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Evidence Base for the Future of Nursing Homes: Special Issue

Christine e bishop.

Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, , USA

Howard B Degenholtz

Department of Health Policy and Management, Graduate School of Public Health, Center for Bioethics and Health Law, University of Pittsburgh, Pittsburgh, Pennsylvania, USA

After decades of exposés, special commissions, and advocacy, the moment has arrived to commit to making the residential nursing home a good place to live ( National Academies of Sciences, Engineering, and Medicine, 2022 ). The modern American nursing home, an unexpected creature of the Medicaid and Medicare programs, has evolved to provide neither a comfortable, functional “home” nor reliably excellent “nursing” ( Grabowski, 2022 ). The COVID-19 pandemic has amplified the impact of nursing home shortcomings with respect to safety, clinical quality, racial and ethnic disparities in care, mental health, and resident well-being. The horrendous death toll for nursing home residents and staff, 15.4% of U.S. deaths by April 2022 ( Centers for Disease Control and Prevention, 2022 ; Centers for Medicare and Medicaid Services, 2022 ), has shocked the nation, as have reports of devastating resident isolation and staff despair.

Sadly, these shortfalls come as no surprise to researchers, advocates, and policy makers who have been grappling with them for decades ( Fashaw et al., 2020 ; Harrington et al., 2019 ; Hawes et al., 1997 ; White House, 2022 ; Wiener et al., 2007 ). But although previous research has uncovered what does not work in nursing homes, policy and practice have not been able to solve the problems of inconsistent clinical quality, disparities in care, high cost, and poor quality of life. Because these deficits seem so intractable and are sometimes seen as inherent in the nursing home setting itself, avoidance of the nursing home has become the main strategy of policy makers and consumers alike: in partnership with Centers for Medicare and Medicaid Services, state Medicaid programs have worked diligently to “rebalance” toward community living and away from residential long-term services and supports ( Bernacet et al., 2021 ; Eiken et al., 2018 ; Kaye & Harrington, 2015 ), and consumers express strong preferences for care in community settings rather than in a nursing home should they become disabled. In a recent survey conducted by AARP, only 2% of people age 50 and older would prefer to receive care in a nursing home ( Harrell et al., 2014 ; see Kasper et al., 2019 ).

Unfortunately, community living is not optimal for everyone. Given the current state of housing inequity, uncertain capacity of family carers, and home care workforce instability, some individuals with substantial functional limitations are likely to find that a nursing home, or a setting that has many nursing-home-like features, is their best choice ( Bishop & Stone, 2014 ). By shining a spotlight on nursing homes, the pandemic compels us to ask: If we can see what is wrong with nursing homes and accept that we will need nursing-intensive residential services for the foreseeable future, what should be done? The time for simply exposing quality and access problems is long past. Families, payers, and governments must act to make good nursing home care available to those who need it.

This Special Issue of Innovation in Aging seizes this pivotal moment. It showcases empirical research for an evidence base to make the nursing home care of the future a preferred setting for older adults with functional deficits. The articles contribute to an agenda for policy and practice to improve the quality of nursing home care. Quality in the nursing home setting is multidimensional, and the articles address quality in several ways. Three articles ( Bowblis, 2022 ; Kishida, 2022 ; Sharma & Xu, 2022 ) focus on adequacy and stability of staffing, a basic requirement for structural quality. Another group ( Carnahan et al., 2022 ; Cross & Adler-Milstein, 2022 ; Davitt & Brown, 2022 ; Hass et al., 2022 ; Ninteau & Bishop, 2022 ) discuss aspects of clinical care that should be targets for improvement and regulation. And a third group ( Grabowski, 2022 ; Morris et al., 2022 ; Shippee et al., 2022 ) take us beyond what is currently measured and regulated to investigate factors affecting meaning and quality of life for nursing home residents.

Managing and Regulating to Support a Stable Nursing Staff

When nursing staff leave or when nursing hours are insufficient, quality suffers. Articles by Kishida, Sharma, and Bowblis and their colleagues provide insights into these issues.

When certified nursing assistants or licensed nurses leave nursing home jobs for positions elsewhere, valuable facility- and resident-specific knowledge is lost. Although nursing homes face the cost of hiring and training replacement workers, the nursing home sector has been living with staff turnover for many years, blaming Medicaid payment constraints for wages that are too low to stem turnover. Both Kishida (2022) and Sharma and Xu (2022) investigate the association of wages, training, and other factors with nursing staff turnover, using data from Japan and Iowa. The Japanese study reports in passing an intriguing policy intervention: bonus payments to nursing homes to be spent directly on training and pay increases. Although low wages are important in retaining direct care workers, both studies find that other unmeasured factors also affect intent to leave. Kishida distinguishes between quitting to take a job in another human services setting and leaving the sector altogether. In the current American labor market, with so many open jobs throughout competing industries, policies to make direct care work more attractive are more important than ever.

The work of the nursing staff becomes next to impossible and quality of care plummets when available staff hours cannot meet resident needs due to turnover, worker shortages, or chronic understaffing. Although a standard for nursing staff adequacy has never been set by regulators, researchers have built up alternative staffing standards from hours of care associated with various resident need characteristics, and the current administration appears ready to codify such a standard ( White House, 2022 ). The article by Bowblis (2022) points out that the majority of U.S. nursing homes staff below and even well below one likely case mix-based staffing standard, and that bringing all nursing homes up to this hypothetical standard would have immense cost, even at current low wage rates.

Improving Clinical Quality

Beyond the fundamental pressure to assure adequate staffing, some initiatives to sustain nursing home clinical quality look to alignment of ownership incentives with public policy goals, whereas others recommend investments to improve care. Aspects of clinical care that can fall short for residents, including unnecessary hospital transfers, palliative care, and protective services interventions, may require additional infrastructure and new measures for accountability.

The article by Hass et al. (2022) considers the correlations between ownership change and clinical quality measures. Their findings support the growing movement for greater transparency in nursing home ownership. Policies that seek to use value-based payments to drive quality improvement will founder without clarity about how ownership structures can diffuse such incentives.

Residential nursing homes should not attempt to be mini-hospitals, but must still provide a medically safe living environment for residents with complex medical conditions. The article by Carnahan et al. (2022) addresses clinical quality provided at the interface between the nursing home and the hospital. By focusing on the specific issues that make a transfer either necessary or optional, their index potentially increases the probability that a nursing home resident will be treated in place without a disruptive transfer. The next step for this research could be to identify the resources needed to take care of ill nursing home residents in-house. A standardized approach to identifying avoidable hospitalizations has the potential to hold nursing homes accountable for better quality and reduced system cost.

Better information about resident medical care and better coordination across setting could improve clinical care in the nursing home. In an invited essay, Cross and Adler-Milstein (2022) note that nursing homes have been excluded from subsidies that fueled the digital revolution for hospitals and physician practices. Nevertheless, there is evidence that a successful digital transformation would yield substantial benefits in terms of quality of care. It is high time to invest in interoperable resident records, to provide the data needed for medical treatment and personal care whether in the nursing home, in a transfer setting, or after a nursing home stay. Although the value of information sharing may be clearest for Medicare post-acute services, age-friendly coordination of care for long-stay residents would also improve with more shared data.

Ninteau and Bishop (2022) look to pandemic experience to understand the supports nursing staff need in their efforts to relieve concerning symptoms for residents, whether on a day-to-day basis or as part of the dying process. Although attention to resident comfort and care goals is intrinsic to every-day nursing care for this high-need population, end of life care is especially crucial, as even during ordinary times 22% of deaths among people aged 65 and older occur in nursing homes ( Centers for Disease Control and Prevention National Center for Health Statistics, 2022 ). Greater attention to the resources needed for good palliative care, and accountability for its provision, would shore up an important dimension of nursing home quality.

Quality of care is especially challenging to assure for residents who need guardianship protection. When caseworkers could no longer visit clients due to pandemic restrictions, the state of Maryland developed an initiative to provide communication through technology. Davitt and Brown (2022) describe its implementation and use and note that individualized digital equipment could also foster communication and social engagement for residents not in need of state guardianship. This case study provides another example of innovation spurred by pandemic necessities that may have broader implications.

Advancing Equitable Access to Resident Quality of Life

The nursing home of the future must be resident centered, equitable, and focused on quality of life even as it meets clinical quality standards. Despite the expansion of the quality survey process to include resident voices, aspects of nursing home care that could support well-being and community engagement have not been sufficiently addressed by nursing homes, their funders, or their regulators. Articles in this Special Issue target the shortcomings of dementia care, inequities in quality of life, and the importance of resident autonomy.

Morris et al. (2022) jolt our thinking by labeling some aspects of current dementia care practices as iatrogenic. Their analysis exposes the violence to personhood inherent in the physical and psychological staff tactics meant to protect and contain reactive residents with cognitive impairments. The conceptual frame implies raising the standard for day-to-day care for the growing proportion of nursing home residents experiencing cognitive deficits. Moving forward, insights from this thoughtful article should inform nursing staff training and regulation alike.

A deeply informative mixed-methods pilot study by Shippee et al. (2022) focuses on quality of life for nursing home residents of color. The authors were able to contrast nursing homes with little disparity in quality of life with those where non-White residents experienced substantially lower quality of life. In-depth interview data from multiple stakeholders uncovered possible drivers of these differences. The good news is that in facilities with the greatest disparity between White and non-White residents, researchers could identify potentially modifiable processes apparently responsible for quality of life inequities. Training and diversifying leadership and staff, especially activities staff, could help, as might fostering engagement from a range of community organizations preferred by the residents. There are broader implications here: too little is known about how good quality of life can be monitored and supported for all nursing home residents, and how nursing homes can be held accountable for providing it.

Finally, David Grabowski’s invited essay ( 2022 ) considers the larger issues facing nursing home policy and follows on from Shippee et al. and others in this Special Issue by articulating an overarching goal for transforming nursing home care: residents are owed environments that are first and foremost resident centered. Grabowski’s summary article argues convincingly that performance can be linked to payment policy, concluding that policy makers should focus on reforms that improve both payment and accountability, with resident centeredness as the ultimate goal.

Conclusion and Next Steps

The body of research collected in this Special Issue suggests some solutions and future directions for policy makers, providers, and researchers. The articles open many new questions and creative concepts. We invite our readers to explore and be inspired to rededicate themselves to improving the quality of life and quality of care for people living in nursing homes.

Conflict of Interest

None declared.

Contributor Information

Christine E Bishop, Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, , USA.

Howard B Degenholtz, Department of Health Policy and Management, Graduate School of Public Health, Center for Bioethics and Health Law, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.

• Bernacet, A., Kordomenos, C., Karon, S., Knowles, M., Archibald, N., & Kruse, A. (2021). Examining the potential for additional rebalancing of long-term services and supports . https://www.macpac.gov/wp-content/uploads/2021/05/Examining-the-Potential-for-Additional-Rebalancing-of-Long-Term-Services-and-Supports.pdf [ Google Scholar ]
• Bishop, C. E., & Stone, R. (2014). Implications for policy: The nursing home as least restrictive setting . The Gerontologist , 54 ( Suppl. 1 ), S98–S103. doi: 10.1093/geront/gnt164 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Bowblis, J. R. (2022). The need for an economically feasible nursing home staffing regulation: Evaluating an acuity-based nursing staff benchmark . Innovation in Aging , 6 ( 4 ), igac017. doi: 10.1093/geroni/igac017 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Carnahan, J. L., Unroe, K. T., Evans, R., Klepfer, S., Stump, T. E., Monahan, P. O., & Torke, A. M. (2022). The avoidable transfer scale: A new tool for identifying potentially avoidable hospital transfers of nursing home residents . Innovation in Aging , 6 ( 4 ), igac017. doi: 10.1093/geroni/igac031 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Centers for Disease Control and Prevention. (2022). COVID data tracker . Department of Health and Human Services, CDC. Retrieved May 9, 2022 from https://covid.cdc.gov/covid-data-tracker/#trends_totaldeaths [ Google Scholar ]
• Centers for Disease Control and Prevention, National Center for Health Statistics. (2022). National vital statistics system, mortality 2018–2020 . CDC WONDER Online Database. Retrieved May 9, 2022 from http://wonder.cdc.gov/mcd-icd10-expanded.html [ Google Scholar ]
• Centers for Medicare & Medicaid Services. (2022). COVID-19 nursing home data . Department of Health and Human Services, CMS. Retrieved May 9, 2022 from https://data.cms.gov/covid-19/covid-19-nursing-home-data [ Google Scholar ]
• Cross, D. A., & Adler-Milstein, J. (2022). Progress toward digital transformation in an evolving post-acute landscape . Innovation in Aging , 6 ( 4 ), igac021. doi: 10.1093/geroni/igac021 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Davitt, J. K., & Brown, J. (2022). Using voice and touchscreen controlled smart speakers to protect vulnerable clients in long term care facilities . Innovation in Aging , 6 ( 4 ), igac024. doi: 10.1093/geroni/igac024 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Eiken, S., Sredl, K., Burwell, B., & Amos, A. (2018). Medicaid expenditures for long-term services and supports in FY 2016 . IBM Watson Health. https://www.medicaid.gov/sites/default/files/2019-12/ltssexpenditures2016.pdf [ Google Scholar ]
• Fashaw, S. A., Thomas, K. S., McCreedy, E., & Mor, V. (2020). Thirty-year trends in nursing home composition and quality since the passage of the Omnibus Reconciliation Act . Journal of the American Medical Directors Association , 21 ( 2 ), 233–239. doi: 10.1016/j.jamda.2019.07.004 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Grabowski, D. C. (2022). Putting the nursing and home in nursing homes . Innovation in Aging , 6 ( 4 ), igac029. doi: 10.1093/geroni/igac029 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Harrell, R., Lynott, J., Guzman, S., & Lampkin, C. (2014). What is livable? Community preferences of older adults . https://www.aarp.org/content/dam/aarp/research/public_policy_institute/liv_com/2014/what-is-livable-report-AARP-ppi-liv-com.pdf
• Harrington, C., Mollot, R., Edelman, T. S., Wells, J., & Valanejad, D. (2019). U.S. nursing home violations of international and domestic human rights standards . International Journal of Health Services , 50 ( 1 ), 62–72. doi: 10.1177/0020731419886196 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hass, Z., Abrahamson, K., & Arling, G. (2022). Ownership change and care quality: Lessons from Minnesota’s experience with value-based purchasing . Innovation in Aging , 6 ( 4 ), igac022. doi: 10.1093/geroni/igac022 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hawes, C., Mor, V., Phillips, C. D., Fries, B. E., Morris, J. N., Steele-Friedlob, E., Greene, A. M., & Nennstiel, M. (1997). The OBRA-87 nursing home regulations and implementation of the Resident Assessment Instrument: Effects on process quality . Journal of the American Geriatrics Society , 45 ( 8 ), 977–985. doi: 10.1111/j.1532-5415.1997.tb02970.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kasper, J. D., Wolff, J. L., & Skehan, M. (2019). Care arrangements of older adults: What they prefer, what they have, and implications for quality of life . The Gerontologist , 59 ( 5 ), 845–855. doi: 10.1093/geront/gny127 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kaye, H. S., & Harrington, C. (2015). Long-term services and supports in the community: Toward a research agenda . Disability and Health Journal , 8 ( 1 ), 3–8. doi: 10.1016/j.dhjo.2014.09.003 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kishida, K. (2022). The effects of wages and training on intent to switch or leave among direct care workers . Innovation in Aging , 6 ( 4 ), igac036. doi: 10.1093/geroni/igac036 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Morris, P., McCloskey, R., & Bulman, D. (2022). Iatrogenesis in the context of residential dementia care: A concept analysis . Innovation in Aging , 6 ( 4 ), igac028. doi: 10.1093/geroni/igac028 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• National Academies of Sciences, Engineering, and Medicine. (2022). The National imperative to improve nursing home quality: Honoring our commitment to residents, families, and staff . Washington, DC: The National Academies Press. doi: 10.17226/26526 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ninteau, K., & Bishop, C. E. (2022). Nursing home palliative care during the pandemic: Directions for the future . Innovation in Aging , 6(4), igac030. doi: 10.1093/geroni/igac030 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Sharma, H., & Xu, L. (2022). Association between wages and nursing staff turnover in Iowa nursing homes . Innovation in Aging , 6 ( 4 ), igac004. doi: 10.1093/geroni/igac004 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Shippee, T., Davila, H., Ng, W., Bowblis, J., Akosionu, O., Skarphol, T., Thao, M. S., Woodhouse, M., & Thorpe, R. J. (2022). Evidence to inform policy and practice: Mechanisms to address racial/ethnic disparities in nursing home quality of life . Innovation in Aging , 6 ( 4 ), igac037. doi: 10.1093/geroni/igac037 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• White House. (2022). Fact sheet: Protecting seniors by improving safety and quality of care in the nation’s nursing homes . https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/
• Wiener, J. M., Freiman, M. P., & Brown, D. (2007). Nursing home care quality: Twenty years after the Omnibus Budget Reconciliation Act of 1987 . http://www.kff.org/medicare/upload/7717.pdf

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Open Access

Peer-reviewed

Research Article

A qualitative assessment of factors affecting nursing home caregiving staff experiences during the COVID-19 pandemic

Roles Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America

Roles Formal analysis, Methodology, Project administration, Writing – original draft, Writing – review & editing

Roles Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing

Roles Formal analysis, Writing – review & editing

Roles Data curation, Formal analysis

Roles Conceptualization, Investigation, Writing – review & editing

Roles Conceptualization, Investigation, Supervision, Writing – review & editing

Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing

• Rachel L. Snyder, 
• Laura E. Anderson, 
• Katelyn A. White, 
• Stephanie Tavitian, 
• Lucy V. Fike, 
• Heather N. Jones, 
• Kara M. Jacobs-Slifka, 
• Nimalie D. Stone, 
• Ronda L. Sinkowitz-Cochran

• Published: November 15, 2021
• https://doi.org/10.1371/journal.pone.0260055
• Reader Comments

A large portion of COVID-19 cases and deaths in the United States have occurred in nursing homes; however, current literature including the frontline perspective of staff working in nursing homes is limited. The objective of this qualitative assessment was to better understand what individual and facility level factors may have contributed to the impact of COVID-19 on Certified Nursing Assistants (CNAs) and Environmental Services (EVS) staff working in nursing homes.

Based on a simple random sample from the National Healthcare Safety Network (NHSN), 7,520 facilities were emailed invitations requesting one CNA and/or one EVS staff member for participation in a voluntary focus group over Zoom. Facility characteristics were obtained via NHSN and publicly available sources; participant demographics were collected via SurveyMonkey during registration and polling during focus groups. Qualitative information was coded using NVIVO and Excel.

Throughout April 2021, 23 focus groups including 110 participants from 84 facilities were conducted homogenous by participant role. Staffing problems were a recurring theme reported. Participants often cited the toll the pandemic took on their emotional well-being, describing increased stress, responsibilities, and time needed to complete their jobs. The lack of consistent and systematic guidance resulting in frequently changing infection prevention protocols was also reported across focus groups.

Conclusions

Addressing concerns of low wages and lack of financial incentives may have the potential to attract and retain employees to help alleviate nursing home staff shortages. Additionally, access to mental health resources could help nursing home staff cope with the emotional burden of the COVID-19 pandemic. These frontline staff members provided invaluable insight and should be included in improvement efforts to support nursing homes recovering from the impact of COVID-19 as well as future pandemic planning.

Citation: Snyder RL, Anderson LE, White KA, Tavitian S, Fike LV, Jones HN, et al. (2021) A qualitative assessment of factors affecting nursing home caregiving staff experiences during the COVID-19 pandemic. PLoS ONE 16(11): e0260055. https://doi.org/10.1371/journal.pone.0260055

Editor: Anat Gesser-Edelsburg, University of Haifa, ISRAEL

Received: August 31, 2021; Accepted: October 30, 2021; Published: November 15, 2021

This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

Data Availability: De-identified qualitative transcripts are available only upon request noting the sensitive nature of the SARS-CoV-2 (COVID-19) response and the need to protect participants identities. Data requests should be fielded to CDC publishing coordinator: [email protected] .

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

A large portion of COVID-19 cases and deaths in the United States have occurred in nursing homes and other long-term care settings, with over 1.3 million confirmed cases and over 137,000 confirmed deaths among residents and staff as of September 12, 2021 [ 1 ]. During the pandemic, nursing homes have also experienced shortages of both personal protective equipment (PPE) and staff, potentially affecting their ability to safely provide care [ 2 ]. In addition to the risk of both contracting and spreading SARS-CoV-2, the virus causing COVID-19, the mental health of nursing home staff may also be affected by the pandemic, as several studies have illustrated symptoms of anxiety, depression, and post-traumatic stress in frontline healthcare personnel during the pandemic [ 3 – 5 ]. As staff are likely important contributors to the transmission of SARS-CoV-2 in nursing home settings [ 6 ], more knowledge is needed regarding the experiences of nursing home staff during the COVID-19 pandemic.

Despite their important role in both the care of residents and preventing spread of SARS-CoV-2, current literature that includes the frontline perspective of Certified Nursing Assistants (CNA) and Environmental Services (EVS) staff members (also referred to as housekeeping) working in nursing homes is limited. The objective of this qualitative assessment was to better understand what individual and facility-level factors may have contributed to the impact of the COVID-19 pandemic in nursing homes by examining the perceptions of CNAs and EVS staff regarding COVID-19 prevention efforts and self-reported behaviors and beliefs.

Four pilot focus groups were conducted with a total of 30 CNAs from Genesis Healthcare nursing home facilities from February 3–12, 2021. Pilot data were used to standardize discussion and polling questions and refine recruitment processes for the expanded focus groups. Data collected during the pilot are not included in this manuscript.

Recruitment

Facilities were selected based on a simple random sample of the 15,351 long-term care facilities actively reporting to the National Healthcare Safety Network (NHSN) as of March 23, 2021. NHSN Administrators from 7,520 facilities were emailed invitations requesting one CNA and/or one EVS staff member from each facility to voluntarily participate in a focus group.

Focus groups

Focus groups were conducted homogenous by participant role (CNAs separate from EVS) and were offered during weekdays and weekends, with morning, afternoon, and night sessions to accommodate differing shifts. On average, focus groups ranged in length from 35–50 minutes and varied in size from one to ten participants. To encourage open sharing, all responses provided by participants were confidential and no individual comments from focus groups were shared with supervisors or nursing homes where participants were employed.

Data sources

Facility characteristics were obtained via NHSN, the National Center for Health Statistics (NCHS) Urban-Rural Classification Scheme [ 7 ] and the Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI) [ 8 ] based on facility county. Chi-square tests were used to compare the distribution of selected variables (urban/rural facility location, SVI quartile, facility bed size quartile, and facility ownership) between participant facilities and the general population of nursing homes actively reporting into NHSN, with p values < 0.05 considered statistically significant. Analyses were conducted using SAS version 9.4 software (SAS Inc., Cary, NC, USA) for Windows. Individual participant demographics were obtained via a voluntary and anonymous SurveyMonkey during registration, as well as voluntary polling on the Zoom platform during the focus groups. As such, individual demographic data were not provided for all participants, and the demographics summaries may include data from individuals who registered but did not participate in the focus groups. Polling on the Zoom platform was also used to obtain voluntary responses to questions regarding perceived risk of getting COVID-19 in the facility (at the beginning of the pandemic and at the time of focus groups), greatest barrier/challenge to preventing COVID-19 in the facility (at the beginning of the pandemic and at the time of focus groups), and preferred channels of communication. The remaining information was obtained during open discussion with the use of a standardized script and questions guided by a trained facilitator regarding facility strengths and weaknesses, changes in job responsibilities, what the participants wish they had known at the start of the pandemic, what they are most worried/concerned about moving forward, and other topics specific to COVID-19. These data were qualitatively coded by question using an immersion and crystallization technique and summarized using NVIVO and Excel across a team of trained coders to ensure reliability [ 9 ]. No tests for statistical significance were performed among discussion responses or individual participant demographics.

All responses were provided voluntarily and, due to the open discussion format, not every participant provided a response to every question nor were they directly asked to do so during the focus groups. Percentages presented are calculated based on the total number of participants that provided a response to the individual question, not the total number of focus group participants. Participants’ responses were categorized to each individual code only once; however, responses may be categorized to more than one code. Therefore, percentages within a question may sum to over 100% and may not sum to the percentages for the broader convergent themes presented in text. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy (See e.g., 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. §241(d); 5 U.S.C. §552a; 44 U.S.C. §3501 et seq.). Participants provided verbal consent prior to the start of the focus groups. Per determination by the CDC’s National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) Human Subjects Advisor, this qualitative assessment does not meet the definition of research under 45 C.F.R. 46.102(l) and IRB review is not required. NCEZID’s determination holds that the project did not require submission to CDC’s Human Research Protection Office as granting authority is delegated to the CDC Centers, Institutes, and Offices under CDC Policies SSA-2010-01 and SSA-2010-02.

Demographics

Throughout April 2021, 23 focus groups were held including 110 participants from 84 nursing home facilities across 34 states. Twelve of the focus groups were held for CNAs (51 participants total) and 11 for EVS staff (59 participants total). Of the 84 participating nursing homes, 73% were located in urban areas and 51% were for-profit facilities ( Table 1 ). When a chi-square test was used to compare the distribution of selected variables between the 84 participant facilities and the general population of nursing homes actively reporting into NHSN, participant facilities had a greater proportion of non-profit ownership, and a smaller proportion of for-profit ownership when compared with the general population of nursing homes ( Table 1 ). A greater percentage of participant facilities were in the second quartile (low/moderate range) of social vulnerability. There were no significant differences in the distributions of bed size or urban/rural facility locations.

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https://doi.org/10.1371/journal.pone.0260055.t001

The majority of participants answering demographic questions at the time of focus group registration were White (68%) and identified as female (89%) with an average age of 43 years ( Table 2 ). Since the beginning of the pandemic, 39% had tested positive for COVID-19, 75% were fully vaccinated with a COVID-19 vaccine at the time of the focus group, and most (95%) were employed directly through their nursing home facilities. The majority (87%) of participants answering Zoom polling questions during the focus groups reported working day shift, 44% reported having over 10 years of work experience in total, and half (52%) reported at least five years of experience at their current facility.

https://doi.org/10.1371/journal.pone.0260055.t002

Perceived risk of getting COVID-19

When answering a Zoom poll of their perceived risk of getting COVID-19 at their facility on a scale of one (“Not at All”) to ten (“To a Great Extent”), the responses among participants were more evenly distributed when asked about their perceived risk of getting COVID-19 in their facility at the beginning of the pandemic (30% reporting 1, 2, or 3; 40% reporting 4, 5, 6, or 7; 30% reporting 8, 9, or 10) than compared with at the time of the focus group (79% reporting 1, 2, or 3; 17% reporting 4, 5, 6, or 7; 4% reporting 8, 9, or 10) ( S1 Fig ). When asked to discuss where they felt more at risk of getting COVID-19, almost 75% of participants mentioned feeling more at risk outside of the facility, often comparing the precautions taken at their workplace with the lack of precautions and unknown COVID status among those they encountered outside the facility. In the words of one participant, they felt more at risk “ Outside the facility , because we can’t make those people out there obey the rules that’s going to keep [COVID] under control .”

Changes in duties and responsibilities of nursing home caregiving staff

When asked how their job responsibilities or duties had changed due to the COVID-19 pandemic, 68% of participants who responded reported performing tasks beyond their scope of work and added responsibilities, 62% reported an increase in time required to complete tasks, and 27% reported added pressures; 7% reported no changes in their responsibilities. Specific changes reported, as shown in Table 3 , included the new responsibility of rule and protocol enforcement, as described by one staff member “ We had to come in long days and screen everybody as well as keep a closer eye on interactions between families , ” and additional cleaning and disinfection of high-touch surfaces with one participant stating that they “ just clean continuously .” Participants specifically reported an increase in time required to complete tasks due to frequent donning and doffing of additional PPE and staffing shortages; in the words of one staff member “ that was difficult , being short-staffed when actually we need to bump up the disinfection and sanitation and having less people to do it .” Participants also reported added pressures specifically from the increased stress and anxiety of their job, describing that “ You’re not only worried about yourself and your residents , but you’re worried about bringing it home as well .” Other changes expressed by participants included frequent changes in policies and protocols, for example, “ policies would change on a daily basis , so it was a problem . It was confusing for most of the staff .” Additionally, staff reported consideration for the mental health of residents, as one participant indicated, “ we’re kind of running emotional support too , trying to be there for the residents while trying to take care of everything else .”

https://doi.org/10.1371/journal.pone.0260055.t003

Perceived barriers to preventing COVID-19 in facility

When answering a Zoom poll of the one greatest barrier to preventing COVID-19 in their facility, the most common barriers participants reported at the beginning of the pandemic were staffing shortages (30%), followed by lack of training or education (20%), lack of PPE (13%), staff disbelief (staff not believing COVID-19 was a problem) (12%), frequent staff turnover (4%) and limited COVID-19 testing (4%); 6% of participants selected that their facility had no barriers to preventing COVID-19 at the beginning of the pandemic and 12% selected the option of other greatest barrier (e.g., “ the Unknown ”).When answering the same question at the time of the focus groups, the greatest barrier to preventing COVID-19 in their facility also was staffing shortages (48%), followed by frequent staff turnover (13%), staff disbelief (8%), lack of leadership support (2%), lack of PPE (1%), and lack of training or education (1%); 15% reported no barriers to preventing COVID-19 at the time of the focus groups and 11% selected the option of other greatest barrier (e.g., opening for visitation).

Considerations for what nursing home facilities could improve on

When asked what their nursing home could improve on, the most convergent themes reported by participants in the discussion were to improve staffing (33% of respondents), improve infection prevention practices (29%), and improve organizational culture (19%), while 31% of respondents reported no areas for improvement in their facility and that the facility did the best they could in the circumstances. Of note, participants specifically mentioned their facilities could improve by mitigating staffing shortages, including that “ if we had more hands on , it could have prevented a lot of things that happened due to COVID ”, in addition to providing incentive payments, as stated by one participant “ If we would have gotten more hazard pay for everyone and not just the people who worked in the COVID [unit] , people would have shown up for work more” , limiting frequency of changes to protocols or guidance (i.e., “We were constantly changing things employee wise , changing things resident wise ”) and improving communication within the facility, as described by one participant, “ Sometimes they don’t give us all the information… sometimes we have no idea what’s going on ” ( Table 4 ).

https://doi.org/10.1371/journal.pone.0260055.t004

Advice/what do you wish you would have known

In a discussion about what participants wish they would have known at the beginning of the pandemic and advice they would give to other CNAs or EVS staff members about COVID-19 in nursing homes, the most common responses were that staff wish they would have known the magnitude of the pandemic (e.g., length, seriousness, transmissibility; including “I wish from the get-go I would have realized that it was as bad as what they were saying” ), along with advice to use PPE, to treat residents like family, and to wash your hands ( Table 5 ). As expressed by participants, it is essential “just to make sure that staff are wearing that PPE right , make sure you’re washing your hands . Have respect for everybody that’s around because it’s not just stressful for you , it’s stressful for everybody . And if nothing else , more stressful for the residents” and “to just remember they [the residents] don’t get to go home . They live here… and we are their family , their friends , their husbands , their wives…it’s a very serious job . ” In addition, one EVS staff member also emphasized “the importance of our role in keeping things at bay . We’re not ancillary employees when it comes to COVID . ”

https://doi.org/10.1371/journal.pone.0260055.t005

Concerns and needs of staff moving forward

When participants were asked what they were most worried or concerned about related to COVID-19 in the nursing home moving forward, the most convergent themes mentioned in discussion were fear of experiencing another COVID-19 outbreak (69% of respondents), concerns about the mental wellbeing of staff (26%) and residents (17%), and concerns about staffing capacity and future workforce development (8%); 6% of respondents reported they had no concerns moving forward. As shown in Table 6 , specific concerns included fear of COVID-19 coming back into the facility, with one participant describing that they are “ afraid that it’s going to come back into our facility with a force , ” along with concerns about complacency in COVID-19 prevention practices and the continued emergence of COVID-19 variants. Concerns about mental well-being specifically included staff emotional strain and anxieties and the effects of social isolation on residents, with one EVS staff member stating, “ To see the heartbreak [of our residents]… it’s heart wrenching to watch… And then [to have to] take that home [as staff members] . That’s really difficult . For housekeeping especially… We don’t really have all of those tools in our toolbox . That mental health , being able to process that , and not take work home all the time . That’s difficult . That’s real difficult .” Additionally, participants expressed concerns about staffing shortages with one participant describing they “hope that the staffing gets better . No one wants to come and work in a nursing home . ”

https://doi.org/10.1371/journal.pone.0260055.t006

Methods of communication for information about COVID-19

When responding to a Zoom poll question regarding where they go to find information about preventing COVID-19 in nursing homes, the majority of participants selected through their nursing home facility (63%), followed by the CDC website (19%), their state or local public health department (9%), the news (6%), their contracting agency (2%), and their coworkers (2%). Additionally, when asked how CDC can best reach staff with new guidance or information about COVID-19, most selected through their nursing home facility (64%), followed by a direct email from CDC (25%), a CDC webinar (4%), state or local public health department (3%), direct mail from CDC (2%), social media (1%), and through their professional organization or society (1%).

The objective of this qualitative assessment was to understand the impact of COVID-19 among nursing home staff and how both individual and facility level factors may have played a role in the pandemic experience. To explore such factors, we examined CNA and EVS staff perceptions of COVID-19 prevention efforts and self-reported behaviors and beliefs. Convergent themes and perceptions reported across the focus groups included the problem of staffing shortages, the toll of the pandemic on staff emotional and psychological well-being, concern for the physical and emotional well-being of nursing home residents, and the lack of consistent and systematic guidance resulting in rapidly changing infection prevention protocols. Additionally, the need for directly engaging CNAs and EVS staff members became evident, as many participants were grateful for the opportunity to participate in the discussion and shared invaluable insight through the lens of frontline staff members.

Participants across focus groups consistently reported the need to mitigate staffing shortages. Concerns included, but were not limited to, low wages and inconsistent employment benefits and incentives, such as supplemental hazard pay for essential workers. Participants shared the demands of taking on entirely new responsibilities and an increasing resident-to-staff ratio as nursing home staff quit or were placed under quarantine, and hiring new staff proved difficult. Staffing concerns have been similarly reported by frontline staff in previous studies [ 10 , 11 ] and align with an analysis of NHSN data finding that nursing homes across the US have experienced significant staffing shortages during the COVID-19 pandemic [ 2 ]. Improving the employment outlook of CNA and EVS nursing home staff members may help ensure nursing home capacity and employee retention, as participants reported quickly burning out under the added pressure of an ongoing pandemic. Empowering CNAs has previously been associated with increased staff retention in US nursing homes [ 12 ] and a qualitative study with CNAs found the availability of resources, such as equipment and staffing, may help to enable coping with the increased emotional burden of the COVID-19 pandemic [ 13 ]. One observation of note from our findings was that when a participant stated they had received hazard pay, or other financial incentive for working during the pandemic, they tended to make more positive statements about their facility and its overall handling of the pandemic. Additionally, improving pay and benefits such as paid sick leave may be especially important, as even prior to the COVID-19 pandemic, a survey of staff working in long-term care facilities found that 70% of respondents reported feeling obligated to work while sick and almost 20% of CNAs held a second job [ 14 ].

Another resounding theme that emerged amongst the participants was the toll the pandemic took on the emotional and psychological wellbeing of CNA and EVS staff members, as well as concern for the physical and emotional well-being of the nursing home residents in their care. Due to prolonged isolation and restricted visitation in the nursing home, CNA and EVS staff described filling a familial role for residents, increasing both responsibility and emotional burden on an already taxing workload. CNA and EVS staff members emphasized their dedication to their residents, describing them as family, feeling heartbroken and helpless to improve their often-perceived hopeless situation. Both CNA and EVS staff reported feeling unprepared to handle the stress of their position in a pandemic that often felt never-ending. As this theme of stress and burnout has also been reported in other qualitative studies of nursing home staff [ 10 , 11 ], mental health services may be important for nursing home staff affected by the close and compassionate role they serve for residents in nursing home care.

Participants also repeatedly described a lack of consistent and systematic guidance resulting in rapidly changing facility infection prevention protocols. Despite this, many felt their facilities did the best they could with what they had to support their staff, and that teamwork was an integral part to their collective survival through the COVID-19 pandemic. In the end, the focus groups became a space where participants could process the trauma of the pandemic amongst their peers and voice their invaluable perspectives on what went right and wrong through the lens of frontline nursing home staff. Participants expressed their gratitude for being included in this discussion, and for the space they were given to safely discuss their experiences.

This qualitative assessment was subject to several limitations. Participating nursing home facilities and staff represented a voluntary convenience sample. All data collected were self-reported and subject to recall bias, as well as social desirability bias. Generalizability of participant perceptions may be limited, as participants may not be representative of the overall nursing home staff population in the United States, with more participating facilities located in counties in the low/moderate range of social vulnerability and more facilities having non-profit ownership than the general population of non-participating US nursing homes. A higher percentage of focus group participants also identified as White compared to an analysis of long-term care staff nationally (68% versus 52%) [ 15 ] and a higher percentage of participating CNAs reported vaccination compared to aides in an analysis of nursing homes reporting vaccination coverage to NHSN as of March 1-April 4, 2021 (62% versus 46%) [ 16 ]. Additionally, generalizability may also be limited due to the small number of responses for some discussion questions and because outreach was conducted though nursing home administrators who facilitated staff member participation. All focus groups were conducted using the Zoom platform which posed unique challenges with varying Internet bandwidth and a learning curve with less technologically adept participants. In addition, due to the voluntary and anonymous nature of select data sources, the ability to measure associations between individual demographics (e.g., race, age, gender, COVID-19 infection status) and responses was limited; it may be of future interest to further explore potential relationships between individual and facility factors and participant responses in larger sample sizes. Future assessments should also examine staffing shortages and the impact of geographical location, SVI, facility ownership, and facility bed sizes on staffing ratios in a non-pandemic setting.

Despite these limitations, the focus group discussions illustrated that the overall impact of the pandemic was not simply whether a nursing home staff member tested positive for COVID-19, but rather the effect the pandemic had on the entire lived experience of these participants in both a professional and personal capacity. Addressing concerns of low wages and lack of financial incentives may have the potential to attract and retain employees to help alleviate nursing home staff shortages. Furthermore, access to mental health resources could help CNA and EVS staff cope with the emotional burden of the COVID-19 pandemic and increase resiliency. Additionally, CNA and EVS staff may benefit from training to improve their ability to care for residents’ emotional and psychological well-being. Speaking to these frontline staff members provided invaluable insight. Moving forward, CNAs and EVS staff should be a direct target audience for messaging of guidance changes. These frontline staff members should be included in improvement efforts to support nursing homes recovering from the impact of COVID-19 as well as future pandemic planning at the facility, state, and national levels.

Supporting information

S1 fig. zoom poll responses: how at risk were you of getting covid-19 in your facility..

https://doi.org/10.1371/journal.pone.0260055.s001

S1 Table. Qualitative codes operationalized by select quotes from discussion: How have your job responsibilities or duties changed because of COVID-19?.

https://doi.org/10.1371/journal.pone.0260055.s002

S2 Table. Qualitative codes operationalized by select quotes from discussion: What can your nursing home improve on? what is one thing you wish your nursing home could have done for CNAs/EVS staff during the pandemic to make things better?.

https://doi.org/10.1371/journal.pone.0260055.s003

S3 Table. Qualitative codes operationalized by select quotes from discussion: What do you wish you would have known? what one piece of advice would you share with another CNA/EVS staff member about COVID-19 in nursing homes?.

https://doi.org/10.1371/journal.pone.0260055.s004

S4 Table. Qualitative codes operationalized by select quotes from discussion: Moving forward, what are you most worried/concerned about related to COVID-19 in the nursing home? what do CNA/EVS staff need most moving forward?.

https://doi.org/10.1371/journal.pone.0260055.s005

S1 File. Script of qualitative discussion questions and poll questions.

https://doi.org/10.1371/journal.pone.0260055.s006

Acknowledgments

We want to express our gratitude to the CNA and EVS staff members who graciously shared their experiences throughout the COVID-19 pandemic. The dedication to their residents and nursing homes was inspiring and made clear the invaluable role they serve for nursing home residents.

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

• 1. COVID-19 Nursing Home Data. Centers for Medicare and Medicare Services (CMS). [Cited 2021 September 28]. Available from https://data.cms.gov/stories/s/bkwz-xpvg .
• View Article
• PubMed/NCBI
• Google Scholar
• 7. NCHS Urban-Rural Classification Scheme for Counties. National Center for Health Statistics. [Cited 2021 March 19]. Available from https://www.cdc.gov/nchs/data_access/urban_rural.htm .
• 8. CDC/ATSDR Social Vulnerability Index. Agency for Toxic Substances and Disease Registry. [Cited 2021 March 18]. Available from https://www.atsdr.cdc.gov/placeandhealth/svi/index.html .
• 9. Krueger RA and Casey MA (2014). Focus groups: A practical guide for applied research. 5th ed. Thousand Oaks, California: SAGE Publications; 2014.

• Research article
• Open access
• Published: 29 June 2020

What matters to you when the nursing home is your home: a qualitative study on the views of residents with dementia living in nursing homes

• Agnete Nygaard   ORCID: orcid.org/0000-0001-6659-0582 1 , 2 ,
• Liv Halvorsrud 1 ,
• Ellen Karine Grov 1 &
• Astrid Bergland 1  

BMC Geriatrics volume  20 , Article number:  227 ( 2020 ) Cite this article

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A Correction to this article was published on 18 February 2021

This article has been updated

Dementia is recognised as one of the greatest global public health challenges. A central tenet of national health and social care policy is to ensure that services support people in achieving their personal well-being and outcomes, defined as the things important to people in their lives, also people with dementia. The aim of this study is to explore what matters to nursing home residents with dementia based on their perceptions of nursing homes as home.

There were conducted 35 interviews with people with dementia in nursing homes. We conducted the in-depth unstructured qualitative interviews. Thematic analysis was applied to analyse the data.

The analysis resulted in one over-arching theme “tension between the experiences of a nursing home being a home and an institution” and five themes; “myself and my relationships with fellow residents", “creation of individualised living spaces”, "single rooms with personal decor that enhances a sense of connectedness”, “transition between the old home and the new home” and “significant activities providing meaning”. The participants stated that the transition to the supported, structured living environment in nursing homes to be a clear need based on immediate, serious safety concerns. They went from being masters of their own lives to adhering to nursing home routines. Fellow residents could be both resources and burdens, creating feelings of security and insecurity. A home-like environment was created by allowing the participants to bring their important personal belongings into private spaces. The participants said they needed to be able to decorate their rooms to their own specifications. They wanted involvement in meaningful activities.

Conclusions

The findings showed that ‘home’ was an emotive word that awakened many associations. The participants reported mixed feelings and stated that they could thrive even if they missed their old homes. What mattered was that the participants felt safe, had single rooms where they could retire from the community, their own belongings and did activities. The participants wanted greater possibilities for meaningful relations. They appreciate that nursing home were similar to their previous homes. They desired opportunities to continue some activities they did in their former home.

Peer Review reports

A central tenet of international and national health and social care policy is to ensure that services support people with dementia in achieving their personal well-being and outcomes, defined as the things important to people in their lives [ 1 , 2 ].

Actively involving patients and the public in research is considered to be a good practice. Patient and public involvement (PPI) thus may improve the quality of research projects and strengthen their relevance and impact. PPI entails carrying out research ‘with’ and ‘by’ patients and the public [ 3 ]. Amid the growing number of people suffering from dementia-related diseases, interest in PPI and awareness of the need for it have increased [ 4 , 5 ]. Research suggested that people with dementia are able to communicate their feelings and thoughts about their lives in nursing homes [ 6 ]. Scholars have argued that research should be carried out ‘with’ and ‘by’ users rather than ‘to’, ‘about’ and ‘for’ them [ 7 ]. Understanding older nursing home residents’ perspectives is important to make nursing homes good places to live and work as it helps identify residents’ needs, enabling providers to develop appropriate, responsive services [ 8 ].

To people with dementia are supporting relationships, social engagement and everyday functioning, addressing and high-quality care are important to have focus on [ 9 ]. Things matter to people and make a difference in ‘how they are’. People’s lives go well or badly, and their sense of well-being depends on the relationship with other people, the treatment of the healthcare, the living area, and the social and political environment. In some respects, the answers from the people are very subjective and personal, but they are not free-floating ‘values’ or expressions projected onto the world. Instead, they are feelings about various events and circumstances that are not merely subjective [ 10 ]. Barry and Edgman-Levitan [ 11 ] proposed the question ‘What matters to you?’, which Jason Leitch, national clinical director of the Scottish government, asserted has become ‘the new vital sign, a vital sign of compassion and care’ [ 12 ]. Furthermore, the question ‘What matters to you?’ is presented as a tool for developing personal goal, serving the ideal that the ‘end users’ in this case nursing home residents have opportunities to determine and strive towards personal goals [ 13 , 14 , 15 ]. This question prompted us to explore in more depth the important research topic of residents’ perceptions and experiences of what matters to them in everyday life while making nursing homes their home.

Across the world, moving into nursing homes has been documented as a major life change for many older adults [ 16 , 17 , 18 , 19 , 20 , 21 , 22 ], and adjustment to nursing homes can be difficult for both persons with dementia and their family members [ 22 ]. Research has been focused on describing older adults’ experiences of adjusting to nursing home life and the factors that influence their adjustment. Less research has been dedicated to exploring their adjustment processes [ 20 ]. A recent study investigated adjusting to residential aged-care facilities from the perspectives of persons with dementia, their family members and facility healthcare workers. The study identified meaningful activities as critical to facilitating adjustment to life in these facilities [ 23 ].

Conceptual framework: nursing homes as home

The health and social sciences have widely acknowledged that home is more than a physical place. Gram-Hanssen and Darby [ 24 ] described four aspects of the concept of home: it is a place for security and control, activities, relationships and continuity, and identity and values. Home can be a feeling or a state of mind not tied to any place [ 25 ]. Feelings of home can but do not have to be related to a dwelling place. Understandings of home can be attached to physical structures including houses, streets, neighbourhoods, cities and countries [ 25 , 26 ]. What makes a house a home are ‘homemaking practices’, or habits and routines that make a house feel safe and comfortable and include mundane activities such as cooking, cleaning and hobbies [ 27 , 28 ].

Burrell argued that homemaking consists of a continuous process in which people try to get control over their living space [ 29 ]. However, this process is often disrupted by factors both inside and outside the dwelling place such as neighbourhood noise and other inhabitants of the living space (35). Frailty and decreased physical capacities can hinder (older) people’s homemaking practices, so their dwelling place may not be ideal or desirable for the end of life.

Previous research has shown that people are capable of creating a sense of home in other places such as nursing homes [ 30 ]. Homemaking, therefore, can be done anywhere and is not confined to dwelling places. Home results from a complex interplay of space, relationships, the body and time [ 31 ]. The question of to what extent older people feel at home during their nursing home stays thus should be revisited frequently. A sense of belonging best encapsulates what makes a care home homely, underlining the importance of the concept of ageing in place. A sense of belonging implies that individuals feel that they are in the right place at the right time, and they are safe, secure and socially connected. For nursing home residents, this feeling is related to their state of health due to their increased frailty [ 32 ].

The aim of this study is to explore what matters to nursing home residents with dementia based on their perceptions of nursing homes as home. This study adds important knowledge about how to facilitate to a high quality of everyday life for nursing home residents and enhance their feeling being at home. By exploring what is the basis through the conceptual lens of the concept ‘nursing homes as home’, we hope to provide useful information to decrease the gap between intention and practice in nursing home policy, research and clinical work. We believe that greater insight into nursing home residents with dementia perceptions will benefit all researchers and stakeholders in the field of health and social care in nursing homes. Exploring how nursing home residents perceive and experience what matters to them, therefore, may shed light on how nursing home policies are interpreted and practiced.

Study design and setting

This exploratory qualitative study followed the Consolidated Criteria for Reporting Qualitative Research [ 33 ]; (see attachment) to explore what matters to people with dementia living in nursing homes. The unstructured interview guide allowed conducting interviews that were more like conversations on the premises of the residents’ nursing homes. Our study took part in three nursing homes in a large municipality in Norway.

Participants and recruitment

We recruited 35 people with dementia living in nursing homes. All the participants had been diagnosed with dementia and were long-term residents. They were recruited by the heads of the three nursing homes in the municipality, and team leaders in each unit identified potential participants. Their relatives were contacted by phone and provided consent to ask the residents if they wanted to participate in the study. The team leaders informed the residents face to face about the study and asked if they wanted to participate. Two residents declined to participate, and one relative stated that their resident was unable to express what mattered to them. In two interviews, the residents’ daughters were present at their request. The daughters acted as observers and remained quiet during the interviews. The term ‘participants’ and ‘residents’ are used as synonymous and residents means nursing home residents.

Data collection

The first author (hereafter, Author 1), who conducted the interviews, was a nurse and PhD- student with previous experience in dementia care. The data were collected from October 2018 to April 2019. All the interviews were conducted in the residents’ rooms where they felt safe and talked freely. Author 1 introduced herself and the project before starting the interviews. The in-depth, unstructured qualitative interviews were conducted as scheduled, extend conversations between the researcher and the residents. In the unstructured interviews, the researcher had a general topic in mind but formatted many specific questions as the interviews proceeded in response to what the residents said to encourage them to answer at length and in vivid detail [ 34 ]. The interviews lasted 6–30 min. Author 1 constantly observed how the residents were feeling and whether they became uneasy and expressed that they wanted to end the interviews. When the interviews no longer seemed to yield new information relevant to the study topic, saturation as sufficient ‘information power’ was achieved [ 35 ]. In our case the last four interviews yielded no new information.

Data analysis

Author 1 audio-recorded all the interviews and then transcribed them verbatim. Field notes made after the interviews were not included in the analysis. The data were subjected to thematic analysis, a method developed by Braun and Clark [ 36 ] to identify, analyse and report themes within data and to describe patterns across qualitative data [ 36 ]. To describe these patterns, the authors, who were all female and included three nurses and a physiotherapist at the time of the study, made explicit their pre-understanding and existing knowledge about the context. They carried out the analysis based on Braun and Clarke [ 36 ].

First, to become familiar with the data, all four authors separately read and re-read the transcripts and noted codes. In a face-to-face meeting, all the authors shared, discussed and compared their overall understandings of the data to determine the essential meanings. Second, all the authors separately noted initial codes on the transcripts manually and then met to compare their codes and construct a mutual coding tree. See Table  1 . Third, to search for themes, they identified central quotations and inserted them into a common matrix under the following headlines: quote, our understanding, theme and subtheme/candidate theme (Table 1 ). Fourth, the research group met to review, compare and discuss the themes. Author 1 then compared the findings across all groups and explored the similarities and differences between the researchers’ answers on the same topics in dialog with the co-authors. Fifth, defining and naming themes involved a back-and-forth process of mutual reflections by the researchers involved in the coding and further discussions of the findings with Author 1. This process resulted in the themes presented in the results. Sixth, to produce a report, Author 1 initiated writing the thematic findings, and the other authors gave on-going commentary on the writing in process [ 36 ].

Regarding trustworthiness and potential threats to validity, we used the four “trustworthiness” criteria described by Lincoln and Guba [ 37 ]: credibility, transferability, dependability and confirmability. Credibility was ensured through unstructured interviewing - in-depth, detailed and descriptive analysis of the data and by quoting participants’ responses to substantiate the findings enhanced transferability. To increase dependability, the transcripts were reviewed several times and then checked and coded by each author. Interpretations were also based on consensus among the authors. Confirmability was reached by substantiating each emergent theme with rich quotes extracted from the participants’ responses.

Ethical approval

The Regional Ethical Committee considered this study outside the scope of the Norwegian Health Research Act (ref. REK (Sør-Øst) 2017/1591–3). The Health Research Act and the guide provided by the Ministry of Health and Care Services define what is considered “medical and health research” in Norway. This work had support from the Research Council of Norway (grant number OFFPHD prnr 271,870), Lørenskog Municipality and Oslo Metropolitan University. The funders had no role in the study design, data collection and analysis, publishing decisions or manuscript preparation. The participants provided oral consent, and their relatives were informed about the project by phone and verbally agreed about participation for the participants. Thirty-two of the participants were able to make a written consent. Furthermore, given the severity of cognitive impairment in the participating residents, written consent was obtained from three of the residents’ relatives before the residents were included in the study. Both groups were also informed that at any time during the interview and research process, the participants and their relatives were free to withdraw permission to continue the research [ 38 ].

Totally 35 residents participated in our study. Details about the participants can be found in Table  2 .

The thematic analysis produced five themes integrated into an overarching theme: tensions between the experiences of a nursing home being a home and an institution . The themes indicated the importance of managing the ambivalences of being nursing home residents living in environment with set boundaries, fixed daily schedules and little privacy and choice. The essential ambiguity experienced was the tension between the residents’ perceptions of the healthcare staff’s working conditions and their personal experiences of the quality of care and possibilities for activities and relationships. The residents reported that their nursing homes were nice places to live, but they also perceived themselves as homeless while experiencing increasingly dependence, losses of functions and roles as well as social isolation. The following sections present the five themes illustrated by selected excerpts from the transcribed material. See Table  3 .

In this study the public nature of nursing homes could create tensions as they were and were not home. The transition to the supported, structured living environment in nursing homes was reported from the participants to be a clear need based on immediate and serious safety concerns. The participants went from being masters of their own lives to adhering to nursing home routines. The participants said that fellow residents could be both resources and burdens, creating feelings of both security and insecurity in everyday life. A home-like environment was created by allowing the residents to bring their important personal belongings into private spaces such as their bedrooms. The residents needed to be able to decorate their rooms to their own specifications, creating their own private homes with pictures and dolls that had deep meaning for them. Moreover, the participants found activities such as walking, reading, watching television and listening to music to be important to them. Quotations from participants serve to illustrate and exemplify participants’ experiences of the phenomenon of interest. In this article, quoted participant experiences are presented in italics and refer to which number of the 35 participants the quotation represents.

Myself and my relationships with fellow residents

When moving to nursing homes, the residents did not decide who they would live next to as both neighbours and cohabitants. The residents were at the mercy of those with whom they shared daily life. Some residents stated that they gained new, good friendships after moving to nursing homes, but others reported that some residents caused trouble and made the units noisy. Some residents also had difficulties identifying with others due to their degree of impairment. Some participants also wanted more attention and responses from fellow residents, while other residents expressed indulgence towards them.

Making friends with other nursing home residents with common interests enriched everyday life. One participant described this:

‘ We sit here [on the porch] and watch. Both she and I smoke, and we can’t do that inside, so we go out. That is very nice after all’. (Participant (P) 33)

Others had more difficulties forming new relationships as they had little in common with their fellow residents and could not identify with them. The residents could be at different physical, cognitive, age and interest levels. One reported:

‘Not all other residents are as uplifting as you might think, which I think is just as much fun to be with. But there are a number that you feel you have quite a bit in common with, not least in terms of age’. (P1)

Another stressed thus:

‘Have you seen those sitting out there’? (P2)

With no influence over with whom they lived, the residents found commonalities and made relationships with each other only by coincidence. Some residents felt strange sitting together with those they did not know. One participant pointed out:

‘We’re a weird bunch getting together here, but we’re not together. ... That’s what makes us so different’. (P28)

Some residents became anxious when they observed fellow residents struggling with the activities healthcare workers gave them to do. One participant called it a feeling of embarrassment:

‘They [the patients] are behaving so nervously when they fold clothes. But I am such an insensitive person that I just laugh when, like, a shaky needle falls on the floor. It’s no fun then’. (P12)

Another obstacle to forming relationships was fellow residents’ loss of the ability to speak about their wishes and needs, which could be perceived as burdensome. One participant stated:

‘I know most people. I am very lucky to be known by people. Not everyone can [talk] even, and I feel sorry for them as it must be awful to be unable to talk to people as that is how you express yourself’ . (P10)

The inability to express oneself could trouble those with dementia. Some troubled patients contributed to fellow residents’ stress and discomfort, especially at night. One participant reported:

‘She was screaming at my mom all night, and my mom couldn’t sleep. I couldn’t get mad at her then as I believe she was sick. ... She’s been screaming at my mom all the time, and it’s been a pain’. (P9)

One stressed this experience:

‘ They’re old ones here, and it’s hard to ask them any questions, so that’s not what I’m about to do as it could be misconstrued if I go around asking questions. As a nurse, I see what needs to be done to improve things. I know I could talk more with the patients. They are old ones who are here and unable to think about what they used to have or do. If it is reading, I read to them, but they can’t do it. It would be upside down’. (P17)

The participants experienced their situations differently and expressed themselves in different ways. Some residents perceived the hassle and complaining of other residents as burdensome, whereas a few residents saw the importance of being patient and indulgent with the situation. One participants pointed out:

‘I get so annoyed when I sit and listen to their fuss in their conversations at the tables and stuff. Like can’t accept it and that. One gets to close one’s eyes’. (P31)

Creation of individualised living spaces

Many residents experienced being in communities with common frames of reference. Their nursing homes provided care and protection against the burden of being ill, and the residents felt safe. In this arena, the boundaries between privacy and social interests constantly intersected in potentially conflicting situations.

Several residents described experiencing security without worrying, especially at night. One participant reported:

‘Here, you do not have to worry about anything. I sleep in the evening and get up in the morning, and it couldn’t be nicer’. (P8)

Another stated:

‘And I’m perfectly safe, the door is not locked, and I’m not afraid that someone may come who doesn’t belong here. At night, it is dark, and you fall asleep. You feel so safe anyway. Not many people do that’. (P14)

Some patients felt safe sitting in their own rooms and being observers, looking at what other residents and healthcare workers were doing. One participant stated:

‘I have my door open, and I look straight at the patients. … If I were to just sit with the door shut, I don’t know what would have happened’. (P15)

Other patients felt completely carefree and thrived in their own company.

‘I sleep like a marmot. Here, it is just cosy. When I lie in bed at ten o’clock, I am just a lone mother alone tormenting only myself. When I can relax, I also sleep’. (P16)

Some participants felt confused due to their dementia. They did not remember where they were or recognise themselves in their nursing homes, and at times, they felt insecure. One participant stated:

‘I hope to get to know some good people. I’m very scared. I’m not used to it, that’s it. So, I’m really dreading … I’m always so nervous and scared. Actually, I shouldn’t have gone to a place like this. I was going to a place that was special, so I don’t know who got me here. I don’t remember who got me out, so I’m a little scared now. I’m not good at that. Now, I don’t know where to go to find my way’. (P24)

Another expressed this confusion:

‘In a way, I feel slightly at home, but now, I’m so forgetful that I don’t remember if it’s Dad or me who was here. Who owns this room in a way?’ (P15)

Single rooms with personal decor that enhances a sense of connectedness

One factor in well-being mentioned by many residents was living in their own rooms where they could have their personal belongings, create their own home, do as they wanted and feel like home. For the relatives, single rooms could also be sanctuaries where they could be with residents without interruption. Not all nursing homes had single rooms, and consequently, the residents could experience less privacy.

Some participants had previously experienced living in double rooms and appreciated getting their own rooms. Some residents had no expectations of living alone and were surprised when they moved into single rooms. One participant stated:

‘I knew that I was given my own room and could get up to do just as I was doing. … When I was at the other nursing home, there were two and two in a room. There was just a curtain between the beds, and it was noisy’. (P8)

Another participant expressed excitement:

‘I’ve got my own room. I didn’t think it was true. I feel like a countess!’ (P16)

The participants pointed to photos of family and their younger selves as some of the most important assets they had in their rooms. One participant commented:

‘A small little house can be just the size that is nice to have for the things you have. I also hung up some pictures to remember those in the family’. (P14)

‘I’m afraid I might forget them, I think. That’s why I like to have photos of the family’. (P10)

Other personal belongings they appreciated having in their single room were dolls, furniture and flowers, which helped them create a home-like atmosphere where they could be alone and relax. Single rooms could also provide security and protection against the large common areas of their nursing homes. One participant shared:

‘My doll I have with me too. ... I also arrange my flowers here. ... We have some of our furniture here, and ... we can’t have it better. Also, I’m very happy about that television over there. … I can go in here and relax a little and lie on the couch or on the bed there and relax a bit’. (P9)

‘I’m fine when I’m in here, but otherwise, it’s not so good. … For here, I am free. ... I can sit here and watch TV, have breakfast and dinner served, and some in the family, my kids call or come. … Therefore, I enjoy the room well here. I’m sitting with my book or my books and newspaper. ... I have to have that’. (P17)

Single rooms could also be havens for the relatives who came to visit residents, making their visits enjoyable and improving their interactions. One participant reported:

‘People thrive here. It’s something so strange. They come here and sit for hours … Yes, it must be the quiet. My spouse does not fly off in anger here. Isn’t that nice?... But it is so strange that just as there is something that reassures people here. My son is a restless type and was at my spouse’s birthday at home, and I couldn’t bear it. I was out of shape visiting home. Then, he had sat for a while, and then, he was restless, but here, he can sit for three hours’. (P35)

Transition between the old home and the new home

Some people with dementia had difficulties understanding why they needed to move from their homes to nursing homes. In contrast, others with dementia understood that they could no longer live in their own homes and expressed satisfaction with living in nursing homes, even though they missed their own homes.

The residents understood why they lived in nursing homes but still felt hurt. One commented this:

‘I think I’m fine here. I have, and I must as now, they are responsible for me as now, I have no one to care for me. I do not have a place to stay other than here. It’s my home now. I think that’s something hurtful’. (P9)

‘Of course, it’s better to stay home, I can only say that. If you are capable of sustaining it, then it is the best. … Of course, it is not like it [nursing home] is at home though’. (P31)

Some residents felt that they had been put away, and they had no understanding of why they lived in nursing homes. One described this situation:

‘To be such a hall [nursing home] as you are put away, to say. You are put away at home [nursing home], or yes’. (P18)

Some participant was happy to live in nursing homes as they had experienced difficulties living in their previous homes. They described the design of their former homes:

‘It’s [to live in nursing home] very nice, and I don’t want to live at home as there is a basement there. First, the basement, then there is the first floor where there is a dining room and kitchen and such a living room, and on the third floor, there are beds and bedrooms. ... Had I lived at home I would not have been able to do anything as when you are old, it just gets buzzing, and you can’t bear to go out and do something’. (P14)

Some residents experienced relief at living in nursing homes as they received the help they needed and no longer had the same responsibilities as in their former homes.

‘It’s safe and good to be here in the nursing home. Also, I can no longer cope with housekeeping and such things’. (P31)

Several participants stated they were doing well in nursing homes but did not feel like they were living at home. They adapted to the situation. One stated:

‘It’s not exactly like home then. Otherwise, it’s not that much worse here, but home it isn’t’ . (P21)

When moving into nursing homes, the residents became dependent on when and if they had assistance to perform practical tasks. One commented:

‘Yes, for those who do not have the money to buy a new bed, and they have no money to do anything about it either ... yes, but now they have bought one that is going to be screwed up in the ceiling, and I can manage lifting it up myself. But that is what the caretaker will do here, though I doubt it will be done this year here’. (P35)

Significant activities providing meaning

Significant activities were meaningful to the residents and reflected their current and past interests, routines, habits and roles adjusted to their abilities. Although some residents described a lack of activities in daily life, others noted listening to music as a nice touch in nursing homes, and several residents mentioned walking outdoors as important to them:

‘ A good day is when we have a trip ... I love to be out’. (P7)

However, some residents said they were not allowed to go for walks without healthcare workers. One said:

‘I must not go alone. I’ve gotten that printed I don’t know how many times’. (P13)

‘We used to be very good at going for walks and things like that as we had a helper here, who has now moved up to another department, so we lost him then. He was so good at taking a lady and me out. Also, we walked in the garden in the summer, and it’s a pretty big garden here’. (P31)

The residents mentioned that they also liked to do different indoor activities together. One commented:

‘We have thrown such big balls between us. [It is] very nice when you get your arms touched then. It is very nice. Also, we have had games such as Ludo’. (P7)

Another noted the importance of exercise:

‘Gym, yes. After all, I am an old gym teacher who taught it as a subject’. (P16)

Some residents describing keeping themselves active by sitting alone and reading books or watching TV. One stated:

‘One night, I can sit here reading or relaxing and watching TV’. (P1)

Another mentioned:

‘I’m happy to read, but I don’t know. I read a lot then’. (P9)

Several residents felt bored by the lack of activity in nursing homes. One participant stated:

‘Nothing. That’s what it is. It’s boring, of course, as it is when you’re in an institution like that. When you’re just there, it’s boring in the long run. Very little happens’. (P29)

Music had different meanings to all the residents. They reported that nursing homes often played music, but they had different preferences about what music they liked to hear. One stated:

‘A good day is to listen to songs and music ... The old songs we had then, we who are almost 90 years old, soon to be 90’. (P7)

Another shared:

‘I listen to that music, but to be perfectly honest, I am not so fond of this music being played. ... I like to hear the accordion, I do’. (P8)

Still another reported:

‘Especially old dance music, I miss that. Quite simply, I miss it. That’s what I was born and raised on, you could say’. (P32)

The residents stated that they also liked to join in and sing with others and by themselves.

‘We sit and sing a bit and have songbooks. I really like to sing! But they never make me sing alone, no, they don’t. ... When I sit here alone, I sit and hum and sing. Then I know I can sit here, and then no one hears me, so then can I sing a little. … Yes, I definitely think that old people who sit alone and like that very well [should] sit and sing a little. Also, you should not be so careful if it is right what you sing. You forget, but you get in a little better mood, at least I do’. (P19)

‘I’m in [sitting together with the other residents], but I’m not singing’. (P25)

The residents talked about songs and music as important weekly activities. One stated:

‘After all, something happens every week here, such concerts and stuff. … I used to be good at singing once but not anymore’. (P31)

The main focus in this study was to listen to the voices of people with dementia on how they experienced what mattered in everyday life in nursing homes. We found that the participants talked about the characteristics of nursing homes as home. As noted, the vast majority of the residents reported having a good everyday life. Regarding what the residents identified as important for experiencing nursing homes as home, they described their nursing homes as places where they could feel safe, retire when desired. They wanted to have their personal things and enjoy opportunities to socialise and form communities with other residents. Falk et al. [ 39 ] argued that the construction of attachment and the creation of home in residential care involve strategies related to three dimensions of the environment: attachment to place, attachment to space and attachment beyond the institution. The participants’ accounts indicated awareness of these three dimensions. They stated that they appreciated having single rooms where they could keep their personal belongings. However, they missed their own homes and raised important questions about potential attachment to other residents due to experiences of troublesome behaviour such as screaming and arguing during conversations.

Attachment to place and having a sense of home are subjective feelings that can result in feelings of familiarity with and attachment to a setting. Nursing home residents being surrounded by items associated with meaningful memories and engaging in social interactions with relatives, friends, fellow residents and care professionals have also been reported to be important for nursing home resident [ 31 ]. Similarly, we found that some residents were content having a couple pictures and a chair, whereas others wanted to bring more furniture pieces and introduce personal items to improve the interior design of the common living room. The most frequently mentioned items were pictures, postcards and small furniture pieces [ 31 ].

None of the participants regarded nursing homes as their real home. Likewise, Dijk-Heinen et al. [ 31 ] reported that residents did not experience nursing homes as ‘true homes’. Our participants reported mixed feelings as they missed their old homes and wished that they could be there. Similarly, Nakrem et al. [ 40 ] reported that residents perceived nursing homes as their home but at the same time as not home. The residents reported ambiguities in nursing homes as homes and as places that enabled living as they could not manage everyday life at home. In our study, some participants stated that they were not ‘capable of sustaining’ home although it would have been ‘better to stay at home’. Likewise, Nakrem et al. [ 40 ] reported perceptions of two opposite feelings among those moving to nursing homes: great desires and great defeat. Home was as a place of safety, security and joy but also frustration where the participants could avoid stress [ 41 ]. In line with our findings, Førsund et al. [ 42 ] further described home as an arena for coping, comfort and continuity in relation to traditions and social life. Our participants experienced few possibilities for meaningful coping. In fact, one resident stated, ‘We’re a weird bunch getting together here, but we’re not together’ (P28). Such perspectives might have caused frustration. Regarding comfort and continuity, the participants appreciated having their own furniture in their rooms with pictures of family members on the walls.

Having personal belongings was an important but not the only important factor in creating a sense of home. Studies have shown that a sense of home is influenced by possibilities in the built environment such as access to personal belongings, private space and the outdoors [ 43 ]. Our participants reported they had possibilities to enjoy reading books, arrange flowers and walk in the garden in the summer.

The participants experienced difficulties related to social aspects related to home as a place of connection and socialisation but stressed their importance for a sense of home in nursing homes [ 43 ]. Other participants also mentioned positive interactions with other nursing home residents related to smoking, listening to music together and playing games as Ludo. As we found, Lewinson et al. [ 44 ] stressed the importance of having things in common with other nursing home residents to establish new relationships.

Attachment to space and living together with other residents also underscored the ambiguous tensions between nursing homes as home in residents’ private spaces but not home in public places. Spending time with fellow residents offered both an opportunity to be socially active and a source of irritation [ 40 ]. Furthermore, living with troubled people could be burdensome, creating insecurity among fellow residents, as described by the participants. Having opportunities to retreat to their private rooms with their own belongings was important to the participants. According to Dijk-Heinen et al. [ 31 ], the residents thought that watching other older people with physical limitations was depressing. Others’ treatment of the participants was very important to residents. Half of the participants stated that they had experienced disrespectful treatment. Deciding their own friendships was not necessarily a right as two participants mentioned that they were denied it. Dijk-Heinen et al. [ 31 ] further explained that developing a true sense of home required considering fellow residents. Some residents showed evasive behaviours. Some participants experienced a greater sense of autonomy and sense of safety and security in nursing home environments when they were not forced to engage with fellow residents. Accordingly, in our findings, the participants stated that they enjoyed sitting alone in their rooms while watching what was happening outside. Slettebø et al. [ 45 ] pointed out the importance of the feeling of autonomy and the possibilities to decide for themselves what the residents wanted to do and how they spent their days.

Johs-Artisensi et al. [ 46 ] reported that most residents valued a variety of activities that fit with their personal preferences. This helped them stay physically and mentally active and allowed them to leave the facilities. Our participants valued taking walks, doing gym activities, reading books, singing, listening to music and musical entertainment and playing bingo. Many participants talked about music they enjoyed and missed, including old dance music.

The findings from Slettebø et al. [ 45 ] and our participants explained the significance of being active as meaningful. In particular, singing fostered a feeling of being seen and heard as an important member in the social life of nursing homes. Furthermore, some nursing home residents shared that they were sometimes asked to sing for and along with other residents. This was important as they enjoyed singing together with other participants. Active participation gave meaning to life [ 47 ], identified as essential to the residents’ functional and emotional well-being. In addition, research has suggested that a stronger reported sense of purpose leads to better health and well-being outcomes for older adults [ 48 ]. Music also appeared to contribute to the interactions between people with dementia and their caregivers in nursing homes [ 49 ].

Attachment beyond the institution facilitated through outdoor activities was considered to be central to the experience of meaning. Some participants emphasised that it was important for them to do as much as they could for as long as they were able to. Going outside, for instance, to take a walk in a familiar environment allowed them to maintain their current status and sense of coping. To some, doing so even expressed hope in life. One woman explained how walking enhanced her feeling of enjoying a good day. She had taken walks with a couple of different residents, but they could no longer do so. Another study showed that residents who had the ability to walk and possibilities to spend time outdoors had higher levels of thriving [ 50 ]. Meaningful activities in everyday life also had to be individualised to allow the residents to experience meaningful fellowship in nursing homes. In addition, reading emerged as an activity important to some residents. It required little on their part but took their minds off sometimes boring days. Several participants stated that they appreciated the ability to do an activity on their own regardless of what the other residents did [ 45 ]. Engaging in social activities, being with friends and family and attending to socio-emotional preoccupations were important aspects of the participants’ experiences of home. The healthcare workers approaches seemed to have great impact on the residents ‘experiences. The organizational milieu were responsible for facilitating and hindering healthcare workers to provide best interaction and care [ 51 ].

Moments of privacy that were imperative to the feeling of being at home included the ability to independently set the day’s agenda and to live in the same manner as previously, for instance, by solving crosswords, knitting, listening to the radio, looking at photographs, reading newspapers, playing solitaire and watching TV [ 39 ]. The participants reported that, in contrast, a lack of activity made the days long, and a lack of participation and attention by other residents was a threat to dignity. Some said that meals were the only activity that made the days’ worth living. The careful attention to the psychosocial needs and social togetherness with other residents was important and gave much meaning to the days [ 45 , 51 ]. However, some participants experienced daily life as uneventful as they could not take the initiative to do things. Meaningfulness was related to the ability to be occupied in interesting, relevant activities when living in long-term care. Some residents experienced long-term care as an important arena for social activities, meeting people and expanding their social opportunities. However, for others, relocating to long-term care had the opposite effect, and they longed for privacy. In line with earlier research [ 42 ], the participants also expressed that they felt bored in this setting, long-term care lacked alternatives for activities, and they longed for their own home and well-known activities.

Strengths and limitations

Data describing people’s experiences of their own situations always involve multiple meanings dependent on subjective interpretations is a strength of this study. Another strength of this study is the high number of residents interviewed. Through the analysis, the authors engaged in a valuable dialogue seeking agreement on the data. The study was limited by being conducted in one medium-sized municipality in Norway. Particular patient groups such as those from ethnic minorities were not included in the sample.

In this study, we explored the perceptions of nursing home residents with dementia about what mattered to them when nursing homes became their home. The participants talked about the characteristic of nursing homes as home. The analysis showed that ‘home’ was an emotive word that awakened many associations. The participants reported mixed feelings and stated that they could thrive even if they missed their old homes. What mattered was that the participants felt safe, had single rooms where they could retire from the community, had their own belongings such as family photos and did activities such as walking outside, reading, listening to music and playing games. Other main findings were that the residents wanted nursing homes to be similar to their previous homes, and they desired opportunities to continue some activities they did when living in their former home.

Availability of data and materials

The datasets generated and analysed during this study are not publicly available to protect the participants’ confidentiality. However, they are available from the corresponding author upon reasonable request.

Change history

18 february 2021.

A Correction to this paper has been published: https://doi.org/10.1186/s12877-021-02065-5

Abbreviations

• Patient and public involvement

Miller E. Individual outcomes; getting back to what matters. Dunedin: Edinbourgh; 2012.

Google Scholar  

Ministry of Health and Care Services. Meld. St. 15. Leve hele livet. En kvalitetsreform for eldre (live all your life. A quality reform for the elderly people); 2018. https://www.regjeringen.no/contentassets/196f99e63aa14f849c4e4b9b9906a3f8/no/pdfs/stm201720180015000dddpdfs.pdf . Accessed 20 Feb 2020.

Domecq J, Prutsky G, Elraiyah T, Wang Z, Nabhan M, Shippee N, et al. Patient engagement in research: a systematic review. BMC Health Serv Res. 2014;14(1):89.

Article   PubMed   PubMed Central   Google Scholar  

Gove D, Diaz-Ponce A, Georges J, Moniz-Cook E, Mountain G, Chattat R, et al. Alzheimer Europe's position on involving people with dementia in research through PPI (patient and public involvement). Aging Ment Health. 2018;22(6):723–9.

Article   PubMed   Google Scholar  

World Health Organization, Dementia. 2019. https://www.who.int/news-room/fact-sheets/detail/dementia . Accessed 20 Feb 2020.

Mjørud M, Engedal K, Rasvik J, Kirkevold M. Living with dementia in a nursing home, as described by persons with dementia: a phenomenological hermeneutic study. (report). BMC Health Serv Res. 2017;17(1):93.

NIHR INVOLVE, INVOLVE 2017. https://www.invo.org.uk/find-out-more/what-is-public-involvement-in-research-2/ . Accessed 20 Feb 2020.

McMahon S, Talley KM, Wyman JF. Older people’s perspectives on fall risk and fall prevention programs: a literature review. Int J Older People Nurs. 2011;6(4):289–98.

Martyr A, Nelis S, Quinn C, Wy Y-T, Lamont RA, Henderson C, et al. Living well with dementia: a systematic review and correlational meta-analysis of factors associated with quality of life, well-being and life satisfaction in people with dementia. Phsycol Med. 2018;48(13):2130–9.

Sayer RA. Why things matter to people. Cambridge: Cambridge University Press; 2011.

Book   Google Scholar  

Barry MJ, Edgman-Levitan S. Shared decision making — the pinnacle of patient-centered care. N Engl J Med. 2012;366(9):780–1.

Article   CAS   PubMed   Google Scholar  

Leitch J. What matters to you? – a new vital sign. Word on the streets; 2017. Available from: https://www.wordonthestreets.net/Articles/496077/What_matters_to.aspx . Accessed 20 Feb 2020.

Bisognano M. Ask patients: 'What matters to you?'. AHA News. 2012;48(17):4.

Bisognano M. A simple lesson plan for patient-centered care. (AHA voices). Hosp Health Netw. 2012;86(7):12.

PubMed   Google Scholar  

Kebede S. Ask patients 'What matters to you?' rather than 'What’s the matter?'. Br Med J. 2016;354:i4045.

Article   Google Scholar  

Brooke V. How elders adjust. Geriatr Nurs. 1989;10(2):66–8.

Chenitz CW. Entry into a nursing home as status passage: a theory to guide nursing practice. Geriatr Nurs. 1983;4(2):92–7.

Fiveash B. The experience of nursing home life. Int J Nurs Pract. 1998;4(3):166–74.

Iwasiw C, Goldenberg D, Macmaster E, McCutcheon S, Bol N. Residents' perspectives of their first 2 weeks in a long-term care facility. J Clin Nurs. 1996;5(6):381–8.

Lee DTF, Woo J, Mackenzie AE, Lee DTF. The cultural context of adjusting to nursing home life: Chinese elders' perspectives. Gerontologist. 2002;42(5):667–75.

Nay R. Nursing home residents' perceptions of relocation. J Clin Nurs. 1995;4(5):319–25.

Sury L, Burns K, Brodaty H. Moving in: adjustment of people living with dementia going into a nursing home and their families. Int Psychogeriatr. 2013;25(6):867–76.

Davison TE, Camões-Costa V, Clark A. Adjusting to life in a residential aged care facility: perspectives of people with dementia, family members and facility care staff. J Clin Nurs. 2019;28(21–22):3901–13.

Gram-Hanssen K, Darby SJ. 'Home is where the smart is'? Evaluating smart home research and approaches against the concept of home. Energy Res Soc Sci. 2018;37:94–101.

Mallett S. Understanding home: a critical review of the literature. Sociol Rev. 2004;52(1):62–89.

van Gent W. A review of 'Politics of home: belonging and nostalgia in Western Europe and the United States': by Jan Willem Duyvendak. Int J Hous Policy. 2012;12(2):250–2.

Blunt A, Dowling R. Home. London: Routledge; 2006.

Bowlby S, Gregory S, McKie L. 'Doing home': patriarchy, caring, and space. Womens Stud Int Forum. 1997;20(3):343–50.

Burrell K. Spilling over from the street: contextualizing domestic space in an inner-city neighborhood. Home cultures. 2014;11(2):145–66.

Hauge S, Kristin H. The nursing home as a home: a field study of residents’ daily life in the common living rooms. J Clin Nurs. 2008;17(4):460–7.

Dijck-Heinen VCJML, Wouters EJM, Janssen B, Hoof VJ. A sense of home through the eyes of nursing home residents. Int J Innov Res Sci Technol. 2014;1(4):57–69.

Fleming A, Kydd A. What makes a nursing home homely? A Scottish based study, using Q methodology of the perceptions of staff, residents and significant others. J Res Nurs. 2018;23(2–3):141–58.

PubMed   PubMed Central   Google Scholar  

Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International J Qual Health Care. 2007;19(6):349–57.

Rubin HJ, Rubin I. Qualitative interviewing: the art of hearing data. 3rd ed. Thousand Oaks: Sage; 2012.

Malterud K, Siersma VD, Guassora AD. Sample size in qualitative interview studies: guided by information power. Qual Health Res. 2016;26(13):1753–60.

Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101.

Lincoln YS, Guba EG. Naturalistic inquiry. Beverly Hills, Calif: Sage; 1985.

World Medical Association. Human experimentation: code of ethics of the world medical association, human experimentation: code of ethics of the world medical association (declaration of Helsinki). Can Med Assoc J. 1964;91(11):619.

Falk H, Wijk H, Persson LO, Falk K. A sense of home in residential care. Scand J Caring Sci. 2013;27(4):999–1009.

Nakrem S, Vinsnes AG, Harkless GE, Paulsen B, Seim A. Ambiguities: residents’ experience of ‘nursing home as my home’. Int J Older People Nurs. 2013;8(3):216–25.

Førsund LH, Ytrehus S. Finding a place to connect: a qualitative study exploring the influences of the physical and social environments on spouses’ opportunities to maintain relationships when visiting a partner with dementia living in long-term care. Dementia. 2018;17(7):858–79.

Førsund LH, Grov EK, Helvik A-S, Juvet LK, Skovdahl K, Eriksen S. The experience of lived space in persons with dementia: a systematic meta-synthesis.(report). BMC Geriatr. 2018;18(1):33.

Rijnaard MD, van Hoof J, Jansen BM, Verbeek H, Pocornie W, Eijkelenboom, et al. The factors influencing the sense of home in nursing homes: a systematic review from the perspective of residents. J Aging Res. 2016. Availible from: http://downloads.hindawi.com/journals/jar/2016/6143645.pdf . Accessed 17 June 2020.

Lewinson T, Robinson-Dooley V, Grant KW. Exploring “home” through residents’ lenses: assisted living facility residents identify homelike characteristics using photovoice. J Gerontol Soc Work. 2012;55(8):745–56.

Slettebø Å, Sæteren B, Caspari S, Lohne V, Rehnsfeldt AW, Heggestad AKT, et al. The significance of meaningful and enjoyable activities for nursing home resident's experiences of dignity. Scand J Caring Sci. 2017;31(4):718–26.

Johs-Artisensi JL, Hansen KE, Olson DM. Qualitative analyses of nursing home residents' quality of life from multiple stakeholders' perspectives. Qual Life Res. 2020;29:1229–38.

Haugan G. Meaning-in-life in nursing-home patients: a correlate with physical and emotional symptoms. J Clin Nurs. 2014;23(7–8):1030–43.

Irving J, Davis S, Collier A. Aging with purpose: systematic search and review of literature pertaining to older adults and purpose. Int J Aging Hum Dev. 2017;85(4):403–37.

Calkins M. From research to application: supportive and therapeutic environments for people living with dementia. Gerontologist. 2018;58:S114–28.

Patomella A-H, Sandman P-O Bergland Å, Edvardsson D. Characteristics of residents who thrive in nursing home environments: a cross-sectional study. J Adv Nurs. 2016;72(9):2153–61.

Hung L, Chaudhury H. Exploring personhood in dining experiences of residents with dementia in long-term care facilities. J Aging Stud. 2011;25(1):1–12.

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Acknowledgements

The authors thank the 35 residents who participated in the interviews and the nursing home team leaders who helped recruit the residents.

This work was supported by the Research Council of Norway (grant number OFFPHD prnr 271870), Lørenskog Municipality and Oslo Metropolitan University. The funders had no role in the study design, data collection and analysis, publishing decisions or manuscript preparation.

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Agnete Nygaard, Liv Halvorsrud, Ellen Karine Grov & Astrid Bergland

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AN, LH, EKG and AB designed the study. AN coordinated the project and conducted the interviews and was responsible for analysing the data and writing the initial draft of the manuscript. AN, LH, EKG and AB participated in interpreting the data and drafting the manuscript. All the authors contributed to data analysis and interpretation and critically revised the manuscript to enhance its contents. The authors read and approved the final manuscript draft.

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The Regional Ethical Committee considered this study outside the scope of the Norwegian Health Research Act (ref. REK (Sør-Øst) 2017/1591–3). The Health Research Act and the guide provided by the Ministry of Health and Care Services define what is considered “medical and health research” in Norway. This study was registered and pre-approved by the Norwegian Centre for Research Data (project number 54978). Before the interviews, the participants were informed verbally and in writing about the study’s purpose and were assured that they could withdraw their consent at any time without consequence. Thirty-two of the participants gave written consent by themselves. In addition, relatives gave written consent on behalf of three participants due to their health conditions. Their relatives were informed orally about the study’s purpose and were assured that the participants could withdraw their consent at any time without consequence. Given the severity of cognitive impairment in the participating residents, written consent was obtained from three of the residents’ relatives before the residents were included in the study. The project was conducted following the World Medical Association’s Declaration of Helsinki.

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The original version of this article was revised: the title of the article had been written incorrectly as "What matters to you when the nursing is your home: a qualitative study on the views of residents with dementia living in nursing homes". It should be "What matters to you when the nursing home is your home: a qualitative study on the views of residents with dementia living in nursing homes.

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Nygaard, A., Halvorsrud, L., Grov, E.K. et al. What matters to you when the nursing home is your home: a qualitative study on the views of residents with dementia living in nursing homes. BMC Geriatr 20 , 227 (2020). https://doi.org/10.1186/s12877-020-01612-w

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Article Contents

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Living well in care homes: a systematic review of qualitative studies

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Siobhan Aine Bradshaw, E. Diane Playford, Afsane Riazi, Living well in care homes: a systematic review of qualitative studies, Age and Ageing , Volume 41, Issue 4, July 2012, Pages 429–440, https://doi.org/10.1093/ageing/afs069

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Background: research in care home settings is often negatively focused, portraying life as sterile and devoid of meaningful experiences. Care homes have the potential to influence people's lives socially, physically and psychologically. It is important to understand what factors contribute to this.

Objective: to conduct a systematic qualitative review of care home life and provide practical recommendations to enhance residents' quality of life.

Methods: the following databases were searched: PsycINFO, Medline, Web of Science, EMBASE, Allied and Complementary Medicine Database and Cumulative Index to Nursing and Allied Health Literature. References from appropriate journals and individual articles were checked. Papers that fitted our selection criteria were selected. Two independent reviewers assessed methodological study quality. Thematic analysis and meta-ethnographic methods were adapted to synthesise findings.

Results: thirty-one studies were identified. People in care homes voiced concerns about lack of autonomy and difficulty in forming appropriate relationships with others. Four key themes were identified: (i) acceptance and adaptation, (ii) connectedness with others, (iii) a homelike environment, (iv) caring practices.

Conclusion: positive experiences in care homes can occur and are important for residents' quality of life. The review supports literature highlighting the need for relationship-centred approaches to care and emphasises the importance of understanding the resident's attitude towards living in care homes.

People of all ages live in care homes [1], although most research has focused on older people [2]. Moving into a care home involves life changes that significantly impacts on an individual's quality of life (QoL). These include substantial alterations in social interactions and adapting to issues involving privacy, dignity and independence [2].

Residents are often marginalised and excluded from research [3]. Negative aspects of care home life are often highlighted, e.g. some would rather die than move to a care home [4]. Lack of privacy and dignity [5], regimented routines and a feeling of emptiness can affect a person's sense of control [6]. However, some positive aspects, such as improved self-worth [7], morale [7] and physical functioning [8] have been reported.

With the rising cost of care homes and financial implications for both society and the individual, we need to synthesise residents' views on what influences QoL, so that care homes can deliver high quality care and minimise distress. While a vast amount of quantitative data are available, the validity of using subjective QoL outcomes measures, especially for older people, has been questioned [9]. Previous qualitative research synthesised older residents' views on QoL in care homes [ 10 ], but did not use systematic methods in relation to synthesis or study quality. To our knowledge, there has been no systematic attempt to collate the views of different types of people living in care homes, including younger adults, and those with dementia and disabilities.

Our aim is to produce a systematic review of qualitative studies that have examined residents' views of QoL. Specifically, it aims to identify and summarise the factors that positively influence care home life, and provide an evidence base of practical recommendations to improve QoL.

Inclusion criteria

English language studies of mixed methodology but including qualitative research methods as described below.

The views of residents in a care home. Care home refers to nursing and residential homes. Accommodation described as community villages, supported living or respite stays were excluded.

Studies had to examine factors that contribute to care home life.

Qualitative research is broadly defined as ‘any kind of research that produces findings not arrived at by means of statistical procedures or other means of quantification’ [12, p. 17]. We excluded studies of personal narratives and stories that lacked data analysis, as some classify them as ‘no finding reports' [13, 14].

Search strategy

The following bibliographic databases were searched: PsycINFO (1887-April 2009), Medline (1966-April 2009), Web of Science (1982-March 2010), EMBASE (1980-March 2010), Allied and Complementary Medicine Database (1985-Jan 2011) and Cumulative Index to Nursing and Allied Health Literature (l982-March 2010). As there are no gold standard methodological filters in Medline for ‘qualitative research’, consultation was sought from key literature [15]. We used medical subject headings (MESH) and freetext searches related to care/nursing homes and QoL. MESH terms were exploded and combined. Proven search strategies for PsycINFO for finding qualitative research were used [16]. For other search strategies, please see Appendix 1 in the Supplementary data available in Age and Ageing online .

References from all appropriate journals and individual articles were also checked and relevant articles were retrieved. Figure  1 shows the flow of the study retrieval.

Flow diagram of study retrieval.

Data extraction and quality assessment

Papers were screened for relevance from the title and abstract. Participant details, recruitment methods, qualitative methods, setting and study data (i.e. participant quotes and author summaries) were extracted. Where there were insufficient details in the abstract, full papers were retrieved. For study quality, papers received a score out of 7 for its methodological rigour by establishing the inclusion of:

an explicit framework and/or literature review;

clear aims and objectives;

description of context so the reader could relate the findings to other settings;

clear description of sample with basic descriptive data;

clear description of data analysis methods taking into account audit trails, searching for disconfirming cases and identification of themes;

reliability and validity taking into account confidentiality, consent procedures, credibility checks and data triangulation methods;

sufficient original data to mediate between evidence and interpretation to allow the appraisal of the fit between the data and authors' understanding [17–20]. We did not exclude any qualitative studies as poor reporting of methods does not necessarily imply poorly conducted research [21]. All papers were assessed independently for quality and disagreements resolved by the research team.

Data synthesis

For the data synthesis, we followed a thematic analysis approach [ 22 ] with a number of features adopted from the literature on meta-ethnography [23]. The acts of synthesising and reviewing qualitative research are still unclear. However, by using the earliest published work on qualitative synthesis [23], we utilised an established research method of systematic comparison of studies [23] and employed ‘thematic analysis’ in order to formalise the identification and development of themes [ 22 ].

First, each study was repeatedly read and findings highlighted on a line by line coding of data. For more details, please see Appendix 2 in the Supplementary data available in Age and Ageing online .

Codes were organised in Microsoft Excel, allowing similarities and differences between studies to be identified easily. Towards the end of analysis, diagrams identified links and inter-relationships among categories, to develop themes and subthemes. The final step went beyond the content of the data and themes identified, analysing data in a way that offered an, ‘interpretive explanation through which the meanings of social phenomena are revealed’ [23]. This stage is the most difficult to describe, since it is dependent on the insights of the reviewers, and the inference of additional concepts, understandings or hypotheses as generated from the data.

Literature search and study descriptions

We identified 1,048 papers, and 31 papers [ 24 , 54 ] fulfilled the inclusion criteria (see Figure  1 ). The synthesis of findings involved 1,223 participants aged from 20 to 100 (see Table  1 ). There were 29 studies of older residents, 1 in people with multiple sclerosis [ 49 ] and 1 did not offer any age-related information [ 35 ]. Four homes specifically stated that people with dementia resided in the homes [ 31 , 34 , 41 , 42 ]; one study was multisited and included homes specialising in Alzheimer's disease [ 25 ]. Nine [ 26 , 27 , 33 , 37–39 , 43 , 49 , 50 ] included residents with mixed cognitive and physical abilities, and 17 [ 24 , 28–30 , 32 , 35 , 36 , 40 , 44–48 , 51–54 ] did not report the residents' cognitive or physical abilities. Ethnicity was reported by 12 and 27 used in-depth/semi-structured interviews. Studies covered a range of epistemological perspectives (grounded theory, content analysis, thematic analysis etc). This methodology fulfils the goal of qualitative synthesis: ‘to produce a new and integrative interpretation of findings that is more substantive than those resulting from individual investigations’ [55].

Descriptive details of studies in review

In terms of study quality, only 8 [ 25 , 27 , 29 , 33 , 44 , 49 , 52 , 53 ] met all 7 quality criteria and 17 [ 24–27 , 29–33 , 36 , 38 , 40 , 44 , 49 , 51–53 ] met both criteria evaluating reliability and validity. Sensitivity analyses (calculating the contribution of each study to the four themes) according to the quality rating score, showed all findings contributed to key themes irrespective of score (contact author for further details). In terms of generalisability, studies from two countries had poor quality scores [ 28 , 34 ].

Acceptance and adaptation to their living situation

Acceptance of one's living situation resulted in a more positive outlook (see Table  2 for resident quotes and Table  3 for themes) [ 25 , 27 , 30–33 , 35 , 37 , 41 , 44 , 46–49 , 51 , 53 , 54 ]. A positive attitude was found to reduce the impact of losses, e.g. with dependency [ 27 , 35 , 41 , 42 , 46 , 51 , 53 ]. Those with positive attitudes reported behaviours that helped preserve their independence [ 25 , 35 , 48 , 49 , 53 ]. Maintaining independence meant making their own decisions [ 25 ], or doing simple tasks [ 35 , 53 ]. Being positive also enabled resilience in adapting to shared surroundings [ 27 , 31 , 35 , 41 , 42 , 46 , 51 , 53 , 54 ]. This resilience supported their sense of self-efficacy, allowing them to thrive in the care home, quote 1 [ 51 ]. However, accepting care home life requires both positivity and a strong sense of self and awareness, quote 2 [ 46 ].

Resident quotes for each of the key themes

The contribution of key themes from each study

x* = not mentioned.

Acceptance enabled a strengthening of internal resources [ 27 , 41 , 44 , 46 , 49 , 53 ], which may contribute to living well in care homes, despite restraints. Residents reported actively making decisions to adapt certain behaviours in order to lead a good life, quote 3 [ 53 ].

Connectedness with others

Connectedness and involvement with others ( n  = 21 studies) was integral for good care home life [ 24–27 , 48 , 31 , 33–35 , 38 , 40–42 , 44 , 45 , 48–50 , 52–54 ]. These connections represented social ties that either reinforced acceptance or distanced residents from care home life. Having peer residents contributed to friendships [ 25 , 33 , 49 , 50 ], belonging [ 25 , 32 , 35 , 37 ] and reassurance of being important to others [ 25 , 27 , 31 , 33 , 46 , 50 ]. Lack of peer residents impinged on privacy, loneliness, boredom, autonomy and self-identity. Less impaired residents described withdrawing from relationships with other residents to maintain privacy [ 38–41 , 52 ]. However, this led to loneliness and isolation, quote 4 [ 52 ]. Privacy was also affected by more impaired residents coming into their room unannounced or taking their possessions [ 37 , 41 , 52 ]. A lack of peer residents was seen as a reflection of how ‘far they had fallen’, a representation of their reduced circumstances [ 32 , 37 , 38 , 49 , 52 ]. Thus, close relationships with peer residents contribute greatly to connectedness within the care home.

A reciprocal relationship with staff also contributed to good care home life. Where staff provided emotional or psychosocial care, e.g. by sharing their own life, quote 5 [ 26 ], residents reported this affirmed respect and feeling of worth [ 24 , 26 , 32 , 33 , 35 , 38 , 42 ].

The final aspect regarding connectedness revolved around changes in the resident–family relationship. For some the care home served to relinquish any feelings of burden [ 25 , 30 , 31 , 35 , 46 , 49 ], representing a sense of freedom and a way to re-establish familial roles, quote 6 [ 25 ]. For others, the care home represented a place to regain some independence [ 46 ].

A homelike environment

The majority of studies reported that factors within the care home environment facilitated acceptance [ 25 , 27 , 29 , 30 , 32 , 33 , 35 , 36 , 39 , 40 , 42–45 , 48 , 49 , 52 , 54 ]. A homely physical environment [ 25 , 27 , 29 , 32 , 33 , 35 , 39 , 40 , 42–44 , 48 , 49 , 52 ] ensured continuation of their QoL, allowing a smoother transition from home to care home. Having one's own room and bathroom, enough storage and a quiet place [ 35 , 37 , 39–41 , 45 , 48 , 51 ], facilitated residents' abilities to exercise control, quote 7 [ 27 ]. When a homelike environment is absent, quote 8 [ 45 ] a sense of institutionalised living occurs [ 29 , 31 , 32 , 37 , 39 , 42 , 51 , 52 ]. The home is described as regimented and restricted, where daily life is routine and boring [ 30 , 32 , 40 , 42 , 45 , 46 , 51–53 ].

Meaningful daily life, characterised by the care home providing opportunities to go out [ 27 , 42 , 53 , 54 ] and appropriate activities [ 35 , 40 , 42 , 49 ] influenced QoL by allowing autonomy. Care homes providing variety in how residents spent their day, allowed greater feelings of control [ 25 , 28 , 29 , 32 , 35 , 40 , 45 ], preventing helplessness, quote 9 [ 49 ]. A meaningful daily life and homelike environment both emphasise the importance of the care home as a home, recognised in conjunction with the care home as a place that also provides care.

Caring practices

How care is provided has a significant influence on resident's experiences [ 24–29 , 32 , 33 , 35 , 37 , 39 , 44 , 46–49 , 52 ]. Residents needed to feel their needs were adequately met without carers rushing off to the next task [ 24 , 28 , 29 , 35 , 37 , 46 , 48 ], as this can leave residents feeling vulnerable [ 33 , 39 , 46 , 48 ] and helpless, quote 10 [ 33 ].

Carers' competence and caring attitude, quote 11 [ 26 ], can contribute to positive care home experiences [ 24–27 , 35 , 39 , 40 , 46 , 47 , 49 ]. Carers who knew their residents [ 24 , 26 , 27 , 48 , 49 ] and their personal needs [ 26 , 27 , 41 ], and had an understanding of their life story [ 24 , 33 , 48 ] helped residents to be seen as both the person they are and once were, fostering their self-worth, quote 12 [ 42 ]. Residents also reported that feeling safe [ 27 , 35 , 41 , 43 , 46 , 51 , 52 ] combined with staff continuity [ 27 , 32 , 33 , 49 ] led to rapport and trust, ensuring a feeling of attachment [ 27 , 32 , 33 , 49 , 50 ].

This systematic thematic review found four key themes that affect good QoL in care homes: acceptance and adaptation, connectedness, homelike environment and caring practices. In particular, the theme caring practices echoes previous research where care home resource constraints affect older peoples' QoL, and where quality of care is still the caregiver's primary concern [ 10 , 55]. This review also supports and extends the finding that a positive approach to living in care homes is associated with effective coping and adaptation [56]. More importantly, this review is the first, to our knowledge, to provide a synthesis of qualitative studies of various groups of people living in care homes.

Moving to a care home can change a person's ‘psycho-physical’ balance [57], resulting in feelings of worthlessness and uselessness [58]. The first theme, ‘acceptance and adaptation’, demonstrated the importance of residents' own attitudes, where residents taking an active stance in daily living felt more control of their lives [ 26 ]. This is supported by literature on older people, where adaptation in the face of changes was essential for a ‘feeling of anchorage to life’ [59]. For residents in care homes, a response shift [60] may occur, where those who constantly appraised their interactions with others and their environment, explicitly addressed changes they had to make in order to adapt effectively to their new lives. Whether this is due to changing expectations with age, or adaptability in the face of significant changes is difficult to ascertain, and further research is needed. Our findings suggest that carers can promote successful adjustment by communicating the impact of ‘institutional’ living on residents, and, providing a positive mindset. The second theme, ‘connectedness with others,’ demonstrates the importance of appropriate peer relationships [ 35 ]. This is also supported by studies on older people where the quantity and quality of social engagement were found to prolong a person's life [61].

A homelike environment where carers treat residents with respect, taking into account their individuality and identity [59], can reduce the impact of ‘institutionalisation’ [ 10 , 62]. In care homes, routines are often designed to maximise the quality of care, with little room for negotiation and individualised care. However, when some control was given to residents, this contributed to a sense of well-being. Even the illusion of perceived control [63] can help an individual to interact successfully with their environment. However, while competent carers are important, considerate care is equally important [64], and promoting autonomy and independence depends on the nature of the caring relationship between staff and residents.

Methodological issues

Many studies ( n  = 11) reported that staff identified suitable participants, and provided little information regarding who carried out the research. Thus response, gender and selection biases may have occurred. Only a third of studies reported residents' ethnicities, although residents' race is related to QoL [65].

Almost three-quarters of people in care homes have dementia [66], yet few studies have qualitatively assessed QoL in this population. Cognitively impaired individuals are seen as vulnerable and incapable of making decisions [67]. However, the studies reviewed demonstrate that people with dementia can voice their concerns [ 31 , 34 ], echoing findings in acute care setting [68]. Thus more research is needed in this client group.

Only 17 studies in this review adequately reported recruitment methods and descriptions of care homes. This raises concerns about the generalisability of findings. Research has shown, for example, that care homes in rural areas are more comfortable, and that private facilities provide better dignity, security and lower levels of dissatisfaction [69, 70].

Strengths and limitations of the review

We used available qualitative methodological checklists for evaluating study quality, and synthesised findings using an established method to consider the original theoretical perspective of each study and authors' interpretations. We also contacted authors where information was missing. However, not searching the grey literature and limiting studies to English may have excluded some relevant literature.

Future research

Only three studies included the views of younger residents i.e. <65 years of age. Some previous studies report no age differences in residents' QoL [71], while others report [65] better QoL in older residents. QoL domains may also vary in priority according to age [67]. However, the findings from a review of social discourse with younger care home residents with neurological and physical disabilities paralleled many of our key findings, e.g. the importance of peer residents and staff relationship reciprocity [72].

As demonstrated with the four key themes of this review, a relationship-centred approach to care [ 73 ] is highly desired by residents. However, this requires the well-being of both staff and residents, and an examination of the philosophy and values of the administration as these will undoubtedly affect the psychological milieu (or well-being) of all who live and work there [ 45 ]. This review did not look at the influence of care homes' mission statements on QoL. Evidence suggests care home workers may view QoL differently from the mission statements [74].

We acknowledge that there are enormous economic, social and cultural barriers that militate against the easy operationalisation of our recommendations. The reasons behind these barriers were not the explicit focus of our review, and are beyond the scope of this paper. However, these seem to be centred on the issues of lack of staff, training and supervision [ 33 , 45 , 46 ]. Nevertheless, further qualitative reviews that specifically focus on the barriers to adopting these recommendations may address these issues more explicitly. Furthermore, although we have limited our recommendations to those that directly link in with our main findings, a qualitative study that specifically examines recommendations from the perspectives of service users, staff and others involved in service delivery is useful, and may address these issues more directly.

This is the first systematic thematic review consolidating the views of people in care homes. For good QoL in care homes, there needs to be an understanding of the residents' attitudes towards living there, and how factors within the care home impact upon their attitude. This echoes quantitative research where psychological functioning and social support were most strongly correlated to resident satisfaction [64]. Care homes need to make allowances to the care home environment to more closely align with residents' personal preferences and meanings [ 73 ], e.g. match compatibility of roommates to promote meaningful engagement [75]. Care staff providing both practical and emotional support can enhance residents' QoL. Organisational policies need to support this by maintaining continuity of care and less rigid time schedules and routines [ 45 ]. Capabilities of residents must be promoted and valued, to redefine the care home as one that promotes choice, not one that simply takes it away.

This is the first systematic thematic review of factors affecting good QoL in care homes.

For a good QoL in care homes, four key themes are necessary; the person's ‘acceptance and adaptation to their living situation’, their ‘connectedness’ with others, living in ‘a homelike environment’ and carers displaying ‘caring practices’.

Previous research shows that people with cognitive impairments can successfully self-report on their QoL [76]. More qualitative research is needed within this population, especially with people with dementia.

Care homes need to provide a ‘home’ that is person centred for each individual, using a carer relationship-centered approach that examines the personal preferences of each person to allow autonomy, self-identity and independence to be maintained.

This work was supported by a grant from the MS Society of Great Britain and Northern Ireland (Grant ref: 905/08).

We thank Ms. Stephanie Cheng for her assistance in assessing the study quality. We are grateful to the authors who responded to our requests for further information about their research.

The very long list of references supporting this review has meant that only the most important are listed here. The remaining references are available in Appendix 3 of Supplementary data at Age and Ageing online .

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A, Total direct care staffing hours each week (registered nurses [RNs], licensed practical nurses [LPNs], and certified nursing assistants [CNAs]) at participant facilities and compared with national trends. B, Hours per resident-day for total direct care staff (RNs, LPNs, and CNAs) at participant facilities and compared with national trends.

A, Use of an agency for direct care staff including registered nurses (RNs) (A), licensed practical nurses (LPNs) (B), and certified nursing assistants (CNAs) (C).

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Brazier JF , Geng F , Meehan A, et al. Examination of Staffing Shortages at US Nursing Homes During the COVID-19 Pandemic. JAMA Netw Open. 2023;6(7):e2325993. doi:10.1001/jamanetworkopen.2023.25993

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Examination of Staffing Shortages at US Nursing Homes During the COVID-19 Pandemic

• 1 Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island
• 2 Student, PhD Program in Health Policy, Harvard University, Cambridge Massachusetts
• 3 Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
• 4 Division of Geriatrics and Aging, Department of Medicine, University of Rochester Medical Center, Rochester, New York

Question   Do nursing home administrator perspectives on staffing in US nursing homes during the COVID-19 pandemic provide context for conflicting staffing data reports?

Findings   In this study, qualitative and quantitative data from 40 US nursing homes were integrated to assess staffing levels during the pandemic. Short-term compensatory strategies were used by administrators to comply with minimum staffing regulations and offset staffing shortages.

Meaning   Findings from this study suggest that staffing shortages during the COVID-19 pandemic placed strain on nursing homes.

Importance   Staffing shortages have been widely reported in US nursing homes during the COVID-19 pandemic, but traditional quantitative research analyses have found mixed evidence of staffing shortfalls.

Objective   To examine whether nursing home administrator perspectives can provide context for conflicting aggregate staffing reports in US nursing homes during the COVID-19 pandemic.

Design, Setting, and Participants   In a qualitative study, convergent mixed-methods analysis integrating qualitative and quantitative data sets was used. Semistructured qualitative interviews were conducted between July 14, 2020, and December 16, 2021. Publicly available national Payroll Based Journal data were retrieved from January 1, 2020, to September 30, 2022, on 40 US nursing homes in 8 health care markets that varied by region and nursing home use patterns. Staffing and resident measures were derived from Payroll Based Journal data and compared with national trends for 15 436 US nursing homes. Nursing home administrators were recruited for interviews. Of the 40 administrators who consented to participate, 4 were lost to follow-up.

Exposure   Four repeated, semistructured qualitative interviews with participants were conducted. Interview questions focused on the changes noted during the COVID-19 pandemic in nursing homes.

Main Outcomes and Measures   Thematic description of nursing home administrator compensatory strategies to provide context for quantitative analyses on nursing home staffing levels during the COVID-19 pandemic.

Results   A total of 156 interviews were completed with 40 nursing home administrators. Administrators reported experiencing staff shortages during the COVID-19 pandemic and using compensatory strategies, such as overtime, cross-training, staff-to-resident ratio adjustments, use of agency staff, and curtailing admissions, to maintain operations and comply with minimum staffing regulations. Payroll Based Journal data measures graphed from January 1, 2020, to September 30, 2022, supported administrator reports showing that study facilities had reductions in staff hours, increased use of agency staff, and decreased resident census. Findings were similar to national trends.

Conclusions and Relevance   In this qualitative, convergent mixed-methods study, nursing home administrators reported the major staffing strain they experienced at their facilities and the strategies they used to offset staffing shortages. Their experiences provide context to quantitative analyses on aggregate nursing home census data. The short-term compensatory measures administrators used to comply with regulations and maintain operations may be detrimental to the long-term stability of this workforce.

The COVID-19 pandemic has put tremendous strain on the US nursing home workforce. 1 - 3 Burnout, 4 , 5 low wages, 6 poor work conditions, 7 and the increased burden of caring for vulnerable residents during a health crisis 3 , 8 have contributed to a 13.3% decrease in nursing home sector employment since the start of the pandemic. 9 Nursing homes currently employ 1.37 million workers (roughly 10% below projected demand) 9 and continue to face staff shortages. 10 , 11 Administrators have responded to ongoing staff shortages by increasing staff workloads, 12 , 13 halting or decreasing new admissions, 14 - 16 and offering substantial wage raises 10 , 17 and other incentives to retain staff. 18 Despite these efforts, only 2% of all nursing homes in the US reported being fully staffed in 2022. 19 , 20

Although staff shortages at nursing homes have been widely reported, 12 , 18 , 19 , 21 quantitative studies have found mixed evidence of staffing shortfalls. One study found no decrease in staffing levels during the early part of the pandemic after accounting for a decreased census. 22 The Kaiser Family Foundation reported that nursing home staffing shortages coincided with COVID-19 variant surges, varied widely by state, and peaked in January 2022 at 34%. 11 In contrast, an analysis that used detailed employee-level payroll data found staffing patterns consistent with reports of nursing homes experiencing major staffing challenges during severe COVID-19 outbreaks and for extended periods of time after the outbreak. 23

This study conducted a qualitative assessment of nursing home administrator experiences during the pandemic and integrated qualitative findings with quantitative analysis of national payroll staffing data. The objective was to provide context to conflicting aggregated data on nursing home staffing levels during the COVID-19 pandemic.

This convergent mixed-methods study 24 - 26 used semistructured qualitative interviews with nursing home administrators and merged thematic results with quantitative analyses of publicly available facility-level staffing data. This project followed the Consolidated Criteria for Reporting Qualitative Research ( COREQ ) reporting guideline for qualitative research and was approved by the Brown University Institutional Review Board, which determined it to not be human research. Verbal consent was obtained prior to audiorecording interviews. The nursing home administrators received compensation for participation.

Using the Hospital Referral Region table from the Centers for Medicare & Medicaid Services Geographic Variation Public Use file, 8 health care markets were identified. 27 Markets varied based on US region and nursing home use patterns. Using purposive sampling, 5 nursing homes that varied by 5-star rating, size, payer mix, and profit status were selected in each market. 28 Administrators were recruited by email and telephone to participate in semistructured interviews. Interviews were repeated at 3-month intervals from July 14, 2020, to December 16, 2021, to understand the outcomes associated with COVID-19 in US nursing homes over time.

Interview protocol development and testing consisted of 3 cognitive interviews with the immediate research team and 3 pilot interviews with nursing home administrators, after which final revisions to the interview guide were made. The interview guide included open-ended questions and subsequent probes about COVID-19 at nursing homes and was used as a baseline across all 4 interviews, with modifications to add or discontinue questions as needed. Interview guides for interviews 2 and 3 included follow-up questions specific to the facility’s previous interview. A summary report detailing preliminary findings and emerging themes was sent to participants before their third interview. During the third interview, targeted questions were asked to solicit feedback on the summary report, confirm preliminary findings, and refine emerging themes. The interview guide for interview 4 was further modified to include questions designed to look back on administrator experiences over the 1-year interview time frame (eMethods in Supplement 1 ).

Four qualitative research team members (J.F.B., A.M., R.R.S., and E.A.G.) conducted the interviews. All were women with 5 to 35 years of experience in conducting qualitative research. They included 2 PhD-level faculty members and 2 Master’s-level research staff. The researchers did not know the interview participants before the first interview. The purpose of the research was shared with interview participants during recruitment and at the start of each interview.

Interviews were conducted virtually or by telephone depending on participant preference and lasted approximately 60 minutes. Two qualitative research team members participated in each interview: one conducted the interview while the other took detailed notes to flag questions for follow-up and record emergent themes.

Interviews were recorded, professionally transcribed verbatim, deidentified, and reviewed for accuracy. Transcripts were not shared with participants. Using modified grounded theory, 29 an initial coding scheme was developed based on the interview guide (a priori codes) and on emerging data from interviews (de novo codes). The coding tree was adjusted iteratively, such that codes were added and refined throughout data collection and analysis. Four researchers (J.F.B., A.M., R.R.S., and E.A.G.) double-coded 102 interview transcripts in coding teams of 2. Teams rotated to ensure rigor and prevent drift in code definition understanding. Preliminary emerging themes were identified and noted in an audit trail. Once high coding agreement was reached, 54 transcripts were coded by individual researchers. Coded transcript data were entered into the qualitative software package NVivo, version 12 Plus (QSR International) to facilitate comparative analyses across themes.

Once all interview transcripts were coded, reports were generated that collected all the quotations assigned to the same code and related to an identified preliminary theme. Using the 6 steps devised by Braun and Clarke for thematic analysis, 30 the code reports related to a theme were examined together and reanalyzed to identify quotations that were both supportive of and in contrast to the identified themes and identify additional themes. It was determined that saturation was achieved. 31 During analysis, a comprehensive audit trail 32 was kept to record team decisions, questions and comments, code definitions, and emerging themes.

Daily facility-level staffing data for January 1, 2020, to September 30, 2022, were obtained from the publicly available Centers for Medicare & Medicaid Services Long-term Care Facility Staffing Payroll Based Journal (PBJ) data. 33 All Medicare- or Medicaid-certified nursing homes are required to submit daily staffing data, which includes hours worked by staff type and contract type (ie, agency vs direct employee) and resident census. To construct national averages for comparison, data for the 40 sample nursing homes and all 15 436 nursing homes in the US were obtained.

The PBJ data were used to construct 4 measures between January 2020 and September 2022. Measure 1: the mean total daily direct care staff including registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs) in any given week; measure 2: the mean daily resident census in any given week; measure 3: direct care hours per resident-day, calculated by dividing total hours by patient census on that day 34 ; and measure 4: the share of agency worker hours (rather than direct care employees) that provide temporary staffing to offset potential shortages of RNs, LPNs, and CNAs. The staffing measures provide insights into the adequacy of staffing levels and quality of care during the study period. The share of agency worker hours measure is an indicator of staffing stability and may reflect challenges in recruiting and retaining direct care employees.

Weekly means for the 4 measures for the 40 participating nursing homes and 15 436 nursing homes nationally were calculated. These averages were graphed over time to examine temporal trends in the study sample and compared with national trends for the same time period. To construct the national average for each measure, data were weighted by the size of the nursing home, as measured by the number of residents. To ensure the accuracy of our analyses, any data points with either the resident census or the total staffing reported as 0 for a facility on any given day were excluded.

Qualitative and quantitative data sets were integrated to answer the question, Do nursing home administrator perspectives on staffing in US nursing homes during the COVID-19 pandemic provide context for conflicting staffing data reports? The 3 themes generated by qualitative analysis prompted the development of 4 analytic measures to statistically evaluate facility-level data for the study sample. Qualitative themes were compared with quantitative measures to assess whether administrator experiences with nursing home staffing levels were supported by facility-level data and whether administrator perspectives provided an explanation for how staffing challenges were addressed.

This mixed-methods study included 156 total interviews with 40 nursing home administrators in 8 markets across the US. Although specific demographic information was not gathered, participants were licensed nursing home administrators who self-reported a range of education levels and backgrounds, including nursing, social work, business administration, health care administration, public administration, finance, and marketing. Experience in nursing homes ranged from several months to more than 30 years. Nursing home characteristics are presented in Table 1 .

Using modified grounded theory 29 and thematic analysis, 30 3 major themes that reflect administrator perspectives on nursing home staffing from July 14, 2020, to December 16, 2021, were identified. In theme 1, administrators report on the substantial staffing shortages they experienced during the pandemic. Themes 2 and 3 present major strategies administrators used to offset immediate staffing shortages including hiring agency staff (theme 2) and operating at a reduced resident census (theme 3). Embedded within each theme are concepts that support the theme. Themes, concepts, and illustrative quotations are summarized in Table 2 .

Quantitative analysis of facility-level staffing data assessed changes found in the study sample of nursing homes from January 1, 2020, to September 30, 2022. In measure 1, study nursing homes experienced large reductions in total direct care staff hours throughout the study period ( Figure 1 A). Measure 2 showed that study nursing homes experienced reductions in direct care staff hours per resident-day throughout the study period ( Figure 1 B). Measure 3 indicated that the census at study nursing homes decreased substantially from March 1, 2020, to January 1, 2021 ( Figure 2 ). Measure 4 analyses showed that study nursing homes increased their use of agency staff for all levels of direct care throughout the study period ( Figure 3 ). As a validity check, quantitative results for measures 1 through 4 were compared with the same measures developed for the national sample of 15 436 nursing homes. Changes found for measures 1 to 4 in the study sample of nursing homes were comparable to national changes ( Figure 1 , Figure 2 , and Figure 3 ).

Thematic results from qualitative analysis were merged and compared with the quantitative results of facility-level staffing data measures. Theme 1 results were evaluated against measures 1 and 2 findings, theme 2 was assessed by measure 4 findings, and theme 3 was evaluated by measure 3 for evidence of agreement.

One administrator reflected on the challenge of finding staff throughout the pandemic: “With that many staff members out [due to COVID-19 infection], we had an extreme staffing crisis. There was nobody to help.” (S5N1.3, March 2021). Administrators described an ongoing struggle to maintain safe staff-to-resident ratios, “be in compliance when it comes to staffing” (S6N4.3, June 2021), and provide “good customer service” (S2N4.4, August 2021). Since nursing homes are required to maintain compliance with state and federal regulations around safe staff-to-patient ratios, administrators used compensatory strategies, such as overtime, cross-training, and increasing staff-to-resident ratios to balance regulatory requirements with staffing shortfalls at their facilities. Table 2 , theme 1, provides representative quotations.

Using PBJ data to assess staff hours per resident-day per week, our analyses substantiate the qualitative findings indicating that nursing homes faced staffing challenges during the COVID-19 pandemic (theme 1). In support of theme 1, our analyses showed a decrease in total direct care staffing hours for study sample nursing homes throughout the study period (July 14, 2020, to December 16, 2021) (measure 1). As noted in theme 1, administrators used various strategies to compensate for staff shortages and remain in regulatory compliance. Measure 2 analyses of staff hours per resident-day support administrator reports and show an increase of staff hours per resident-day at the outset of the pandemic. The impact of staff shortages extended beyond a facility-wide COVID-19 outbreak with staff hours per resident-day decreasing over time. This was evident at the facilities composing our study sample which, although slightly higher than the national trend, followed the national trend trajectory through December 2021. We continued our analyses through 2022 and found the facilities in our study sample followed national trends but at a higher rate ( Figure 1 A, B).

To compensate for staffing shortages, many nursing home administrators brought in agency staff to maintain facility functionality and meet regulatory compliance requirements. As one administrator noted: “We’re still utilizing agency, and all of that to be able to keep the building staffed according to the guidelines” (S6N4.4, September 2021). For some administrators, it was the first time (S2N4.2, February 2021) they had ever needed to rely on agency staff. Hiring agency staff proved problematic during the pandemic as the demand for agency staff soared due to competition with hospitals and other health care settings. As a result, administrators found that agencies could demand high payments for service that was often unreliable. Administrators expressed concerns about the prioritization by agency staff of monetary reward, which negatively impacted existing staff morale and resident care. Table 2 , theme 2 presents representative quotations.

Our quantitative analyses using PBJ data support our qualitative findings that nursing home administrators hired agency staff to manage staffing shortages at all levels of patient care (measure 3). Quantitative analyses showed a corresponding change of increasing agency use in both our sample of 40 nursing homes and nationally throughout the study period (July 14, 2020, to December 16, 2021), and continuing in 2022. Additionally, our analyses reflect the increase in agency use by nursing homes for all levels of nursing staff: RNs, LPNs, and CNAs. For our study sample, agency RNs were increasingly used over the course of the study period but at a lower rate than the national average; LPN and CNA agency staff, however, were used at rates higher than national averages by the 40 nursing homes in our study ( Figure 2 ).

A longer-term impact of staff shortages was nursing homes being unable to increase their admissions and census. As one administrator noted: “Yeah, the only restraint on us getting a little bit higher census is staffing issues. We’re running into staffing issues” (S5N2.4, July 2021). For many administrators, low staffing levels impacted their ability to increase their resident census. Thus, curtailing admissions was their only recourse until additional staff could be hired. Table 2 , theme 3, presents representative quotations.

Analyses of PBJ data substantiated administrator reports of a decrease in resident census (theme 3). Our analyses (measure 3) found that the number of nursing home residents in our study sample decreased substantially in March 2020 and continued to decrease through January 2021—a trend also found nationally. As nursing home administrators reported, resident census increased through 2022 but, at the time of the study, had not yet reached prepandemic levels ( Figure 3 ).

This study of nursing home administrator perspectives and facility-level staffing data aimed to address a critical gap in understanding how nursing homes met minimum staffing levels and remained operational while experiencing substantial staffing shortages. Using both quantitative and qualitative data, this study may help illuminate crucial ways nursing homes have dealt with the pandemic with 3 important findings.

First, while aggregate staffing and resident census data suggest that resident-to-staff ratios remained stable in the earlier part of the pandemic as a result of the decreasing resident census, our qualitative data provide an important explanatory context not shown by these analyses. Administrators used crisis management compensatory strategies to meet regulatory staffing minimums and maintain operations. As administrators noted, increasing resident-to-staff ratios, hiring agency staff, and reducing resident census enabled them to comply with regulations and continue to care for residents.

Second, although the compensatory strategies administrators used addressed an immediate staffing crisis created by the pandemic, these measures came with a financial cost. Increased staff overtime pay, the high cost of agency staff, and the decreased revenue from new resident admissions has had major financial influences on nursing homes already coping with high operational costs due to the pandemic. 35 - 37

Third, the stop-gap compensatory mechanisms administrators used to maintain operations have only exacerbated staff burnout. Not only have staff had to manage higher caseloads, they have had the additional burden of supervising and training temporary agency staff unfamiliar with facility protocols. This raises concerns for quality of care at nursing homes as staff burnout and high turnover 38 , 39 have been reported to be associated with poor resident outcomes. 40 - 42

Staffing ratios alone are an incomplete picture of the staffing environment in nursing homes, particularly in the midst of a public health crisis. It took an immense effort with substantial financial and staff costs for nursing homes to maintain minimally adequate staffing ratios and remain operational during the pandemic. The long-term consequences of these compensatory strategies will likely greatly affect the stability of an already strained workforce. 9

This study has several limitations. First, although our sample size of 40 nursing home administrators in 8 health care markets is robust for qualitative research, our findings may not be generalizable to all US markets and all nursing homes. Our quantitative analyses for facilities participating in this study, however, showed trends that were consistent with national trends. Second, while quantitative analyses continued through September 2022 and show trends continuing, our interviews were conducted between July 14, 2020, and December 16, 2021. Although we were able to capture administrator perspectives close to the beginning of the pandemic, we were not able to explore administrator perspectives into 2022. Third, our interviews focused on nursing home administrator perspectives, which may not represent staff perceptions as they responded to the loss of colleagues and patients, increased workloads, and the influx of agency help.

Findings from this qualitative mixed-methods study may have implications for future research and policy. The dual approach of quantitative and qualitative analyses provides depth and context to our understanding of complex topics such as staffing and nursing home care. It remains unclear how long the crisis adaptation techniques nursing home administrators used can persist without major effects on staff and resident safety. More mixed-methods research is needed to better understand the long-term outcomes of the COVID-19 pandemic associated with nursing home staffing and how policies and regulations around staffing during a crisis, such as a pandemic, have aided or limited the efficacy of administrator responses to maintain quality care for their residents. Policymakers should consider reviewing current nursing home regulations around staffing and work with nursing home administrators to create policies that more nimbly adjust to crisis management.

Accepted for Publication: June 15, 2023.

Published: July 27, 2023. doi:10.1001/jamanetworkopen.2023.25993

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Brazier JF et al. JAMA Network Open .

Corresponding Author: Joan F. Brazier, MS, Brown University School of Public Health, 121 S Main St, Box 6, Providence, RI 02903 ( [email protected] ).

Author Contributions: Ms Brazier and Dr Gadbois had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Brazier, Meehan, White, McGarry, Shield, Rahman, Gadbois.

Acquisition, analysis, or interpretation of data: Brazier, Geng, Meehan, McGarry, Shield, Grabowski, Rahman, Santostefano, Gadbois.

Drafting of the manuscript: Brazier, Meehan, Rahman.

Critical review of the manuscript for important intellectual content: Meehan.

Statistical analysis: Geng, McGarry, Santostefano, Gadbois.

Obtained funding: Rahman.

Administrative, technical, or material support: Brazier, Meehan, McGarry, Rahman, Santostefano, Gadbois.

Supervision: Shield, Grabowski, Rahman, Gadbois.

Conflict of Interest Disclosures: Dr Grabowski reported receiving personal fees from the AARP, Analysis Group, GRAIL LLC, and Medicare Payment Advisory Commission outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by the Warren Alpert Foundation (D.C.G. and M.R.).

Role of the Funder/Sponsor: The Warren Alpert Foundation had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2 .

Additional Contributions: Aseel Rafat (Brown University), provided substantial editorial contributions to this article; no financial compensation was provided.

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Owner Incentives and Performance in Healthcare: Private Equity Investment in Nursing Homes

Amid an aging population and a growing role for private equity (PE) in elder care, this paper studies how PE ownership affects U.S. nursing homes using patient-level Medicare data. We show that PE ownership leads to lower-risk patients and increases mortality. After instrumenting for the patient-nursing home match, we recover a local average treatment effect on mortality of 11%. Declines in measures of patient well-being, nurse staffing, and compliance with care standards help to explain the mortality effect. Overall, we conclude that PE has nuanced effects, with adverse outcomes for a subset of patients.

We are grateful to Abby Alpert, Pierre Azoulay, Zack Cooper, Liran Einav, Paul Eliason, Arpit Gupta, Jarrad Harford, Steve Kaplan, Holger Mueller, Aviv Nevo, Adam Sacarny, Albert Sheen, Arthur Robin Williams, numerous seminar participants, and two anonymous referees for their comments and suggestions. Jun Wong, Mei-Lynn Hua, and Sarah Schutz provided excellent research assistance. A previous version of this paper was titled “Does Private Equity Investment in Healthcare Benefit Patients: Evidence from Nursing Homes." Funding from the Wharton Mack Institute and the Laura and John Arnold foundation (Gupta, Yannelis), the Kauffman Foundation (Howell), and the Fama Miller Center at the University of Chicago (Yannelis) is greatly appreciated. We gratefully acknowledge funding through National Institute of Aging pilot grant P01AG005842-31. All remaining errors are our own. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

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• February 16, 2021

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• How Patients Fare When Private Equity Funds Acquire Nursing Homes Author(s): Atul Gupta Sabrina T. Howell Constantine Yannelis Abhinav Gupta Purchases of nursing homes by private equity firms are associated with higher patient mortality rates, fewer caregivers, higher...

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Atul Gupta & Sabrina T Howell & Constantine Yannelis & Abhinav Gupta & Gregor Matvos, 2024. " Owner Incentives and Performance in Healthcare: Private Equity Investment in Nursing Homes, " The Review of Financial Studies, vol 37(4), pages 1029-1077.

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Developing ash-free high-strength spherical carbon catalyst supports

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• Published: 28 June 2013
• Volume 5 , pages 156–163, ( 2013 )

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• V. V. Gur’yanov 1 ,
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The possibility of using furfurol for the production of ash-free high-strength active carbons with spheroidal particles as adsorbents and catalyst supports is substantiated. A single-stage process that incorporates the resinification of furfurol, the molding of a spherical product, and its hardening while allowing the process cycle time and the cost of equipment to be reduced is developed. Derivatographic, X-ray diffraction, mercury porometric, and adsorption studies of the carbonization of the molded spherical product are performed to characterize the development of the primary and porous structures of carbon residues. Ash-free active carbons with spheroidal particles, a full volume of sorbing micro- and mesopores (up to 1.50 cm 3 /g), and a uniquely high mechanical strength (its abrasion rate is three orders of magnitude lower than that of industrial active carbons) are obtained via the vapor-gas activation of a carbonized product. The obtained active carbons are superior to all known foreign and domestic analogues and are promising for the production of catalysts that operate under severe regimes, i.e., in moving and fluidized beds.

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Burushkina, T.N., Zh. Ross. Khim. O-va im. D.I. Mendeleeva , 1995, vol. 39, no. 6, p. 122.

CAS   Google Scholar  

Kryazhev, Yu. G., Abstract of Papers, Materialy XII vserossiiskogo simpoziuma s uchastiem inostrannykh uchenykh “Aktual’nye problemy teorii adsorptsii, poristosti i adsorptsionnoi selektivnosti” (Proc. of XII th All-Russia Symposium with the Participation of Foreign Scientists “Urgent Problems of the Theory of Adsorption, Porosity, and Adsorption Selectivity”), Moscow, 2008, p. 69.

Google Scholar  

Kartel’, N.T., in Adsorbtsiya, adsorbenty i adsorbtsionnye protsessy v nanoporistykh materialakh (Adsorption, Adsorbents, and Adsorption Processes in Nanoporous Materials), Tsivadze, A.Yu., Ed., Moscow: Granitsa, 2011, p. 381.

RF Patent 2026813, 1993.

RF Patent 2257343, 2003.

RF Patent 2301701, 2006.

Dubinin, M.M., Zaverina, E.D., Ivanova, L.S., Kaverov, A.T., and Kasatochkin, V.I., Rus. Chem. Bull. , 1961, vol. 10, no. 1, p. 14.

Article   Google Scholar  

Usenbaev, K. and Zhumalieva, K., Rentgenograficheskoe issledovanie struktury i termicheskikh preobrazovanii amorfnykh uglerodov (X-ray Study of the Structure and Thermal Transformations of Amorphous Carbons), Frunze: Mektep, 1976.

Gur’yanova, L.N. and Gur’yanov, V.V., Zh. Fiz. Khim. , 1984, vol. 58, no. 6, p. 1459; 1989, vol. 63, no. 1, p. 161; 1989, vol. 63, no. 2, p. 426; 1989, vol. 63, no. 3, p. 683.

Guryanov, V.V., Petukhova, G.A., and Dubinina, L.A., Prot. Metal. Phys. Chem. Surf. , 2010, vol. 46, no. 2, p. 191.

Article   CAS   Google Scholar  

Guryanov, V.V., Dubinin, M.M., and Misin, M.S., Zh. Fiz. Khim. , 1975, vol. 49, no. 9, p. 2374.

Gur’yanov, V.V., Petukhova, G.A., and Polyakov, N.S., Rus. Chem. Bull. , 2001, vol. 50, no. 6, p. 974.

Dubinin, M.M., Carbon , 1989, vol. 27, no. 3, p. 457.

Belyaev, N.M., Soprotivlenie materialov (Strength of Materials), Moscow: Nauka, 1976.

Temkin, I.V., Proizvodstvo elektrougol’nykh izdelii (Production of Electrocarbon Articles), Moscow: Vysshaya shkola, 1980.

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Gur’yanov, V.V., Mukhin, V.M. & Kurilkin, A.A. Developing ash-free high-strength spherical carbon catalyst supports. Catal. Ind. 5 , 156–163 (2013). https://doi.org/10.1134/S2070050413020062

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Received : 08 December 2011

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Issue Date : April 2013

DOI : https://doi.org/10.1134/S2070050413020062

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