, Young, & van Leynseele, 2005). STAR demonstrated reduced levels of affective and behavioral distress compared with control residents. Additionally, the staff reported less adverse impact and reaction to residents’ problems (p < .05) and more job satisfaction (p < .10) compared with control staff. Landreville, Dicaire, Verreault, and Levesque (2005) reported a reduction in BPSD with the use of 8 h of class instruction followed by 8 h of weekly supervision by the trainers (Type IV intervention). In addition to supervisory support, care planning has been a critical complement to some training programs. In a large cluster randomized trial, Chenoweth and colleagues (2009) demonstrated that dementia care mapping along with patient-centered care training and leadership engagement, was associated with less agitation in persons with BPSD (Type IV intervention). Falls were less in the sites that used mapping alone but falls increased in the sites that used patient-centered care alone (Chenoweth et al., 2009). More recently, the OASIS educational program, also a Type IV intervention, targeted all NH staff (direct care and nondirect care), engaged supervisory staff and used a train-the-trainer model that emphasizes reframing behavior and care plans that capitalize on resident strengths (Tjia et al., 2017). The nursing homes that implemented OASIS experienced a reduction in antipsychotic use in persons with dementia, but the improvement was not sustained. Although undetected pain is a common problem in persons with dementia (Husebo, Wilchterberg, & Flo, 2016), it has rarely been the focus of training programs. PAIN-Dem training was delivered to care staff from three care homes in South London, along with guidance to supervisors and resources to encourage improved pain management over 4 weeks (Type IV intervention). Although staff demonstrated improved pain management behavior, there was no improvement in pain outcomes (Petyaeva et al., 2017). DCPs and staff in community based and long-term care environments specifically request additional training and the chance to be involved in the development of the training programs (Talbot & Brewer, 2016). Staff desire more practical learning methods and application, as well as training that is relevant to their daily work including real life situations and solutions (Bishop, 2014; Kolanowski, Van Haitsma, Penrod, Hill, & Yevchak, 2015; Stanyon, Griffiths, Thomas, & Gordon, 2016; Talbot & Brewer, 2016). Training and Organizational Outcomes In a study of training requirements and outcomes, Trinkoff found that training for certified nursing assistants above the mandated federal requirement led to less adverse events, pain, falls with injury and depression. A strong association between the number of inservice hours and quality indicators suggested a link between ongoing training and quality of care (Trinkoff, Storr, Lerner, Yang, & Han, 2016). There is a need to make training relevant and accessible for DCPs and all staff, in all long-term care environments. Additional research is needed to evaluate organizational strategies that support and engage DCPs in training, orientation, and education, as well as determine the impact of training on staff stress, satisfaction, and retention, and effect on persons with dementia. Compensation The “monetary needs” of nursing assistants working in long-term care settings for older people with dementia was identified in qualitative work as an important reason to work in long-term care (Sung, Chang, & Tsai, 2005). This finding is consistent with early studies (Garland, Oyabu, & Gipson, 1988; Monahan & McCarthy, 1992). Compensation in wages, the provision and payment of health insurance is a concern for DCPs in regard to satisfaction, recruitment, and retention in all sectors of long-term care (Howes, 2008; Kemper et al., 2008; Paraprofessional Healthcare Institute, 2013; Probst, Baek, & Laditka, 2010). However, Squires and colleagues (2015) found in a systematic review that organizational factors such as workload, resources, and individual factors such as autonomy and empowerment to be greater predictors of job satisfaction than satisfaction with salary/benefits. Meaningful work was more important than hourly wages with intent to leave for residential DCPs (Gao et al., 2015). Stone and colleagues (2017) found that intent to leave for home care workers was dependent upon the overall household income level over the federal poverty level and the provision of health insurance though hourly wages were not. Thus, though compensation is important, it is only one of the expressed needs of DCPs across settings (Stone et al., 2017). Supportive Work Environment Many challenges exist for DCPs in the provision of care to persons with dementia while at the same time meeting the many expectations and demands of families (Coates & Fossey, 2016; Zimmerman et al., 2005). DCPs have reported that the work environment influences their experience as well as those of the residents in long-term care residences. A national survey conducted in the Netherlands found that person-centered care is beneficial to the nursing staff, specifically when the nursing staff feel supported by their supervisor (Willemse et al., 2015). Qualitative reports indicate that efforts to provide individualized care are supported by supervisors who provide hands-on help working with residents, are open to new ideas, and policies that promote an inclusive approach to care planning (Cohen-Mansfield & Bester, 2006; Curry et al., 2000). Further, phenomenological research conducted by Law, Patterson, and Muers (2017b) suggests the need for supervisors to support strong and supportive relationships between health care assistants and residents. They suggest opportunities for staff to explore their emotional reactions through reflective practice groups or clinical supervision in order to reduce any adverse impact on care provision (Law et al., 2017b). This recommendation is corroborated by earlier work conducted by Edvardsson, Sandman, Nay, and Karlsson (2009) with nursing staff in residential dementia care. The researchers identified that in addition to staff age and educational level, perception of the caring environment and opportunity to have discussions of difficulties and ethics at work were salient predictors of job strain (Edvardsson et al., 2009). Career Growth and Retention In an integrative analysis of reports, articles, and website information on the labor market for dementia care, researchers found that the main reason for quitting a care job was lack of job satisfaction. Dementia care workers describe a lack of appreciation and dissatisfaction about the quality of care they were able to provide as the major sources of job dissatisfaction (Vernooij-Dasssen et al., 2009). In contrast, a mixed method study with Australian nurses in acute, subacute, community, and residential health care settings reported reasonable satisfaction (Chenoweth, Merlyn, Jeon, Tait, & Duffield, 2014). Nurses who felt valued and supported by the organization and their colleagues were more positive about their work. Perceived facilitators of job satisfaction were education, training, supervision, mentoring opportunities, and appropriate compensation. There is also evidence that management practices used to empower certified nurse assistants (CNAs) and nurses can increase retention and improve resident outcomes (Brannon & Mor, 2005). LEAP (“Learn,” “Empower,” “Achieve,” “Produce”), a comprehensive long-term care workforce development initiative, aims to educate, empower, and retain long-term care nurses and CNAs (Hollinger-Smith & Ortigara, 2004). LEAP consists of two modules. One module is a 6-week (18 h total) workshop targeting nurse managers and charge nurses to develop essential roles of leader, care role model, clinical expert, and care team builder. The second module is a 7-week (14 h total) workshop focused on career development for CNAs. LEAP demonstrated increases in leadership effectiveness, work empowerment, job satisfaction, and perceptions of the organizational climate. Improvements in quality indicators, reduced number of health deficiencies, and decreased nurse and CNA turnover were also reported (Hollinger-Smith & Ortigara, 2004). In anticipation of a pending workforce shortage to care for an aging population, human resource experts recommend traditional practices to recruit and retain quality staff, including benefits packages, reward and recognition, and flexible scheduling (Jarousse, 2011). Additionally, they recommend behavior-based interviewing and peer interviewing to build effective, long-term teams. Sung and colleagues (2005) recommend the use of a screening process to assess job motivation and attitudes toward persons with dementia. Researchers at the Indiana University Center for Aging Research have developed an innovative method of screening for critical abilities expected in the frontline care provider position, the Care Coordinator Assistant (Cottingham et al., 2014). They created a new screening process, building on the multiple mini interview (MMI) format to evaluate the ability to express “caring” and empathy. The Care Coordinator Assistant MMI is comprised of six stations that simulate frequently encountered, challenging scenarios in persons with dementia. The interviewer then evaluates the candidate’s responses and abilities. Overall, the six-station MMI, with two to three items per station, provided factorial valid measures and good predictive ability. Additionally, the interviewers reported that the process was not burdensome and was helpful in discriminating between candidates (Cottingham et al., 2014). Orientation to include dementia education before a new employee is assigned to provide care for a person with dementia enhances their understanding of the disease and improves their ability to provide care and interact in a more appropriate fashion (Talbot & Brewer, 2016). Additional topics recommended at orientation include person-centered dementia care, behavioral strategies, alternatives to medication, abuse and neglect, and safety (Alzheimer’s Association, 2017c). Providing dementia training in an orientation has been found to benefit not only the organization, but indicates to the new employee that the organization recognizes their importance, and has proven beneficial to staff retention (Gao et al., 2015; Gilster, 2006; National Nursing Home Quality Improvement Campaign, 2016). Engagement With Family Effective partnership with families is recognized as an integral role in the care of persons with dementia (Robison et al., 2007). Hennings, Froggatt, and Keady (2010) conducted a systematic review of families’ experiences with end of life care in care homes. They found that families wanted frequent contact, empathy, reassurance, and engagement in decision-making with support along the way. Graneheim, Johansson, and Lindgren (2014) examined families’ experiences of transition into long-term care through a meta-ethnographic study incorporating a systematic literature search. Families wanted staff to show genuine concern for them and their family member, to consider the family member’s views, and facilitate family’s ability to influence the plan and delivery of care (Graneheim et al., 2014). Law, Patterson, and Muers (2017a) extended this line of inquiry with a systematic review that identified that families want consistent, knowledgeable staff who interact well with both them and the person with dementia. The authors conclude that staff education should focus not only on the clinical and practical needs of persons with dementia but also how to interact and partner with families (Law et al., 2017a). Robison and colleagues (2007) studied an intervention to improve staff and family communication in nursing home dementia units, and found that the program Partners in Caregiving was an effective method to increase support to staff, families, and residents. Many families of persons with dementia enjoy participating in the provision of information such as life stories to encourage DCP’s ability to recognize and value the person with dementia (Grøndahl, Persenius, Bååth, & Helgesen, 2017). Documenting, sharing life stories can be an opportunity to engage residents, families, and staff and particularly important in caring for persons with dementia who have lost their ability to share such information and communicate their needs and desires. Life stories is a way to offer staff insight into the world of the person with dementia before the disease and can enhance the DCPs and staff’s ability to connect, interact, and create improved strategies for caregiving. Grøndahl found in a systematic review that creating life stories, recording and sharing aspects of a person’s past and present life and using that information for planning and providing care was beneficial for the person with dementia, the family, DCPs, and staff. Staff attitude towards persons with dementia improved and the process of creating life stories was enjoyable and enhanced their relationship with the person with dementia. However, in one study the staff perceptions did not improve significantly (Grøndahl et al., 2017). Supportive relationships may be enhanced through the use of consistent assignments, a model supported by many national organizations including Advancing Excellence, The American Health Care Association and Leading Age (National Nursing Home Quality Improvement Campaign, 2016). Consistent assignments are offered as a method to enhance close personal relationships and quality of life, as DCPs come to know the person not simply as an “assignment,” but as an individual with a unique life and history (Corazzani et al., 2015; Roberts, Nolet, & Bowers, 2015). Further, Castle found that consistent assignments have been found to decrease staff turnover in residential care environments (Castle, 2011), while Stone and colleagues (2017) determined that consistent assignments in home care workers increased job satisfaction and was associated with a lower intent to leave (Stone et al., 2017). Additional Considerations to Improve Quality Dementia Care Workforce DCPs are the foundation of long-term care, as they provide the “service” in nursing homes, assisted/residential care, home care and hospice. Yet the industry struggles to create environments that address their needs and desires. Turnover is high in all positions and extremely costly to all organizations. Monetary compensation and benefits, while important, are not the only answer (Stone et al., 2017). It is more than just a job; for many it is a calling (Pfefferle & Weinberg, 2008). Need for Continued Research in Leadership The leader and the culture of an organization play a dominant role and significantly impact the quality of dementia care and quality of life for the people who live and work in long-term care settings (Stanyon et al., 2016). Leaders set the tone, establish the culture of the organization and influence success or failure (Siegel, Bakerjian, & Zysberg, 2017). Requirements and training for leaders, often referred to as administrators, executive directors, directors, etc., vary by setting and location for nursing homes, residential care, assisted living, home care, and hospice care. For instance, nursing home administrators and administrators in RC/AL are subject to state licensure, certification, training requirements, and continuing education although the amount and scope vary widely by state. Only 21 states require the RC/AL administrator to be licensed or certified and the required annual hours of continued education ranges from no requirement to 40 h (Carder, 2017). As of 2018, the administrators of home health agencies with certificates of participation for Medicare and Medicaid are required to be a licensed physician, a registered nurse or have an undergraduate degree with experience in health administration coupled with at least 1 year of administrative or supervisory experience (Centers for Medicare and Medicaid, 2017a). A culture supporting quality person-centered dementia care requires stable, dedicated leadership, and workforce (Koren, 2010). Nursing home administrator turnover is common and ranges from 41% to 45%. A high rate of administrator turnover is associated with high numbers of deficiencies (Geletta & Sparks, 2013) increased DCPs turnover (Castle, 2005) and the quality of care (Castle, 2001; Geletta & Sparks, 2013; Stolee et al., 2005). The importance of this single person and their effectiveness in long-term care settings has not received a great deal of attention (Dana & Olson, 2007; Donoghue & Castle, 2009). There is a need for continued research in leadership in long-term care settings to determine reasons for leader turnover and what may need to be done to prepare leaders for the future to improve DCP and staff competencies (Singh & Schwab, 2000). Need for Systems to Collect and Disseminate Person-Centered Information Care providers and staff want life history information to enable them to respond to the “individual” with dementia and to establish approaches to care and behaviors (Grøndahl et al., 2017). However, barriers to providing quality person-centered dementia care include the inability for DCPs and staff to secure information about the person with dementia, mechanisms for communicating that information to colleagues and the time to do so. Currently, much of this information is communicated verbally, and often the staff lack the time for communicating this information (Kolanowski et al., 2015). Systems need to be created that support a communication process to facilitate the exchange of this person-centered information to DCPs and staff and to share changes in the person with dementia as they occur over time. An expectation within the CMS Dementia Focused Survey Guide is the gathering and dissemination of person-centered care information to DCPs and staff (Centers for Medicare and Medicaid Services, 2015). Encouraging Communication and Interdepartmental Teamwork Interdepartmental meetings that engage staff in all departments have been shown to enhance a sense of team and community, an open mindedness and support for one another regardless of their role (Guzman et al., 2017a). Graf found the strongest predictors of job satisfaction and overall quality of care were collaboration with nursing home director, director of nursing, colleagues and staff resource adequacy (Graf et al., 2016). Coates found usefulness in proving opportunities to reflect with colleagues to promote thought and problem solving, encourage all to look at solutions through the eyes of another person or the person with dementia (Coates & Fossey, 2016). The ability of an organization to enhance interdisciplinary staff participation and interdepartmental collaboration can be accomplished through routinely scheduled all-inclusive staff meetings and in-service programs (Smythe, Jenkins, Galant-Miecznikowska, & Bentham, 2017). Offering meetings and inservices on all shifts for all departments provides an opportunity for all staff to attend, enhances communication, participation, and relationships between departments (Gilster, 2005). Ongoing Evaluation of Programs To ensure a quality care dementia workforce and environment requires an ongoing process to measure continuous quality improvement (Koren, 2010). Quality care, assessment and evaluation programs, processes, and systems continues to challenge the industry (Mills et al., 2017). The most recent initiative to improve quality care is the Quality Assurance and Performance improvement plan (QAPI) is effective November of 2018. QAPI expands the process of quality assurance to put practices in place to improve care and services. Elements of the process serve to include and engage all stakeholders in the program, create a learning organization, leadership role in ensuring stakeholder input and involvement and creating a systematic approach to determine problems, causes, appropriate interventions, and data driven decisions (Center for Medicare and Medicaid Services, 2017b). The implementation of QAPI may very well augment some of the other areas that DCPs and staff have indicated they desire in their work; including a focus on education, involvement in the decision process, the availability of information, team work, a learning environment, and collaboration. Conclusion Training has received considerable attention as the unique characteristics of dementia and resulting behaviors need to be understood by those who provide care. While the quality and quantity of training programs has been examined, more needs to be done to determine how to maintain knowledge and practice over time and how to garner leadership and management support for training programs. Critical to person-centered dementia care is “knowing the person,” the human being, father, golfer, mother, bank president, university professor, and researcher. The use of life history or stories may influence the ability of staff to see the whole person, as a human being with a rich history and life versus an individual with dementia who is difficult to care for and time consuming. However, systems and processes need to be in place to not only secure the information but to develop mechanisms to share and make accessible the information with all DCPs and staff. Professionals and nonprofessional groups in varied environments such as nursing homes versus home care and in other countries present different job needs and desires (Banaszak-Hall et al., 2015). They also fall under varied regulations internationally, nationally, and by state. It is important to note that while organizations may not be required and/or staff are not asking for dementia specific programs as recommended in this article, such programs may still be beneficial. Training, respect and appreciation, communication, participation in decision making, support programs, teamwork and caring, and engaged leadership have all been cited individually as desires, and such programs may prove important for all long-term care settings to promote a quality dementia care workforce. Research on a combination of programs that address these issues may be beneficial. Increasing numbers of people living with dementia and decreasing resources makes it essential to determine what motivates DCPs to work across the long-term care spectrum and what programs are necessary to retain them. Organizations need to address the desires of DCPs and outcomes of research to promote best practice. Creating a competent dementia care workforce is clearly complex and requires a deep inquiry into the multiple needs and desires of DCPs and staff. There will likely not be one program or strategy that solves the workforce issue. Practice Recommendations for Staffing Provide a thorough orientation and training program for new staff, as well as ongoing training A comprehensive orientation should be provided that includes the organization’s vision, mission, and values, high performance expectations, and person-centered dementia training. This training is essential for new staff, and should be included in ongoing education for all staff members. Develop systems for collecting and disseminating person-centered information It is important that all staff know the person living with dementia as an individual. Establish procedures for collecting person-centered information that includes choices, preferences and life history. It is also essential that an effective process be developed to share this information with all staff. Encourage communication, teamwork, and interdepartmental/interdisciplinary collaboration An organization should promote staff participation and interdepartmental/interdisciplinary collaboration through routinely scheduled inservice programs and meetings. Training is most effective when designed to include ongoing education, communication, and support. Offering inservices and conducting meetings on all shifts are important, and will impact attendance, participation, and facilitate relationships between staff. Establish an involved, caring, and supportive leadership team Creating a person-centered “community” is not possible without service-oriented leaders, managers, and supervisors. It is also vital that the leadership team be vision-driven, open, and flexible. High performing leaders know that staff are the foundation of success, and when staff are valued, recognized, and feel served themselves, they in turn will more likely value and serve others. Promote and encourage resident, staff, and family relationships Encouraging relationships among persons living with dementia, staff, and families is central to person-centered care, and is fostered in part by implementing consistent staff assignment. The involvement of all parties in planning care, activities, education, and social events may cultivate successful relationships as well. Evaluate systems and progress routinely for continuous improvement It is important that an organization routinely collect and evaluate information on all staff processes, including hiring, orientation, training, and satisfaction. Analysis of the data should be used to evaluate the effectiveness of all systems and identify areas for improvement. In addition, leaders should share this information with staff, and act upon the results. Funding This paper was published as part of a supplement sponsored and funded by the Alzheimer’s Association. References Alzheimer’s Association. 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Long-Term Care Workforce Issues: Practice Principles for Quality Dementia Care

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Abstract

Abstract Purpose This article is one in a series of articles in this supplement addressing best practice for quality dementia care. The Alzheimer’s Association, in revising their Dementia Care Practice Recommendations for 2017 has identified staff across the long-term care spectrum as a distinct and important determinant of quality dementia care. The purpose of this article is to highlight areas for developing and supporting a dementia-capable workforce. Methods The Alzheimer’s Association Principles For Advocacy To Assure Quality Dementia Care Across Settings provide a framework to examine interventions to support the dementia care workforce in long-term care settings. Evidence-based approaches that represent these principles are discussed: (a) staffing, (b) staff training, (c) compensation, (d) supportive work environments, (e) career growth and retention, and (f) engagement with family. Results Although not all settings currently require attention to the principles described, this article proposes these principles as best practice recommendations. Recommendations and future research considerations to further improve the lives of those who live and work in nursing homes, assisted living, hospice, and home care, are proposed. Additional areas to improve the quality of a dementia care workforce person-centered care information, communication and interdepartmental teamwork, and ongoing evaluation are discussed. Dementia, Person-centered care, Long-term care, Home- and community-based care and services Direct care providers (DCPs) play a vital role in the provision of long-term care (Graf, Cignacco, Zimmermann, & Zuniga, 2016) and dramatically shape the daily lives of persons with dementia (Squires et al., 2015). For the purpose of this article, the term long-term care will be used to encompass nursing homes, assisted living, residential care, hospice, and home health environments. DCPs are the “hands-on” workers in long-term care and are identified specifically as the nurses, nursing assistants or nurse’s aides, medication aides/technicians, personal care, home health, and hospice aides. DCPs assist with all aspects of physical care, offer meaningful activities, and hold in their hands the quality of care and quality of life of individuals with dementia. Through their close contact with persons with dementia, DCPs gain a knowledge of the individual with dementia, preferences, behaviors, and functioning, and are often the first to notice physical changes, signs of illness, pain, or decline (Jansen et al., 2017). Each person who works in a long-term care organization, through their interactions can influence the long-term care experience and quality of life of individuals with dementia and their families. The DCPs collaborate with other staff who are important to the lives of the individuals with dementia and include those who work in dietary, housekeeping, activities, social services, therapy, admissions, and other departments (Gilster, 2006; Hunter, Hadjistavropoulos, Thorp, Lix, & Malloy, 2016). Demand for Dementia Care Providers There are 47 million people worldwide diagnosed with dementia and 9.9 million new cases each year (World Health Organization Media Center, 2017). Currently, there are an estimated 5.5 million Americans with Alzheimer’s disease and dementia and the incidence is expected to increase to 7.1 million in 2025 as the number of people 65 and older surges. More than 80% of the care of individuals with dementia is provided by unpaid care providers (Alzheimer’s Association, 2017a). However, the ratio of the number of family caregivers to recipients is decreasing. In 2010, there were seven caregivers for every older person needing assistance and the number is expected to drop to 4:1 in 2030. The number of unpaid caregivers is not sufficient to meet the increasing number of older adults in need of care, creating an even greater demand for paid DCPs (Redfoot, Feinberg, & Houser, 2013). Increasing numbers of people with dementia will require more caregivers, both family caregivers as well as long-term care providers. The need for paid care providers will continue to increase from 3.27 million in 2014 to 4.56 million in 2024. At the same time the number of those who comprise the bulk of the care providers, women between the ages of 25 and 64 is anticipated to remain the same (Gao, Tilse, Wilson, Tuckett, & Newcombe, 2015). The growing demand and ability to retain care providers continues to challenge the long-term care industry. Turnover is widespread, in home care, hospice, and residential care environments and ranges from 40% to well over 100% (Banaszak-Holl, Castle, Lin, Srivastava, & Spreitzer, 2015). Unless significant changes are made in long-term care the future looks bleak as the demand for DCPs will outpace the supply. Methods: A Framework for a Quality Dementia Workforce The Alzheimer’s Association (AA) posited that the “single most important determinant of quality dementia care across all care settings is direct care staff,” (Alzheimer’s Association, 2017b). The Alzheimer’s Association Principles For Advocacy To Assure Quality Dementia Care Across Settings provide a framework to examine interventions to support the dementia care workforce in long-term care settings (Table 1). Search terms included “dementia” OR “Alzheimer’s” AND “staff” and each of the following terms: (a) levels (OR deployment OR numbers); (b) training (OR education OR teaching); (c) compensation (OR salary OR benefits); (d) work environments (OR practice environment); (e) career growth (OR advancement); (f) family engagement (OR family and partnership); and (g) hiring. Interventional research focused on direct care workers, and published between 2000 and the present were included, representing nursing home, assisted living, residential care, home care and hospice settings. Table 1. Long-Term Care Workforce Issues: Principles for Advocacy to Assure Quality Dementia Care Across Setting Staffing levels should be adequate to allow for proper care at all times—day and night. Staff should be sufficiently trained in all aspects of care, including dementia care. Staff should be adequately compensated for their valuable work. Staff should work in a supportive atmosphere that appreciates their contributions to overall quality care. Improved working environments will result in reduced turnover in all care settings. Staff should have the opportunity for career growth. Staff should work with families in both residential care settings and home health agencies.   Staffing levels should be adequate to allow for proper care at all times—day and night. Staff should be sufficiently trained in all aspects of care, including dementia care. Staff should be adequately compensated for their valuable work. Staff should work in a supportive atmosphere that appreciates their contributions to overall quality care. Improved working environments will result in reduced turnover in all care settings. Staff should have the opportunity for career growth. Staff should work with families in both residential care settings and home health agencies.   Note: Adapted from Alzheimer’s Association (2017b). View Large Results Staffing Levels Staffing requirements for DCPs in long-term care environments providing dementia care vary by the setting, state, and country. Federal mandatory staffing requirements exist for registered nurses and licensed practical nurses in nursing homes, yet there is no minimum requirement for state tested/certified nursing assistants, though many states have established additional staffing requirements for these facilities (Harrington, 2010). Residential care, including assisted living facilities (RC/AL) are licensed by the respective state agencies, though most states do not specify minimum staffing levels or ratios in dementia care (Carder, 2017). Beyond meeting any mandatory DCP staffing numbers required in organizations serving persons with dementia, there is a growing awareness of the need to deploy DCPs in a manner that aligns with resident routines and needs (Cohen-Mansfield & Bester, 2006). Nursing assistants have reported the important role that flexible schedules have in contributing to individualized care (Curry, Porter, Michalski, & Gruman, 2000). Further, flexible schedules may be useful in decreasing turnover and therefore in avoiding the costs associated with frequent hiring and training (Weale, Wells, & Oakman, 2017). For example, the Adards Nursing Home in Tasmania, Australia promotes flexibility as a central management principle in working with both residents and staff members. Flexibility in regard to residents is manifested in their ability to control the time they get up, eat, go outdoors, and go to sleep, with access to multiple opportunities for activities that are common to people who live in the outside community (Cohen-Mansfield & Bester, 2006). The routines of staff members are flexible in that they are encouraged to eat meals with residents, converse and spend time walking with them, or engage in other activities with them. Flexible staff schedules, including shorter hours, support this approach. The flexibility and part-time assignments have positively impacted turnover, staff recruitment, absenteeism, and sick leave. Since the facility opened in 1991, the average tenure of staff members is 7.2 years, and the average turnover rate for those years has been 10% (Cohen-Mansfield & Bester, 2006). This is in marked contrast to the turnover rates of 50%–100% reported in the United States (Castle, 2005; Mukamel et al., 2009). Staff Training Unlike other illnesses, the unique characteristics of dementia, such as impaired communication, disorientation, confusion, and behavioral changes demand training for DCPs to increase understanding and strategies for caregiving (Alzheimer’s Association, 2017a). Care providers working with persons with dementia have identified the need for sufficient training (Pitfield, Shahriyarmolki, & Livingston, 2011). Several literature reviews have described the benefits of dementia training, including a positive approach to dementia and less work-related stress (Barbosa, Nolan, Sousa, & Figueiredo, 2017; Islam, Baker, Huxley, Russell, & Dennis, 2017). Training can be categorized based on three types of targeted outcomes: staff outcomes, patient outcomes, and organizational outcomes. Further, DCPs and staff require an understanding of the concept of person-centered care in an effort to deliver high quality care for individuals with dementia (Kim & Park, 2017). The fundamentals of person-centered care, best practice, and approaches to care are discussed within this supplement in the article on person-centered care, outlining the essential components for care and training (Fazio, Pace, Flinner, & Kallmyer, 2018). Recognizing the person with dementia as a unique individual, with a distinctive life story assists the care providers to view people with dementia as a whole person, not simply a task or person with a disease (Gronhdal, Persenius, Baath, & Helgesen, 2017). Training and Staff Outcomes Spector, Revolta, and Orrell (2016) conducted a systematic review that examined the effect of staff dementia (Type 1) training upon staff outcomes in care homes, nursing homes and assisted living. They found that most training programs incorporated person-centered principles and aimed to improve communication between care staff and residents. Staff outcomes included knowledge, attitude, self-efficacy, burnout, and job satisfaction. In these studies which varied in methodological quality, knowledge showed the greatest increase. Stress and burnout showed more variation as outcomes. There was no association between training intensity and outcomes. Recent studies have examined innovative training approaches. A Norwegian study examined the effectiveness of the Dementia ABC educational program (Rokstad et al., 2017). In addition to written materials, the intervention includes multidisciplinary reflection groups and workshops. The positive impact was evident in scores of patient-centeredness and job satisfaction. The Ladder to the Moon Culture Change Studio Engagement Program (CCSEP) is a staff training approach based on the Positive Psychology framework that uses theatre- and film-based activities. In qualitative responses staff reported an improved sense of teamwork, more positive attitudes towards residents, as well as some concerns about using theatrical intervention (Guzmán, Wenborn, Ledgerd, & Orrell, 2017a). Quantitative responses revealed an increase in positive interactions post intervention, and a significant increase in the building relationship techniques in the care setting. Survey responses also indicated that the intervention did not significantly affect the happiness or job satisfaction of care home staff (Guzmán, Wenborn, Swinson, & Orrell, 2017b). Training and Resident/Patient Outcomes In a review of 19 studies, McCabe, Davison, and George (2007) found no effect of staff training upon outcomes in residents with dementia. However, in a later systematic review of 20 studies that focused specifically on training interventions to reduce behavioral and psychological symptoms of dementia (BPSD), Spector, Orrell, and Goyde (2013) found evidence that training had some positive impact upon BPSD and improved the interaction between staff and residents. Training was also found to impact the way staff behaved towards residents (Spector et al., 2013). No links were found between the theoretical orientation of training programs and their effectiveness. However, studies did demonstrate that training that incorporated the support of management was more likely to be effective (Spector et al., 2013). For example, Burgio and colleagues (2002) supplemented four weeks of behavior management training of nursing assistants, which included hands-on training, with formal staff management (FSM) implemented by nursing supervisors (a Type III intervention). The components of the FSM system included (a) a clear and specific description of behavioral skills, (b) CNA self-monitoring, (c) LPN monitoring of CNA skill performance, (d) verbal and written performance feedback to CNAs, and (e) CNA incentives for achieving established performance criteria. The behavior management skills training program improved CNAs’ ability to interact with nursing home residents who experienced BPSD, and the residents showed sustained reductions in agitation. Also, the FSM system was more effective for maintaining communication skills 6 months after training (Burgio et al., 2002). The STAR intervention, a Type IV intervention, consists of two 4-h workshops augmented by four individualized on-site consultations and three leadership sessions. The intervention reported improved resident outcomes in assisted living (Teri, Huda, Gibbons, Young, & van Leynseele, 2005). STAR demonstrated reduced levels of affective and behavioral distress compared with control residents. Additionally, the staff reported less adverse impact and reaction to residents’ problems (p < .05) and more job satisfaction (p < .10) compared with control staff. Landreville, Dicaire, Verreault, and Levesque (2005) reported a reduction in BPSD with the use of 8 h of class instruction followed by 8 h of weekly supervision by the trainers (Type IV intervention). In addition to supervisory support, care planning has been a critical complement to some training programs. In a large cluster randomized trial, Chenoweth and colleagues (2009) demonstrated that dementia care mapping along with patient-centered care training and leadership engagement, was associated with less agitation in persons with BPSD (Type IV intervention). Falls were less in the sites that used mapping alone but falls increased in the sites that used patient-centered care alone (Chenoweth et al., 2009). More recently, the OASIS educational program, also a Type IV intervention, targeted all NH staff (direct care and nondirect care), engaged supervisory staff and used a train-the-trainer model that emphasizes reframing behavior and care plans that capitalize on resident strengths (Tjia et al., 2017). The nursing homes that implemented OASIS experienced a reduction in antipsychotic use in persons with dementia, but the improvement was not sustained. Although undetected pain is a common problem in persons with dementia (Husebo, Wilchterberg, & Flo, 2016), it has rarely been the focus of training programs. PAIN-Dem training was delivered to care staff from three care homes in South London, along with guidance to supervisors and resources to encourage improved pain management over 4 weeks (Type IV intervention). Although staff demonstrated improved pain management behavior, there was no improvement in pain outcomes (Petyaeva et al., 2017). DCPs and staff in community based and long-term care environments specifically request additional training and the chance to be involved in the development of the training programs (Talbot & Brewer, 2016). Staff desire more practical learning methods and application, as well as training that is relevant to their daily work including real life situations and solutions (Bishop, 2014; Kolanowski, Van Haitsma, Penrod, Hill, & Yevchak, 2015; Stanyon, Griffiths, Thomas, & Gordon, 2016; Talbot & Brewer, 2016). Training and Organizational Outcomes In a study of training requirements and outcomes, Trinkoff found that training for certified nursing assistants above the mandated federal requirement led to less adverse events, pain, falls with injury and depression. A strong association between the number of inservice hours and quality indicators suggested a link between ongoing training and quality of care (Trinkoff, Storr, Lerner, Yang, & Han, 2016). There is a need to make training relevant and accessible for DCPs and all staff, in all long-term care environments. Additional research is needed to evaluate organizational strategies that support and engage DCPs in training, orientation, and education, as well as determine the impact of training on staff stress, satisfaction, and retention, and effect on persons with dementia. Compensation The “monetary needs” of nursing assistants working in long-term care settings for older people with dementia was identified in qualitative work as an important reason to work in long-term care (Sung, Chang, & Tsai, 2005). This finding is consistent with early studies (Garland, Oyabu, & Gipson, 1988; Monahan & McCarthy, 1992). Compensation in wages, the provision and payment of health insurance is a concern for DCPs in regard to satisfaction, recruitment, and retention in all sectors of long-term care (Howes, 2008; Kemper et al., 2008; Paraprofessional Healthcare Institute, 2013; Probst, Baek, & Laditka, 2010). However, Squires and colleagues (2015) found in a systematic review that organizational factors such as workload, resources, and individual factors such as autonomy and empowerment to be greater predictors of job satisfaction than satisfaction with salary/benefits. Meaningful work was more important than hourly wages with intent to leave for residential DCPs (Gao et al., 2015). Stone and colleagues (2017) found that intent to leave for home care workers was dependent upon the overall household income level over the federal poverty level and the provision of health insurance though hourly wages were not. Thus, though compensation is important, it is only one of the expressed needs of DCPs across settings (Stone et al., 2017). Supportive Work Environment Many challenges exist for DCPs in the provision of care to persons with dementia while at the same time meeting the many expectations and demands of families (Coates & Fossey, 2016; Zimmerman et al., 2005). DCPs have reported that the work environment influences their experience as well as those of the residents in long-term care residences. A national survey conducted in the Netherlands found that person-centered care is beneficial to the nursing staff, specifically when the nursing staff feel supported by their supervisor (Willemse et al., 2015). Qualitative reports indicate that efforts to provide individualized care are supported by supervisors who provide hands-on help working with residents, are open to new ideas, and policies that promote an inclusive approach to care planning (Cohen-Mansfield & Bester, 2006; Curry et al., 2000). Further, phenomenological research conducted by Law, Patterson, and Muers (2017b) suggests the need for supervisors to support strong and supportive relationships between health care assistants and residents. They suggest opportunities for staff to explore their emotional reactions through reflective practice groups or clinical supervision in order to reduce any adverse impact on care provision (Law et al., 2017b). This recommendation is corroborated by earlier work conducted by Edvardsson, Sandman, Nay, and Karlsson (2009) with nursing staff in residential dementia care. The researchers identified that in addition to staff age and educational level, perception of the caring environment and opportunity to have discussions of difficulties and ethics at work were salient predictors of job strain (Edvardsson et al., 2009). Career Growth and Retention In an integrative analysis of reports, articles, and website information on the labor market for dementia care, researchers found that the main reason for quitting a care job was lack of job satisfaction. Dementia care workers describe a lack of appreciation and dissatisfaction about the quality of care they were able to provide as the major sources of job dissatisfaction (Vernooij-Dasssen et al., 2009). In contrast, a mixed method study with Australian nurses in acute, subacute, community, and residential health care settings reported reasonable satisfaction (Chenoweth, Merlyn, Jeon, Tait, & Duffield, 2014). Nurses who felt valued and supported by the organization and their colleagues were more positive about their work. Perceived facilitators of job satisfaction were education, training, supervision, mentoring opportunities, and appropriate compensation. There is also evidence that management practices used to empower certified nurse assistants (CNAs) and nurses can increase retention and improve resident outcomes (Brannon & Mor, 2005). LEAP (“Learn,” “Empower,” “Achieve,” “Produce”), a comprehensive long-term care workforce development initiative, aims to educate, empower, and retain long-term care nurses and CNAs (Hollinger-Smith & Ortigara, 2004). LEAP consists of two modules. One module is a 6-week (18 h total) workshop targeting nurse managers and charge nurses to develop essential roles of leader, care role model, clinical expert, and care team builder. The second module is a 7-week (14 h total) workshop focused on career development for CNAs. LEAP demonstrated increases in leadership effectiveness, work empowerment, job satisfaction, and perceptions of the organizational climate. Improvements in quality indicators, reduced number of health deficiencies, and decreased nurse and CNA turnover were also reported (Hollinger-Smith & Ortigara, 2004). In anticipation of a pending workforce shortage to care for an aging population, human resource experts recommend traditional practices to recruit and retain quality staff, including benefits packages, reward and recognition, and flexible scheduling (Jarousse, 2011). Additionally, they recommend behavior-based interviewing and peer interviewing to build effective, long-term teams. Sung and colleagues (2005) recommend the use of a screening process to assess job motivation and attitudes toward persons with dementia. Researchers at the Indiana University Center for Aging Research have developed an innovative method of screening for critical abilities expected in the frontline care provider position, the Care Coordinator Assistant (Cottingham et al., 2014). They created a new screening process, building on the multiple mini interview (MMI) format to evaluate the ability to express “caring” and empathy. The Care Coordinator Assistant MMI is comprised of six stations that simulate frequently encountered, challenging scenarios in persons with dementia. The interviewer then evaluates the candidate’s responses and abilities. Overall, the six-station MMI, with two to three items per station, provided factorial valid measures and good predictive ability. Additionally, the interviewers reported that the process was not burdensome and was helpful in discriminating between candidates (Cottingham et al., 2014). Orientation to include dementia education before a new employee is assigned to provide care for a person with dementia enhances their understanding of the disease and improves their ability to provide care and interact in a more appropriate fashion (Talbot & Brewer, 2016). Additional topics recommended at orientation include person-centered dementia care, behavioral strategies, alternatives to medication, abuse and neglect, and safety (Alzheimer’s Association, 2017c). Providing dementia training in an orientation has been found to benefit not only the organization, but indicates to the new employee that the organization recognizes their importance, and has proven beneficial to staff retention (Gao et al., 2015; Gilster, 2006; National Nursing Home Quality Improvement Campaign, 2016). Engagement With Family Effective partnership with families is recognized as an integral role in the care of persons with dementia (Robison et al., 2007). Hennings, Froggatt, and Keady (2010) conducted a systematic review of families’ experiences with end of life care in care homes. They found that families wanted frequent contact, empathy, reassurance, and engagement in decision-making with support along the way. Graneheim, Johansson, and Lindgren (2014) examined families’ experiences of transition into long-term care through a meta-ethnographic study incorporating a systematic literature search. Families wanted staff to show genuine concern for them and their family member, to consider the family member’s views, and facilitate family’s ability to influence the plan and delivery of care (Graneheim et al., 2014). Law, Patterson, and Muers (2017a) extended this line of inquiry with a systematic review that identified that families want consistent, knowledgeable staff who interact well with both them and the person with dementia. The authors conclude that staff education should focus not only on the clinical and practical needs of persons with dementia but also how to interact and partner with families (Law et al., 2017a). Robison and colleagues (2007) studied an intervention to improve staff and family communication in nursing home dementia units, and found that the program Partners in Caregiving was an effective method to increase support to staff, families, and residents. Many families of persons with dementia enjoy participating in the provision of information such as life stories to encourage DCP’s ability to recognize and value the person with dementia (Grøndahl, Persenius, Bååth, & Helgesen, 2017). Documenting, sharing life stories can be an opportunity to engage residents, families, and staff and particularly important in caring for persons with dementia who have lost their ability to share such information and communicate their needs and desires. Life stories is a way to offer staff insight into the world of the person with dementia before the disease and can enhance the DCPs and staff’s ability to connect, interact, and create improved strategies for caregiving. Grøndahl found in a systematic review that creating life stories, recording and sharing aspects of a person’s past and present life and using that information for planning and providing care was beneficial for the person with dementia, the family, DCPs, and staff. Staff attitude towards persons with dementia improved and the process of creating life stories was enjoyable and enhanced their relationship with the person with dementia. However, in one study the staff perceptions did not improve significantly (Grøndahl et al., 2017). Supportive relationships may be enhanced through the use of consistent assignments, a model supported by many national organizations including Advancing Excellence, The American Health Care Association and Leading Age (National Nursing Home Quality Improvement Campaign, 2016). Consistent assignments are offered as a method to enhance close personal relationships and quality of life, as DCPs come to know the person not simply as an “assignment,” but as an individual with a unique life and history (Corazzani et al., 2015; Roberts, Nolet, & Bowers, 2015). Further, Castle found that consistent assignments have been found to decrease staff turnover in residential care environments (Castle, 2011), while Stone and colleagues (2017) determined that consistent assignments in home care workers increased job satisfaction and was associated with a lower intent to leave (Stone et al., 2017). Additional Considerations to Improve Quality Dementia Care Workforce DCPs are the foundation of long-term care, as they provide the “service” in nursing homes, assisted/residential care, home care and hospice. Yet the industry struggles to create environments that address their needs and desires. Turnover is high in all positions and extremely costly to all organizations. Monetary compensation and benefits, while important, are not the only answer (Stone et al., 2017). It is more than just a job; for many it is a calling (Pfefferle & Weinberg, 2008). Need for Continued Research in Leadership The leader and the culture of an organization play a dominant role and significantly impact the quality of dementia care and quality of life for the people who live and work in long-term care settings (Stanyon et al., 2016). Leaders set the tone, establish the culture of the organization and influence success or failure (Siegel, Bakerjian, & Zysberg, 2017). Requirements and training for leaders, often referred to as administrators, executive directors, directors, etc., vary by setting and location for nursing homes, residential care, assisted living, home care, and hospice care. For instance, nursing home administrators and administrators in RC/AL are subject to state licensure, certification, training requirements, and continuing education although the amount and scope vary widely by state. Only 21 states require the RC/AL administrator to be licensed or certified and the required annual hours of continued education ranges from no requirement to 40 h (Carder, 2017). As of 2018, the administrators of home health agencies with certificates of participation for Medicare and Medicaid are required to be a licensed physician, a registered nurse or have an undergraduate degree with experience in health administration coupled with at least 1 year of administrative or supervisory experience (Centers for Medicare and Medicaid, 2017a). A culture supporting quality person-centered dementia care requires stable, dedicated leadership, and workforce (Koren, 2010). Nursing home administrator turnover is common and ranges from 41% to 45%. A high rate of administrator turnover is associated with high numbers of deficiencies (Geletta & Sparks, 2013) increased DCPs turnover (Castle, 2005) and the quality of care (Castle, 2001; Geletta & Sparks, 2013; Stolee et al., 2005). The importance of this single person and their effectiveness in long-term care settings has not received a great deal of attention (Dana & Olson, 2007; Donoghue & Castle, 2009). There is a need for continued research in leadership in long-term care settings to determine reasons for leader turnover and what may need to be done to prepare leaders for the future to improve DCP and staff competencies (Singh & Schwab, 2000). Need for Systems to Collect and Disseminate Person-Centered Information Care providers and staff want life history information to enable them to respond to the “individual” with dementia and to establish approaches to care and behaviors (Grøndahl et al., 2017). However, barriers to providing quality person-centered dementia care include the inability for DCPs and staff to secure information about the person with dementia, mechanisms for communicating that information to colleagues and the time to do so. Currently, much of this information is communicated verbally, and often the staff lack the time for communicating this information (Kolanowski et al., 2015). Systems need to be created that support a communication process to facilitate the exchange of this person-centered information to DCPs and staff and to share changes in the person with dementia as they occur over time. An expectation within the CMS Dementia Focused Survey Guide is the gathering and dissemination of person-centered care information to DCPs and staff (Centers for Medicare and Medicaid Services, 2015). Encouraging Communication and Interdepartmental Teamwork Interdepartmental meetings that engage staff in all departments have been shown to enhance a sense of team and community, an open mindedness and support for one another regardless of their role (Guzman et al., 2017a). Graf found the strongest predictors of job satisfaction and overall quality of care were collaboration with nursing home director, director of nursing, colleagues and staff resource adequacy (Graf et al., 2016). Coates found usefulness in proving opportunities to reflect with colleagues to promote thought and problem solving, encourage all to look at solutions through the eyes of another person or the person with dementia (Coates & Fossey, 2016). The ability of an organization to enhance interdisciplinary staff participation and interdepartmental collaboration can be accomplished through routinely scheduled all-inclusive staff meetings and in-service programs (Smythe, Jenkins, Galant-Miecznikowska, & Bentham, 2017). Offering meetings and inservices on all shifts for all departments provides an opportunity for all staff to attend, enhances communication, participation, and relationships between departments (Gilster, 2005). Ongoing Evaluation of Programs To ensure a quality care dementia workforce and environment requires an ongoing process to measure continuous quality improvement (Koren, 2010). Quality care, assessment and evaluation programs, processes, and systems continues to challenge the industry (Mills et al., 2017). The most recent initiative to improve quality care is the Quality Assurance and Performance improvement plan (QAPI) is effective November of 2018. QAPI expands the process of quality assurance to put practices in place to improve care and services. Elements of the process serve to include and engage all stakeholders in the program, create a learning organization, leadership role in ensuring stakeholder input and involvement and creating a systematic approach to determine problems, causes, appropriate interventions, and data driven decisions (Center for Medicare and Medicaid Services, 2017b). The implementation of QAPI may very well augment some of the other areas that DCPs and staff have indicated they desire in their work; including a focus on education, involvement in the decision process, the availability of information, team work, a learning environment, and collaboration. Conclusion Training has received considerable attention as the unique characteristics of dementia and resulting behaviors need to be understood by those who provide care. While the quality and quantity of training programs has been examined, more needs to be done to determine how to maintain knowledge and practice over time and how to garner leadership and management support for training programs. Critical to person-centered dementia care is “knowing the person,” the human being, father, golfer, mother, bank president, university professor, and researcher. The use of life history or stories may influence the ability of staff to see the whole person, as a human being with a rich history and life versus an individual with dementia who is difficult to care for and time consuming. However, systems and processes need to be in place to not only secure the information but to develop mechanisms to share and make accessible the information with all DCPs and staff. Professionals and nonprofessional groups in varied environments such as nursing homes versus home care and in other countries present different job needs and desires (Banaszak-Hall et al., 2015). They also fall under varied regulations internationally, nationally, and by state. It is important to note that while organizations may not be required and/or staff are not asking for dementia specific programs as recommended in this article, such programs may still be beneficial. Training, respect and appreciation, communication, participation in decision making, support programs, teamwork and caring, and engaged leadership have all been cited individually as desires, and such programs may prove important for all long-term care settings to promote a quality dementia care workforce. Research on a combination of programs that address these issues may be beneficial. Increasing numbers of people living with dementia and decreasing resources makes it essential to determine what motivates DCPs to work across the long-term care spectrum and what programs are necessary to retain them. Organizations need to address the desires of DCPs and outcomes of research to promote best practice. Creating a competent dementia care workforce is clearly complex and requires a deep inquiry into the multiple needs and desires of DCPs and staff. There will likely not be one program or strategy that solves the workforce issue. Practice Recommendations for Staffing Provide a thorough orientation and training program for new staff, as well as ongoing training A comprehensive orientation should be provided that includes the organization’s vision, mission, and values, high performance expectations, and person-centered dementia training. This training is essential for new staff, and should be included in ongoing education for all staff members. Develop systems for collecting and disseminating person-centered information It is important that all staff know the person living with dementia as an individual. Establish procedures for collecting person-centered information that includes choices, preferences and life history. It is also essential that an effective process be developed to share this information with all staff. Encourage communication, teamwork, and interdepartmental/interdisciplinary collaboration An organization should promote staff participation and interdepartmental/interdisciplinary collaboration through routinely scheduled inservice programs and meetings. Training is most effective when designed to include ongoing education, communication, and support. Offering inservices and conducting meetings on all shifts are important, and will impact attendance, participation, and facilitate relationships between staff. Establish an involved, caring, and supportive leadership team Creating a person-centered “community” is not possible without service-oriented leaders, managers, and supervisors. It is also vital that the leadership team be vision-driven, open, and flexible. High performing leaders know that staff are the foundation of success, and when staff are valued, recognized, and feel served themselves, they in turn will more likely value and serve others. Promote and encourage resident, staff, and family relationships Encouraging relationships among persons living with dementia, staff, and families is central to person-centered care, and is fostered in part by implementing consistent staff assignment. The involvement of all parties in planning care, activities, education, and social events may cultivate successful relationships as well. Evaluate systems and progress routinely for continuous improvement It is important that an organization routinely collect and evaluate information on all staff processes, including hiring, orientation, training, and satisfaction. Analysis of the data should be used to evaluate the effectiveness of all systems and identify areas for improvement. In addition, leaders should share this information with staff, and act upon the results. Funding This paper was published as part of a supplement sponsored and funded by the Alzheimer’s Association. References Alzheimer’s Association. 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