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Past Projects

The Role of Social Relationships in the Job Satisfaction and Retention of Direct-Care Staff in Assisted Living

Principal Investigator: Mary M. Ball, Ph.D.
National Institute on Aging, 2003 - 2004 ($72,750)

Paraprofessional workers who provide hands-on care to elderly and disabled people in a variety of long-term care settings have been called the centerpiece of the formal long-term care system (Stone, 2001). A serious shortage of direct-care staff exists in nursing homes and residential care settings, and demographic changes over the coming decades are expected to worsen this crisis. Low staff retention and high turnover rates, also major problems throughout the long-term care system, contribute to staff shortages and disrupt continuity of care, both of which directly affect resident care and residents’ overall quality of life. Staff shortages and high turnover also lead to increased workloads and disrupted relationships of staff and increase provider costs related to recruitment and training of new staff, overtime pay, and use of temporary staff. (GAO, 2001)

Although few studies have addressed the development and maintenance of a qualified paraprofessional workforce, particularly in residential settings such as assisted living (Hawes & Stone, 2001), research in nursing homes does provide some evidence that social support from residents and co-workers affects satisfaction and turnover of direct-care workers.

The specific aims of the proposed study are: 1) to understand how social relationships in the work place affect the overall work experience of direct-care staff in assisted living; 2) to identify individual, sociocultural, and environmental factors that influence the development and maintenance of these relationships.

Qualitative methods will be used to study two assisted living facilities in the metro Atlanta area. The proposed research sites are a 31-bed non-profit facility and a 90-bed for-profit facility with a special care dementia unit. Data collection will extend over a six month period and will consist of in-depth interviews, informal interviewing, and participant observation. In-depth interviews will be conducted with approximately 40 direct-care staff and with two administrators (the person responsible for management of care staff in each home). Care staff will be selected purposively to represent variation in personal characteristics (race and age), length of employment, shift, full- and part-time status, and job content (assisted living vs. special care unit). Observations and informal interviewing of care staff will take place during bi-weekly visits to each home over the 6-month data collection period. All in-depth interviews will be tape-recorded and transcribed. Data will be analyzed using a grounded theory approach (Strauss & Corbin, 1990).


Caregiver Demonstration Project

Principal Investigator: Molly M. Perkins, Ph.D.
Georgia Department of Human Resources, 2002 - 2003 ($23,630)
The Georgia Division of Aging Services has contracted with the Gerontology Institute to evaluate Georgia’s Caregiver Self-Directed Care Project, a voucher program funded by the National Family Caregiver Support Program. Dr. Molly Perkins, project director, and GRAs Michael Lepore, Keisha Jackson, and Ramani Sambhara are in the process of data collection.


Family Relationships Among Aging Asian Immigrants: The Role of Chinese and Korean Elders in Family Stability and Quality of Life

Principal Investigator: Frank Whittington, Ph.D.
Senior Connections, Inc., 2002 - 2003 ($21,700)

A research team from the Georgia State University Sociology Department and the Gerontology Institute is working with Senior Connections, Inc., an aging services organization in DeKalb County, on a pilot study of the role of elders in childcare, acculturation, and transmission of cultural values in Chinese and Korean immigrant families. The team, consisting of Jung Ha Kim, Jenny Zhan, Sharon King, Frank Whittington, and Gehui Zhang has conducted focus groups with older adults at community centers which serve Chinese and Korean families and now are analyzing data and planning a larger follow-up study with Chinese immigrant elders.


Religion and Health in Multigenerational Black Families

Principal Investigator: Sharon V. King, Ph.D.
National Institute on Aging, 2002 - 2003 ($71,500)

The overall goal of this study is to conduct an interdisciplinary examination of religion, health, and aging in multigenerational African American families and to help create a theoretical framework, which could be used to develop culturally relevant interventions that can contribute to the reduction of health disparities in this population.

Despite indicators that show overall improvement in the nation’s health in the past decade, minorities, including older African Americans, continue to experience significant health disparities. The goal to eliminate health disparities among older African Americans would be advanced by a greater understanding of the cultural contexts of health, specifically the intersections of religion and health in African American family life–a setting in which elders historically have played an important role.

Little of the growing body of research on religion and health addresses this topic in an African American context. Similarly, the family literature on multigenerational households lacks studies that focus on health in African American families or the role of African American elders in cross-generational transmission of religion and health values.

The specific aims for the proposed study are: 1) to understand the social construction of attitudes toward religion and health in multigenerational African American families, 2) to compare, across generations, religious beliefs and health attitudes in these families, 3) to examine the role of African American elders in the cross-generational transmission of religion and health values; and 4) to identify the relationship between religion and health attitudes in these families and health care practice and utilization.


Independence and Autonomy of Elders in Assisted Living

Principal Investigator: Frank Whittington, Ph.D.
National Institute on Aging, 2000 - 2002 ($469,557)

The specific aims of this study were: 1) to gain understanding how independence and autonomy are socially constructed and perceived in the assisted living environment; 2) to gain understanding of how individual, socio-cultural, and environmental factors influence the meanings of, and opportunities for, independence and autonomy in assisted living facilities; 3) to identify strategies of residents, providers, and family members that enable residents to optimize independence and autonomy in the ALF environment; 4) to gain understanding of how individual, socio-cultural, and environmental factors influence strategies of residents, providers, and family members to support independence and autonomy in ALFs; 5) to identify the social and individual barriers to residents’ independence and autonomy in ALFs; and 6) to identify the physical environmental barriers to residents’ independence and autonomy in ALFs.

The sample of five assisted living facilities in and around metro Atlanta was selected to represent maximum variation in size, type, and location of facility and ethnicity and socioeconomic status of residents to include: 1) two urban congregate homes serving moderate-to-high-income residents, one with around 70 mostly Caucasian residents and one with around 50 mostly African American residents; 2) one congregate home in a small-town setting with a mixture of approximately 36 African American and Caucasian residents with low-to-moderate incomes; and 3) two family model homes (4-6 residents), one in a rural area with Caucasian residents, and one in a small town with Caucasian and African American residents.

Qualitative methodology was employed to identify and describe the intensity and range of daily experiences, activities, decisions, perceptions, and formal and informal interactions as they occurred with assisted living facilities. The primary methods of data collection were participant observation, intensive interviewing of residents, their families and friends, and staff, inventory of the environment, and review of resident and facility records and marketing materials. Data were analyzed using the grounded theory method.


Maximizing Independence of Frail African American Elders in Assisted Living Facilities

Principal Investigator: Mary M. Ball, Ph.D.
AARP Andrus Foundation, 1999 - 2000 ($99,986)

Maximizing independence and autonomy—to the degree possible—remains central to the quality of life of older persons with disabling chronic conditions, even those who live in long-term care facilities. Assisted living facilities (ALFs) are non-medical, community-based living environments that provide shelter, board, and 24-hour protective oversight and personal care services to mostly elderly residents. The limited research in ALFs suggests that greater emphasis is placed on resident autonomy in these environments than in nursing homes and that residents have greater opportunity for control and choice. We know, however, very little about the ability of residents of ALFs to realize independence and autonomy or about the impact of face and economic status on these outcomes. This study provides the first comprehensive, in-depth, longitudinal view of life for African Americans in the assisted living setting.

More specifically the study aimed to identify: the dimensions of independence and autonomy most important to African American residents; the strategies that enabled these residents to optimize independence and autonomy; and the barriers that limited and the supports that enhanced independence and autonomy in the AL environment.

Qualitative research was used to study five African-American owned and operated ALFs: three family-model homes (capacity 6 residents) and two group model homes (capacity 13 residents). Fifty-eight residents and 33 providers participated in the study. Most residents were low-income and African American. The primary data gathering techniques were participant observation, informal and in-depth interviewing, and record review. The data gathering period ranged from 12-17 months, with researchers visiting each of the five homes approximately weekly for a total of 272 visits. Twenty-six in-depth interviews were conducted with residents, 23 with providers, and 15 with family members.

Consistent with other research in AL we found that these African American assisted living residents retained a strong value for independence, and their well-being was greatly enhanced by remaining as independent as possible. Although most no longer were able to be independent in a broad sense of the concept, many were able to achieve some degree of independence. Almost half of the residents (44%) needed no assistance with activities of daily living, and many others were able to carry out these routine tasks with minimal help from providers. Most viewed independence primarily in relation to their abilities to carry out routine self-care activities without assistance. Residents also expressed a strong commitment to the value of autonomy. They wanted, and most still were able, to make decisions and choices in their everyday lives. Residents wanted choices that were meaningful to them as individuals and were consistent with past choices and identities. Race and culture were significant determinants of these particular choices.

We found that residents developed a variety of strategies to increase both their independence and autonomy. We found also that most providers supported residents’ efforts to retain their self-care abilities and have control and choice in their daily lives. Both residents and providers, however, encountered significant barriers to the maximal exercise of resident self-care, choice, and control. These included: degree of resident impairment; lack of provider understanding of the importance of self-care and choice; family support; diversity of residents; non-supportive environment; and lack of community support. In all of these African American homes, the effect of the limited financial resources of providers, residents, and residents’ families was far-reaching and intensified the influence of these barriers.


Prevention of Depression, Anxiety, and Medication Problems in Personal Care Homes

Principal Investigator: Frank J. Whittington, Ph.D.
GRN Regional Board for Mental Health, Mental Retardation, and Substance Abuse, 1999 – 2001 ($102,000)
This two-year multidisciplinary team intervention project aimed to improve quality of personal care home residents’ lives in areas of independent physical functioning, direct personal care, nutrition, medication practices, social relationships, and activities. The intervention, carried out in 4 personal care homes (2 target homes and 2 control homes) in the Atlanta area was designed and evaluated by an intervention team comprised of 4 sociologists, a social worker, a nutritionist, a physical therapist, a psychologist and a clinical geriatric pharmacist.

In year 1 of the project, the team designed both the intervention and methods of evaluation in a 70-bed test facility. In the second year, 2 experimental homes (26 and 70 beds) and 2 control homes, matched for size, were selected for study. Pre-test data were collected on residents’ physical function, nutrition status, medication regimens, psychological states, and social relationships. Then an intervention consisting of an exercise program, nutritional assessment and counseling, medication review, social activities, staff training, and a family support group, was implemented, involving residents, staff, and family members. After 6 months, the intervention was concluded and post-test measures were repeated in both experimental and control homes. Prevention was taken to mean reduction in the overall level of depression, anxiety, and medication problems in the facilities.

Results show that, though improvement in target measures (depression, anxiety, medication problems) in the intervention homes was limited, it did occur and no negative changes were noted in those facilities. Moreover, some of those measures in the control homes tended to decline over the study period. Although most residents and staff expressed general satisfaction with life in these facilities, specific findings in each of the target areas (physical function, nutrition, social activities, staff care, family satisfaction, and medication use) suggest many areas for improvement and 11 specific recommendations are made.

We conclude that intervention to prevent mental health and medication problems in assisted living facilities is needed, and general response of residents, staff, and family members to such an intervention is favorable. Much more work is needed, however, to determine “best practices” for this population and better ways to secure acceptance of new ways of caring for residents.

Based on our experiences in implementing this intervention and the results of our evaluation of its effectiveness, we are prepared to offer the following recommendations for how owners, administrators, staff, residents, and family members of residents of assisted living facilities can improve their ability to prevent mental health and medication problems of residents and improve the quality of life of all participants, residents, staff, and families.

Exercise programs can significantly improve assisted living residents’ physical function, even when of limited duration. Given the frailty of this population and mobility and memory deficits, instructor-led, chair exercise program would probably work best but should be regular and continuous.

Room and common space safety evaluations regularly should be done by a qualified person to identify hazards in order to prevent falls.

A nutritional assessment instrument specifically designed for assisted living residents should be used by administrators and food service staff to identify nutritional problems on intake and at least every six months thereafter.

Given their inadequate nutritional intakes, all assisted living residents should take a multi-vitamin/mineral supplement formulated for seniors.

Physicians should review and update their dietary prescriptions for all residents of assisted living facilities, especially those with diabetes and hypertension.

Staff training that focuses on residents’ needs, especially their social and emotional needs (e.g., communication, self-esteem, choice and control) is needed continuously to reinforce a facility policy to encourage independence and autonomy.

Staff should be encouraged to communicate their concerns about resident care and their own working conditions directly to management.

All assisted living facilities should make social activities a regular part of every day. Activities can be inexpensive and led by a staff member but should be guided by resident preferences.

All facilities should regularly monitor their residents for mental health problems, such as depression and anxiety, and seek immediate care for residents who are suspected of having these problems from a qualified mental health professional (i.e., a psychiatrist, psychologist, or professional counselor).

Family support groups would be worthwhile for the few families who would participate, but they would need the support and assistance of management in order to be viable.

Regular medication reviews by a senior care pharmacist are strongly indicated to prevent over-medication, adverse drug events, unnecessary emergency room visits and hospitalizations.

Administrators should work closely with physicians and family members to educate them and seek their support for these reviews and the implementation of their recommendations.