Montessori Impacts on Long-term Care Staff: Results of a Stepped-Wedge Cluster Randomized Trial

Innovation in Aging · 2025-12-01

Abstract Person-centered care practices and staff outcomes have been associated in cross-sectional studies in long-term care settings. However, few clinical trials have examined changes in staff outcomes following introduction of a person-centered intervention delivered to residents. This study is among the first to examine the impact of Montessori approaches on staff outcomes for an intervention focused on meaningful engagement, strengths identification, empowerment, and dignity support of residents. We conducted a hybrid type 3 effectiveness-implementation study in 8 US Veterans Health Administration Community Living Centers (CLCs, VA nursing homes) using a stepped wedge cluster randomized trial design. Staff completed online surveys of perceptions of implementation success and effectiveness during pre-intervention or control time points (i.e., baseline and 1-month before baseline, N = 229) and post-intervention (i.e., 3-months and 6-months after training, N = 218). Changes were modeled over time using generalized estimating equations. Implementation results indicated significant changes in perceptions about whether Montessori would become/was a normal part of routine care within their CLC (p < .001). Staff-reported effectiveness outcomes reflected post-intervention changes of lower staff burnout scores (p = .028) and higher person-centered care scores (p = .014) on a social connectedness and individualized care and services scale. Collection of survey data from staff about their experiences expands understanding of both implementation and effectiveness outcomes in clinical trials of non-pharmacological interventions. Approaches like Montessori may have the potential to improve both person-centered care practices for residents and outcomes for the long-term care staff workforce.

“One Size Doesn’t Fit All”: Design Considerations for an Exercise Program to Improve Physical Function in Older Veterans with Serious Mental Illness

International Journal of Environmental Research and Public Health · 2025-01-29 · 2 citations

Older adults with serious mental illness (SMI) (i.e., schizophrenia, schizoaffective disorder, bipolar disorder) have compromised physical function that adversely affects their quality of life. Exercise is an effective intervention to improve function in older persons; however, older people with SMI experience barriers to exercise engagement. This study sought to obtain feedback on an exercise program in development for older people with SMI that comprised home-based exercise delivery, individualized exercise prescription, and motivational health coaching calls. Individual interviews and focus groups were conducted with older Veterans with SMI (n = 3) and clinical staff serving this population (directors: n = 3; clinicians: n = 15, k = 3) to elicit feedback on the perceived feasibility and acceptability of the preliminary program and recommendations for modifications to the program. Rapid analysis was used to summarize transcripts of audio-recorded interviews and focus groups. Results indicated a strong perceived feasibility and acceptability of the preliminary intervention because of how the individualized exercise prescription component (i.e., exercise plan) would be personalized to the Veteran’s preferences and abilities. Clinical staff participants expressed concerns about how the lack of real-time supervision would negatively affect exercise completion. Participants recommended tailoring the home-based exercise delivery and motivational health coaching calls components to each Veteran’s unique context.

Participation in the Long-Term Care Equality Index to Support Older LGBTQ+ Military Veterans

Innovation in Aging · 2025-12-01

Abstract There are more than 500,000 older LGBTQ+ Veterans currently living in the United States. The US Veterans Health Administration (VHA) aspires to align care preferences to individualized goals and to offer high quality care to all Veterans. Consistent with these priorities, a growing number of VHA Community Living Centers (CLCs) have participated in the Long-Term Care Equality Index (LEI) developed by the Human Rights Foundation and the national Advocacy & Services for LGBTQ Elders group (SAGE). We used mixed methods to describe the formative evaluation process used to complete the LEI tool in 2023 and again in 2025 in a 150-bed CLC in the Deep South that specializes in long-term care, dementia care, mental health recovery, and hospice/palliative care. LGBTQ+ Veterans, CLC residents, clinicians, and administrators contributed to the LEI completion in 2023 resulting in a High Performer designation. Scores across all 4 domains of the LEI were maintained at 100% (foundational policies) or increased in demonstrated best practices from 2023 to 2025 (i.e., 60% to 73% in resident services/supports, 58% to 67% in employee benefits/policies, and 14% to 29% in resident/community engagement). Online trainings were completed by more than 50% of CLC staff (N = 212) with 59.1% (n = 127) completing an introductory course and 56.3% (n = 120) completing modules on sexual orientation or care for older gender diverse Veterans. In conclusion, the LEI offers an opportunity for residential communities to identify, measure, and share best practices within healthcare systems to improve care quality for all residents.

“They’re quite talented”: Nursing Assistant Scope of Practice in VHA Community Living Centers

Innovation in Aging · 2025-12-01

Abstract The U.S. Veterans Health Administration (VHA) operates its skilled nursing homes, known as Community Living Centers (CLCs), using different structures to support nursing assistants (NAs) and nurses’ delivery of care to complex patients as compared to community nursing homes. Structures include adequate staffing, safe patient handling programs and equipment access, effective nurse supervision, higher wages with benefits, and the ability to hire and train NAs without certifications but with relevant healthcare experience in response to recruitment/retention challenges. Thus, a pilot study examined NA training aspects within 4 CLCs in the New England region. Seventeen NAs and 13 nurse leaders (i.e., nurse managers, educators, clinical resource nurse, chief nurse) completed individual interviews (July-October 2024), and a team employed qualitative content analysis using a coding frame based in the Paraprofessional Healthcare Institute (PHI) 5 Pillars of Job Quality. Four themes emerged related to NA scope of practice and care quality: (1) NAs learn advanced clinical skills in partnership with nurses (e.g., electrocardiogram, catheter placement and care); (2) Skills acquisition occurs over years of repetition; (3) Skills are context dependent (e.g., hospice, dementia, subacute); and (4) Insufficient standardization, tailored training, and training resources negatively impact care delivery. In VHA CLCs with nursing oversight and sufficient resources, NA scope of practice appears much greater than in community nursing homes. Research-practice partnerships to design and test learner-centered education using evidence-based models and technologies could benefit current and new NAs by anticipating skills needed with a new admission or using dementia care scenarios with microlearning.

Facilitators of Nursing Assistant Job Commitment and Career Retention in VHA Community Living Centers

Innovation in Aging · 2025-12-01

Abstract Job satisfaction matters for the retention of long-term care aides; however, we know little about this in the Veterans Health Administration (VHA) setting. This study examined the facilitators and barriers to NA job commitment in VHA Community Living Centers (CLCs; VHA nursing homes). We recruited 4 CLCs and interviewed 6-9 staff at each (N = 30), of which 17 were NAs and 13 were nurse leaders. We employed qualitative content analysis based on codes relating to Paraprofesional Healthcare Institute’s (PHI) Five Pillars of Direct Care Job Quality. 100% (N = 17/17) of NAs reported intention to remain employed at the CLC in the next 12 months and/or reported high job satisfaction. Interviewees reported many factors related to job commitment and satisfaction. Facilitators included VA benefits (e.g., healthcare, retirement), passion for NA work, relationships with the Veterans, favorable work conditions (e.g., workload, safe patient handling equipment, training, steady work), and a supportive work environment (e.g., supportive managers/coworkers, teamwork). Suggestions for improvement in retention included addressing dissatisfaction with pay (e.g., non-competitive, pay caps), scheduling, career advancement, staffing (e.g., shortage, human resource (HR) challenges), management practices (e.g., mandatory overtime, inability to take requested leave, floating), staff- and resident-to-staff interactions (e.g., disrespect), and structural supports (e.g., no onsite HR). Job commitment and satisfaction are multilayered. Despite desiring certain changes, NAs remain committed to their roles. VHA nursing home care has been affected by general nursing workforce shortages. Promoting policy change related to NA wages and pay caps concurrent with supportive training, scheduling, and employee wellness may improve retention.

Nursing Assistant Training in VHA Community Living Centers: Resources and Recommendations

Innovation in Aging · 2025-12-01

Abstract Quality training is one component of direct care job quality in long-term care based on non-VA research. This study aimed to identify patterns in nursing assistant (NA) training in Veterans Health Administration Community Living Centers (CLCs; nursing homes). We recruited 2 high-performing and 2 low-performing CLCs based on NA intent to stay from a 2022 survey and completed 6-9 interviews at each (N = 30). We employed qualitative content analysis based on Paraprofessional Healthcare Institute’s (PHI) Five Pillars of Direct Care Job Quality to understand training factors impacting intent to stay. The high-performing CLCs (88% average intent to stay) provided structured and well-coordinated orientation, longer floor orientation, offered NA skills workshops, and leveraged existing relationships with clinical resource nurses (CRNs) who supplemented nurse manager coaching. Whereas the low-performing CLCs (32% average intent to stay) had less well coordinated orientations, shorter floor orientation, lacked regular skills workshops, experienced turnover in nurse educator/CRNs, and reported NA training as an area needing improvement. Recommendations included: NA-tailored, standardized training in various topics (i.e., mental health, dementia, end-of-life, nursing) and more continuing education; synergizing NA and nurse educator/CRN relationships and directly communicating with NAs about training opportunities; and modifications needed to address barriers related to time, staffing, computer access and learning preferences. This study confirms the importance of training to NA job satisfaction in VHA CLCs. Ways to improve training and access to training (e.g., microlearning) may improve job satisfaction and retention.

Nursing Home Staff  With Children: Unique Needs Among Single and Partnered Parents

The Gerontologist · 2024-10-30 · 1 citations

BACKGROUND AND OBJECTIVES: Nursing home (NH) staff job dissatisfaction and turnover are associated with lower care quality. However, little is known about the impact of being single on workplace experiences. Guided by the Job Demands-Control-Support Model, we compared job satisfaction, turnover intention, and psychological distress for single and partnered parents working in NHs. RESEARCH DESIGN AND METHODS: Employee and manager data from the 2011 to 2012 wave of the Work Family Health Network study were combined (N = 1,144) to define parents with complete data (N = 586). Bivariate tests and multivariate regressions clustering observations within NHs were used. RESULTS: Most single parents (n = 190, 32%) were nursing assistants (NAs; n = 142, 74.74%) or licensed practical nurses (LPNs; n = 29, 15.26%). Compared with partnered parents, single parents were similar on turnover intention and job satisfaction, but they were more likely to report distress (OR = 1.79, 95% CI 1.09, 2.94) observed only among NAs (OR = 2.08, 95% CI 1.12, 3.85). Psychological distress was associated with greater turnover intent (β = 0.02, p < .05) among NAs and LPNs, yet only among single parents (β = 0.04, p < .01). Distress was more likely with higher family-to-work conflict (OR = 1.67, 95% CI 1.18, 2.36) and work-to-family conflict (OR = 1.60, 95% CI 1.20, 2.14) among licensed nurses, yet the distress-work-family conflict associations were only significant for partnered parent nurses. DISCUSSION AND IMPLICATIONS: Supporting NH staff depends upon knowing their parental, relationship, and occupational status. Additional research is needed to understand and develop strategies to mitigate psychological distress and increase resources particularly among NA single parents employed in NHs.

LONGITUDINAL QUALITATIVE RESULTS FROM STAFF IMPLEMENTING MONTESSORI DURING THE PANDEMIC

Innovation in Aging · 2024-12-01

Abstract Promoting autonomy, dignity, and independence are core values of Montessori approaches to person-centered care in nursing homes. Yet infection control precautions restricted staff and resident freedoms during the COVID-19 pandemic. We describe longitudinal data from a stepped-wedge, randomized clinical trial examining implementation and effectiveness of Montessori approaches in eight Department of Veterans Affairs nursing homes (2021-2023). COVID-rates were calculated from electronic health records (EHRs) and graphed over 18 months around the intervention. Staff (N=168) participated in qualitative individual or group interviews at baseline, 3-, 6-, 9-, and 12-months. Normalization Process Theory informed questions and qualitative content analysis about the effects of COVID-19 on Montessori implementation and staff experiences. Transcripts were coded by members of the study team using NVivo. There was variability in COVID rates: most NHs concentrated below 1% of resident-days with COVID and occurred after 3-months of Montessori training/implementation, while two sites experienced peaks of 5% and 15%. Qualitative themes across implementation included: 1) Staff described fluctuating waves of COVID, changes in precaution protocols, and variable policy interpretations across sites to be associated with negative impact on residents and staff (isolation, loneliness, burden, burnout, low morale). 2) Staff identified creative adaptations (e.g. walkie-talkies) to implement Montessori within precaution protocols. 3) Staff reported that Montessori principals improved morale, mitigated negative effects of the pandemic and related precautions, and created a pathway for increased advocacy for person-centered care and resident wellbeing despite risks. Findings highlight the importance of reinforcing person-centered care in the midst of safety concerns during crisis.

Trends and geographic differences in social work telehealth utilization

Social Work in Health Care · 2024-03-26 · 3 citations

We plotted trends in social work telehealth use among Veterans in a U.S. national social work staffing program and examined the relationship between geographic factors (rurality and neighborhood disadvantage) and telehealth use (audio and video) using linear probability models. Social work telehealth use increased among Veterans during the COVID-19 pandemic. There were no geographic differences in telephone telehealth use. Video telehealth use was less common among Veterans in isolated rural areas and among Veterans in highly disadvantaged areas. Outreach efforts can address barriers that Veterans who live in rural and disadvantaged areas may experience in using video telehealth.

TRAUMA-INFORMED CARE IN LONG-TERM CARE SETTINGS

Innovation in Aging · 2024-12-01

Abstract By older adulthood, most older adults will have been exposed to at least one potentially traumatic event. Older veterans are likely to experience three traumatic events during their lifetime, with 93% reporting exposure to at least one event. The prevalence of posttraumatic stress disorder (PTSD) among older adults is lower. Nevertheless, the long-lasting psychological effects of trauma can manifest in later life, exacerbated by the normative experiences of aging (e.g., medical illness, loss of loved ones, retirement) and encounters with medical settings. Receiving care in skilled nursing settings, may trigger traumatic memories or exacerbate PTSD of symptoms. As the population ages, more individuals will receive care in long-term care environments, leading to increased risk of worsening PTSD and re-engagement with past traumatic memories and experiences. Staff in long-term care facilities may not have skills or knowledge needed to address symptoms or reduce re-traumatization (i.e., utilize a trauma-informed care approach). Trauma-informed care is an approach that utilizes knowledge of the effects of trauma to meet survivors’ healthcare needs, through collaborative care and recognition of patient strengths in managing their health. This approach is mandated in skilled nursing facilities; however, no models of trauma-informed care practice in long-term care exist. This symposium will review the effects trauma and PTSD in later life, the effects of medical settings on PTSD, and provide a framework for implementing trauma-informed care in long-term care settings.