Rapid review summary

The international research evidence reports varying rates of staff burnout across the aged care sector prior to the COVID-19 pandemic. These range from low to moderate [8, 9] and moderate to high levels of burnout in aged care settings [10, 11] with approximately 30-50% of staff providing direct care reportedly affected. [12-15] Before the 2020 pandemic hit the sector hard, this rate was also shown to be gradually increasing. [9, 10] Younger care workers appear to be more susceptible to burnout. [16] However, those who have been working longer in aged care also show high rates of burnout. [17, 18]

Staff burnout is a complex occupational phenomenon that appears to have interrelated personal, interpersonal, and organisational dimensions. While many of the studies identified in this review could only suggest potential causes of burnout, workplace stress and how a person responds to it appear to be important risk factors.

Personal factors 

Some factors associated with burnout reflect the worker’s personal circumstances. For example, people with high levels of burnout tend to:  

• Speak English as a second language [8, 19] 
• Have personal health issues, including musculoskeletal pain or mental health concerns [19, 20] 
• Experience poor sleep quality. [21] 

How the individual reacts to workplace issues can also influence their level of stress and the potential to experience burnout. Significant risk factors of this kind include: 

• Feeling moral distress at witnessing situations, or being required to work in ways, that clash with personal values and ethics [22-25] 
• Experiencing unresolved grief when a client/resident dies [26-31] 
• Relying on dysfunctional or avoidance coping strategies under pressure. [21, 28, 32, 33] 

Interpersonal factors

The relationships between staff and residents/clients, their friends and family members, [28, 31, 34] and with managers and co-workers [33, 35, 36] can contribute to stress and lead to burnout. Staff who develop close relationships with the people they care for may experience strong grief at their death which can impact their mental health if dismissed as trivial by management and co-workers. [37]

Staff who provide care to people living with dementia are reported to experience burnout when they feel they lack the training and skills to deal with responsive behaviours or experience distress at not being able to communicate with those in their care. Witnessing continued deterioration can also contribute to feelings of stress.  [19, 28, 31, 38-40]

Staff also report stress at being unable to discuss changing goals of care with a person’s family and/or friends as the end of life approached. [29] Verbal or even physical abuse from residents, their family or friends can also cause distress and lead to burnout symptoms. [26, 41-44]

Lacking a sense of team or feeling isolated from colleagues through lack of contact and information sharing are further risk factors for staff burnout. [31, 33] Management can contribute to staff stress and burnout by not recognising and rewarding their work [35, 36] or by being highly controlling and not allowing them to exercise decision-making or voice concerns over working conditions and client care quality. [17, 45-47]

Organisational factors 

How care delivery is structured at the organisational or facility level can put staff at risk of burnout. Frequently reported sources of risk in aged care workplaces include:

• Workloads that staff perceive as heavy [33, 36, 48] 
• Long working hours [32, 33, 35, 36] 
• Time pressures, [11, 13, 36, 49-51] especially when they interfere with providing person-centred care [33] 
• Not having adequate material resources to do the job well [17] 
• Sense of job insecurity [36, 52] 
• A sense that one has not received adequate training for the job [22, 33, 35, 50] 
• Inadequate staff mix leading to working outside one’s scope of practice [50] 
• Lack of belief in the quality of care provided by the organisation. [53, 54]  

For the worker, burnout reduces their level of job satisfaction [15, 25, 46, 47, 55-60] and work-life balance, [61-63] leading potentially to an intention to leave the organisation. [64-72] Burnout has been linked to longer-term chronic conditions such as coronary heart disease and type 2 diabetes [73] and may impact staff mental health and wellbeing, leading to depression and anxiety. [9, 74] When staff feel stressed, they are also more prone to errors in decision making and task performance. [75-77]

Burnout reduces organisational productivity through staff absenteeism [12, 33, 78] and may lead to high rates of workforce turnover. [66] It also has serious implications for quality of care [25] with staff affected reporting that they are less patient-centred in their approach [79] and more likely to delay or miss providing some essential care tasks altogether. [14, 15, 80, 81] Staff with burnout may demonstrate more hostile behaviour [82] or become abusive towards those in their care. [83]

Research studies on burnout suggest a range of actions that organisations might undertake to protect their staff from burnout. Many of these focus on reducing workload and increasing resources for staff to feel they have provided a high quality of care. They suggest: 

• Assessing and reducing levels of work stress [84]
• Providing appropriate levels of material resources [52, 85]
• Creating flexible work schedules that work in well with people’s non-work responsibilities [86]
• Enabling staff to spend enough time with care recipients to perceive they have provided good care [33, 84]
• Facilitating rather than giving lip service to person-centred care practices [87]
• Fostering a strong sense of team by providing staff with opportunities to engage with co-workers. [17, 45, 60, 68, 88]

Other actions involve increasing the individual worker’s sense of confidence and competence in their role. These actions include:  

• Providing adequate job training opportunities [17, 83, 85]
• Authorising staff to make decisions [89]
• Creating work roles with enough complexity to provide challenge and enhance their sense of professional accomplishment [28]
• Acknowledging and rewarding the hard work of staff [17, 45, 46, 49, 60, 84, 85, 88-91]
• Providing staff with a voice to express concerns about care quality. [92]

Research indicates working conditions for aged care staff working in residential facilities deteriorated at the onset of the global COVID-19 pandemic. [93, 94] New occupational stresses were added to existing ones with staff, including facility managers, required to work longer hours to cover for staff shortages due to illness or self-isolation. [95-98] New and challenging tasks were introduced to protect residents such as wearing personal protective equipment (PPE) and routine disinfecting, screening for symptoms, and enforcing restrictions on visits to the facility from family and friends. [96, 99] Staff were also required to keep up with and adhere to new and constantly changing public health advice and regulations aimed specifically at the sector. [94, 96] Early in the pandemic, aged care managers struggled to acquire adequate quantities of PPE and cleaning supplies which added to the weight of responsibility they felt for staff and residents. [94, 95, 100] This led them to feel anxious and ‘burned out’. [93, 101] Staff also describe feeling distressed and emotionally exhausted from:

• A constant fear of bringing the virus into their home or the facility [94, 97, 98, 100, 102, 103]
• Seeing residents inactive, understimulated and isolated from their families and friends [95, 100-102]
• Witnessing the confusion and distress of people with dementia who did not understand the changes [93, 102]
• Having no time to provide person-centred care [93, 96]
• Experiencing high rates of resident deaths and not having time to mourn this loss [96, 97]
• Dealing with relative anger and distress [93, 97, 100, 102]
• Being stigmatised by the media and coming under intense public scrutiny. [93, 94]

COVID-19 was also a catalyst for change for some aged care organisations. [95, 98] Staff were provided with additional training opportunities, [98, 100] increased communication from management, [95, 98, 100, 104] and gained more contact time with colleagues through an increase in meetings and social time spent together. [95, 97] Management-initiated support groups, meditation classes and quiet spaces may have also increased awareness of the importance of staff mental health and wellbeing and personal coping resources. [100, 104]

A variety of interventions to help prevent and address staff burnout are available. Most focus on staff providing care to people living with dementia [84, 105-111] and many measure staff burnout as a secondary, rather than primary outcome. This seems to imply that if care recipients are managed appropriately, staff will be less likely to experience burnout. Interventions that appear effective in reducing rates of staff burnout include self-efficacy [108] and self-care skills and compassion fatigue awareness training. [112] At the time of the COVID-19 pandemic, a web-based stress management programme focused on nurses’ work-related stress was found effective. [113]

Aged care providers have an obligation to provide safe workplaces for their staff. Burnout rates are particularly high in aged care settings and are likely to have worsened since the COVID pandemic, although the evidence of this is, to date, largely from qualitative studies. Organisations can make a raft of changes to improve staff mental health and wellbeing while simultaneously improving efficiency through reduced staff absenteeism and turnover. The evidence suggests that addressing burnout will also lead to improved care quality and better outcomes for residents and clients.

1. Maslach C, Leiter MP. Understanding the burnout experience: Recent research and its implications for psychiatry. World Psychiatry. 2016 Jun;15(2):103-11.  
2. Schaufeli WB, Desart S, De Witte H. Burnout Assessment Tool (BAT)—Development, validity, and reliability. Int J Environ Res Public Health. 2020;17(24):9495.  
3. Maslach C, Leiter MP. Understanding burnout: New models. In: Cooper CL, Quick JC, editors. The handbook of stress and health: A guide to research and practice. Chichester, UK: Wiley Blackwell; 2017. p. 36-56. 
4. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Dev Psychol. 2001;52:397-422. 
5. Figley CR. Introduction. In: Figley CR, editor. Treating compassion fatigue. London: Brunner-Routledge; 2002. p. 1-14. 
6. Dyer S, Valeri M, Arora N, Ross T, Winsall M. Review of international systems of long-term care of older people. Canberra: Royal Commission into Aged Care Quality and Safety; 2020 [cited 2022 Nov 22]. Available from: https://agedcare.royalcommission.gov.au/sites/default/files/2020-09/Research%20Paper%202%20-%20Review%20of%20international%20systems%20for%20long-term%20care%20of....pdf 
7. Maslach C, Jackson SE. The measurement of experienced burnout. J Organ Behav. 1981;2(2):99-113. 
8. Costello H, Walsh S, Cooper C, Livingston G. A systematic review and meta-analysis of the prevalence and associations of stress and burnout among staff in long-term care facilities for people with dementia. Int Psychogeriatr. 2019;31(8):1203-16. 
9. de Rooij AH, Luijkx KG, Declercq AG, Emmerink PM, Schols JM. Professional caregivers' mental health problems and burnout in small-scale and traditional long term care settings for elderly people with dementia in the Netherlands and Belgium. J Am Med Dir Assoc. 2012;13(5):486.e7-11. 
10. Chamberlain SA, Hoben M, Squires JE, Cummings GG, Norton P, Estabrooks CA. Who is (still) looking after Mom and Dad? Few improvements in care aides' quality-of-work life. Can J Aging. 2019;38(1):35-50. 
11. Estabrooks CA, Squires JE, Carleton HL, Cummings GG, Norton PG. Who is looking after Mom and Dad? Unregulated workers in Canadian long-term care homes. Can J Aging. 2015;34(1):47-59. 
12. Petersen J, Wendsche J, Melzer M. Nurses' emotional exhaustion: Prevalence, psychosocial risk factors and association to sick leave depending on care setting-A quantitative secondary analysis. J Adv Nurs. 2022;24:24. 
13. Jameson S, Parkinson L. Work‐related well‐being of personal care attendants employed in the aged care sector: Prevalence and predictors of compassion fatigue. Australas J Ageing. 2022;41(2):e131-e9. 
14. French R, Aiken LH, Fitzpatrick Rosenbaum KE, Lasater KB. Conditions of nursing practice in hospitals and nursing homes before COVID-19: Implications for policy action. J Nurs Regul. 2022;13(1):45-53. 
15. White EM, Aiken LH, McHugh MD. Registered nurse burnout, job dissatisfaction, and missed care in nursing homes. J Am Geriatr Soc. 2019;67(10):2065-71. 
16. Squires JE, Baumbusch J, Demery Varin M, MacDonald I, Chamberlain S, Bostrom AM, et al. A profile of regulated nurses employed in Canadian long-term care facilities. Can J Aging. 2019;38(2):130-42. 
17. Yeatts DE, Seckin G, Shen Y, Thompson M, Auden D, Cready CM. Burnout among direct-care workers in nursing homes: Influences of organisational, workplace, interpersonal and personal characteristics. J Clin Nurs. 2018;27(19-20):3652-65. 
18. Kanios A, Bochenska-Brandt A. Occupational burnout among workers in the long-term care sector in relation to their personality traits. Int J Occup Med Environ Health. 2021;34(4):491-504. 
19. Chamberlain SA, Gruneir A, Hoben M, Squires JE, Cummings GG, Estabrooks CA. Influence of organizational context on nursing home staff burnout: A cross-sectional survey of care aides in Western Canada. Int J Nurs Stud. 2017;71:60-9. 
20. Shnayder MM, Brannan D, Murphy LA, Asfour LS, Hecht EM, Lee DJ, et al. Musculoskeletal pain and interest in meditation and yoga in home health aides: Evidence from the home health occupations musculoskeletal examinations (HHOME) study. Home Healthc Now. 2018;36(2):103-13. 
21. Bamonti P, Conti E, Cavanagh C, Gerolimatos L, Gregg J, Goulet C, et al. Coping, cognitive emotion regulation, and burnout in long-term care nursing staff: A preliminary study. J Appl Gerontol. 2019;38(1):92-111. 
22. Spenceley S, Witcher CSG, Hagen B, Hall B, Kardolus-Wilson A. Sources of moral distress for nursing staff providing care to residents with dementia. Dementia. 2017;16(7):815-34. 
23. de Veer AJE, Francke AL, Struijs A, Willems DL. Determinants of moral distress in daily nursing practice: A cross sectional correlational questionnaire survey. Int J Nurs Stud. 2013;50(1):100-8. 
24. Preshaw DHL, Brazil K, McLaughlin D, Frolic A. Ethical issues experienced by healthcare workers in nursing homes. Nurs Ethics. 2016;23(5):490-506. 
25. Olley R. Hear me, see me, trust you – job burnout and disengagement of Australian aged care workers. Leadersh Health Serv. 2022. 
26. Boerner K, Gleason H, Jopp DS. Burnout after patient death: Challenges for direct care workers. J Pain Symptom Manage. 2017;54(3):317-25. 
27. Giesbrecht M, Stajduhar KI, Cloutier D, Dujela C. “We are to be like machines…fill the bed before it gets cold”: Exploring the emotional geographies of healthcare providers caring for dying residents in long-term care facilities. Soc Sci Med. 2021;272. 
28. Harrad R, Sulla F. Factors associated with and impact of burnout in nursing and residential home care workers for the elderly. Acta Biomed. 2018;89(7-S):60-9. 
29. Pott K, Chan K, Leclerc A, Bernard C, Song A, Puyat J, et al. Death in long-term care: Focus groups and interviews identify strategies to alleviate staff burnout. J Long Term Care. 2020;2020:131-43. 
30. Puyat JH, Leclerc A, Song A, Chan K, Pott K, Bernard C, et al. Exposure to deaths and dying and risks of burnout among long-term care staff: A cross-sectional survey. Palliat Med. 2019;33(6):717-20. 
31. Yeh IL, Samsi K, Vandrevala T, Manthorpe J. Constituents of effective support for homecare workers providing care to people with dementia at end of life. Int J Geriatr Psychiatry. 2019;34(2):352-9. 
32. Yang JB. Contributing factors for compassion fatigue among South Korean social workers in long-term care hospitals. Information (Japan). 2016;19(12):5805-11. 
33. Sanchez S, Mahmoudi R, Moronne I, Camonin D, Novella J. Burnout in the field of geriatric medicine: Review of the literature. Eur Geriatr Med. 2015;6(2):175-83. 
34. Falzarano F, Reid MC, Schultz L, Meador RH, Pillemer K. Getting along in assisted living: Quality of relationships between family members and staff. Gerontologist. 2020;60(8):1445-55. 
35. Dhaini SR, Zuniga F, Ausserhofer D, Simon M, Kunz R, De Geest S, et al. Care workers health in Swiss nursing homes and its association with psychosocial work environment: A cross-sectional study. Int J Nurs Stud. 2016;53:105-15. 
36. Dietrich U, Rosler M, Bellmann M, Scharfe J, Kirch W. Work load and health impairments of inpatient nursing care personnel with particular focus on the care of people with dementia. J Public Health. 2014;22(5):395-405. 
37. Chahal JK, Ewen HH, Anderson K, Miles TP. Institutional bereavement care for fictive kin: Staff grief in CCRCs. J Am Med Dir Assoc. 2015;16(10):892-5. 
38. Savundranayagam MY, Docherty-Skippen SM, Basque SR. Qualitative Insights into the working conditions of personal support workers in long-term care in the context of a person-centered communication training intervention. Res Gerontol Nurs. 2021;14(5):245-53. 
39. Schmidt SG, Dichter MN, Palm R, Hasselhorn HM. Distress experienced by nurses in response to the challenging behaviour of residents - evidence from German nursing homes. J Clin Nurs. 2012;21(21-22):3134-42. 
40. Vandrevala T, Samsi K, Rose C, Adenrele C, Barnes C, Manthorpe J. Perceived needs for support among care home staff providing end of life care for people with dementia: A qualitative study. Int J Geriatr Psychiatry. 2017;32(2):155-63. 
41. Brophy J, Keith M, Hurley M. Breaking point: Violence against long-term care staff. New Solut. 2019;29(1):10-35. 
42. Hirata H, Harvath TA. The relationship between exposure to dementia-related aggressive behavior and occupational stress among Japanese care workers. J Gerontol Nurs. 2015;41(4):38-46. 
43. Ko A, Takasaki K, Chiba Y, Fukahori H, Igarashi A, Takai Y, et al. Aggression exhibited by older dementia clients toward staff in Japanese long-term care. J Elder Abuse Negl. 2012;24(1):1-16. 
44. Stutte K, Hahn S, Fierz K, Zuniga F. Factors associated with aggressive behavior between residents and staff in nursing homes. Geriatr Nurs. 2017;38(5):398-405. 
45. Elliott KEJ, Rodwell J, Martin AJ. Aged care nurses' job control influence satisfaction and mental health. J Nurs Manag. 2017;25(7):558-68. 
46. Kim B, Liu L, Ishikawa H, Park S-H. Relationships between social support, job autonomy, job satisfaction, and burnout among care workers in long-term care facilities in Hawaii. Educ Gerontol. 2019;45(1):57-68. 
47. Kim BJ, Ishikawa H, Liu L, Ohwa M, Sawada Y, Lim HY, et al. The effects of job autonomy and job satisfaction on burnout among careworkers in long-term care settings: Policy and practice implications for Japan and South Korea. Educ Gerontol. 2018;44(5-6):289-300. 
48. Cooper SL, Carleton HL, Chamberlain SA, Cummings GG, Bambrick W, Estabrooks CA. Burnout in the nursing home health care aide: A systematic review. Burn Res. 2016;3(3):76-87. 
49. Cao X, Naruse T. Effect of time pressure on the burnout of home‐visiting nurses: The moderating role of relational coordination with nursing managers. Jpn J Nurs Sci. 2019;16(2):221-31. 
50. Jones MT, Heckenberg RA, Wright BJ, Hodgkin S. Understanding the nature and impact of occupational stress on Australian rural aged care workers. Health Soc Care Community. 2021;29(3):643-53. 
51. Naruse T, Taguchi A, Kuwahara Y, Nagata S, Watai I, Murashima S. Relationship between perceived time pressure during visits and burnout among home visiting nurses in Japan. Jpn J Nurs Sci. 2012;9(2):185-94. 
52. de Jonge J, Gevers J, Dollard M. Managing employee creativity and health in nursing homes: The moderating role of matching job resources and matching occupational rewards. Int J Stress Manag. 2014;21(4):361-83. 
53. White EM, Aiken LH, Sloane DM, McHugh MD. Nursing home work environment, care quality, registered nurse burnout and job dissatisfaction. Geriatr Nurs. 2020;41(2):158-64. 
54. Schmidt SG, Dichter MN, Bartholomeyczik S, Hasselhorn HM. The satisfaction with the quality of dementia care and the health, burnout and work ability of nurses: A longitudinal analysis of 50 German nursing homes. Geriatr Nurs. 2014;35(1):42-6. 
55. Aloisio LD, Baumbusch J, Estabrooks CA, Bostrom AM, Chamberlain S, Cummings GG, et al. Factors affecting job satisfaction in long-term care unit managers, directors of care and facility administrators: A secondary analysis. J Nurs Manag. 2019;27(8):1764-72. 
56. Aloisio LD, Coughlin M, Squires JE. Individual and organizational factors of nurses' job satisfaction in long-term care: A systematic review. Int J Nurs Stud. 2021;123:104073. 
57. Aloisio LD, Gifford WA, McGilton KS, Lalonde M, Estabrooks CA, Squires JE. Individual and organizational predictors of allied healthcare providers' job satisfaction in residential long-term care. BMC Health Serv Res. 2018;18(1):491. 
58. Aloisio LD, Gifford WA, McGilton KS, Lalonde M, Estabrooks CA, Squires JE. Factors associated with nurses' job satisfaction in residential long-term care: The importance of organizational context. J Am Med Dir Assoc. 2019;20(12):1611-6.e4. 
59. Chamberlain SA, Hoben M, Squires JE, Estabrooks CA. Individual and organizational predictors of health care aide job satisfaction in long term care. BMC Health Serv Res. 2016;16(1):577. 
60. Kim BJ, Lee SY. A cross-sectional study on the impacts of perceived job value, job maintenance, and social support on burnout among long-term care staff in Hawaii. Int J Environ Res Public Health. 2021;18(2):08. 
61. Min D. Effects of resilience, burnout, and work-related physical pain on work-life balance of registered nurses in South Korean nursing homes: A cross-sectional study. Medicine. 2022;101(30):e29889. 
62. Mockli N, Denhaerynck K, De Geest S, Leppla L, Beckmann S, Hediger H, et al. The home care work environment's relationships with work engagement and burnout: A cross-sectional multi-centre study in Switzerland. Health Soc Care Community. 2020;28(6):1989-2003. 
63. Steinheiser MM, Crist JD, Shea KD. Compassion fatigue among rns working in skilled nursing facilities. Res Gerontol Nur. 2020;13(6):320-8. 
64. Chu CH, Wodchis WP, McGilton KS. Turnover of regulated nurses in long-term care facilities. J Nurs Manag. 2014;22(5):553-62. 
65. Costello H, Cooper C, Marston L, Livingston G. Burnout in UK care home staff and its effect on staff turnover: MARQUE English national care home longitudinal survey. Age Ageing. 2019;49(1):74-81. 
66. Ejaz FK, Bukach AM, Dawson N, Gitter R, Judge KS. Examining direct service worker turnover in three long-term care industries in Ohio. J Aging Soc Policy. 2015;27(2):139-55. 
67. Eltaybani S, Noguchi-Watanabe M, Igarashi A, Saito Y, Yamamoto-Mitani N. Factors related to intention to stay in the current workplace among long-term care nurses: A nationwide survey. Int J Nurs Stud. 2018;80:118-27. 
68. Gao F, Newcombe P, Tilse C, Wilson J, Tuckett A. Models for predicting turnover of residential aged care nurses: A structural equation modelling analysis of secondary data. Int J Nurs Stud. 2014;51(9):1258-70. 
69. Gaudenz C, De Geest S, Schwendimann R, Zuniga F. Factors associated with care workers' intention to leave employment in nursing homes: A secondary data analysis of the Swiss nursing homes human resources project. J Appl Gerontol. 2019;38(11):1537-63. 
70. McGilton KS, Tourangeau A, Kavcic C, Wodchis WP. Determinants of regulated nurses' intention to stay in long-term care homes. J Nurs Manag. 2013;21(5):771-81. 
71. Nelson H, Yang BK, Carter MW, Monahan E, Engineer C. Nursing home administrator's job satisfaction, work stressors, and intent to leave. J Appl Gerontol. 2021;40(1):67-76. 
72. Schmidt KH, Diestel S. Job demands and personal resources in their relations to indicators of job strain among nurses for older people. J Adv Nurs. 2013;69(10):2185-95. 
73. Chmelar C, Jorres RA, Kronseder A, Muller A, Nowak D, Weigl M. Associations between age, psychosocial work conditions, occupational well-being, and telomere length in geriatric care professionals: A mixed-methods study. J Occup Environ Med. 2017;59(10):949-55. 
74. Hegney DG, Rees CS, Eley R, Osseiran-Moisson R, Francis K. The contribution of individual psychological resilience in determining the professional quality of life of Australian nurses. Front Psychol. 2015;6:1613. 
75. Chaudhuri T, Yeatts DE, Cready CM. Nurse aide decision making in nursing homes: Factors affecting empowerment. J Clin Nurs. 2013;22(17-18):2572-85. 
76. Diestel S, Cosmar M, Schmidt K-H. Burnout and impaired cognitive functioning: The role of executive control in the performance of cognitive tasks. Work Stress. 2013;27(2):164-80. 
77. Yoshimatsu K, Nakatani H. Home visiting nurses' job stress and error incidents. Home Health Care Manag Pract. 2020;32(2):110-7. 
78. Josefsson K. Registered nurses' health in community elderly care in Sweden. Int Nurs Rev. 2012;59(3):409-15. 
79. Hunter PV, Hadjistavropoulos T, Thorpe L, Lix LM, Malloy DC. The influence of individual and organizational factors on person-centred dementia care. Aging Ment Health. 2016;20(7):700-8. 
80. Dhaini SR, Zuniga F, Ausserhofer D, Simon M, Kunz R, De Geest S, et al. Are nursing home care workers' health and presenteeism associated with implicit rationing of care? A cross-sectional multi-site study. Geriatr Nurs. 2017;38(1):33-8. 
81. Knopp-Sihota JA, Niehaus L, Squires JE, Norton PG, Estabrooks CA. Factors associated with rushed and missed resident care in western Canadian nursing homes: A cross-sectional survey of health care aides. J Clin Nurs. 2015;24(19-20):2815-25. 
82. Tanaka K, Iso N, Sagari A, Tokunaga A, Iwanaga R, Honda S, et al. Burnout of long-term care facility employees: Relationship with employees' expressed emotion toward patients. Int J Gerontol. 2015;9(3):161-5. 
83. Cooper C, Marston L, Barber J, Livingston D, Rapaport P, Higgs P, et al. Do care homes deliver person-centred care? A cross-sectional survey of staff-reported abusive and positive behaviours towards residents from the MARQUE (Managing Agitation and Raising Quality of Life) English national care home survey. PLoS ONE. 2018;13(3):e0193399. 
84. Jeon YH, Luscombe G, Chenoweth L, Stein-Parbury J, Brodaty H, King M, et al. Staff outcomes from the caring for aged dementia care resident study (CADRES): A cluster randomised trial. International J Nurs Stud. 2012;49(5):508-18. 
85. Johnston L, Malcolm C, Rambabu L, Hockley J, Shenkin SD. Practice based approaches to supporting the work related wellbeing of frontline care workers in care homes: A scoping review. J Long Term Care. 2021;2021:230-40. 
86. Peters V, Houkes I, de Rijk AE, Bohle PL, Engels JA, Nijhuis FJN. Which resources moderate the effects of demanding work schedules on nurses working in residential elder care? A longitudinal study. Int J Nurs Stud. 2016;58:31-46. 
87. van den Pol-Grevelink A, Jukema JS, Smits CH. Person-centred care and job satisfaction of caregivers in nursing homes: A systematic review of the impact of different forms of person-centred care on various dimensions of job satisfaction. Int J Geriatr Psychiatry. 2012;27(3):219-29. 
88. Spenceley S, Caspar S, Pijl E. Mitigating moral distress in dementia care: Implications for leaders in the residential care sector. Nurs Leadersh. 2017;30(4):45-59. 
89. Willemse BM, De Jonge J, Smit D, Visser Q, Depla MF, Pot AM. Staff's person-centredness in dementia care in relation to job characteristics and job-related well-being: A cross-sectional survey in nursing homes. J Adv Nurs. 2015;71(2):404-16. 
90. Willemse BM, de Jonge J, Smit D, Depla MF, Pot AM. The moderating role of decision authority and coworker- and supervisor support on the impact of job demands in nursing homes: A cross-sectional study. Int J Nurs Stud. 2012;49(7):822-33. 
91. Woodhead EL, Northrop L, Edelstein B. Stress, social support, and burnout among long-term care nursing staff. J Appl Gerontol. 2016;35(1):84-105. 
92. Yamaguchi I. Mediating effects of upward communications on the relationship between team autonomy and burnout: A study of employees at care facilities in Japan. J Media Bus Stud. 2019. 
93. Beattie M, Carolan C, Macaden L, Maciver A, Dingwall L, Macgilleeathain R, et al. Care home workers experiences of stress and coping during COVID-19 pandemic: A mixed methods study. Nurs Open. 2022. 
94. White EM, Wetle TF, Reddy A, Baier RR. Front-line nursing home staff experiences during the COVID-19 pandemic. J Am Med Dir Assoc. 2021;22(1):199-203. 
95. Palacios-Cena D, Fernandez-Pena R, Ortega-Lopez A, Fernandez-Feito A, Bautista-Villaecija O, Rodrigo-Pedrosa O, et al. Long-term care facilities and nursing homes during the first wave of the COVID-19 pandemic: A scoping review of the perspectives of professionals, families and residents. Int J Environ Res Public Health. 2021;18(19):26. 
96. Savage A, Young S, Titley HK, Thorne TE, Spiers J, Estabrooks CA. This was my Crimean War: COVID-19 experiences of nursing home leaders. J Am Med Dir Assoc 2022;12:12. 
97. Schulze S, Merz S, Thier A, Tallarek M, Konig F, Uhlenbrock G, et al. Psychosocial burden in nurses working in nursing homes during the COVID-19 pandemic: A cross-sectional study with quantitative and qualitative data. BMC Health Serv Res. 2022;22(1):949. 
98. Turner S, Botero-Tovar N, Herrera MA, Borda Kuhlmann JP, Ortiz F, Ramírez JC, et al. Systematic review of experiences and perceptions of key actors and organisations at multiple levels within health systems internationally in responding to COVID-19. Implement Sci. 2021;16(1). 
99. Laher Z, Robertson N, Harrad-Hyde F, Jones CR. Prevalence, predictors, and experience of moral suffering in nursing and care home staff during the COVID-19 pandemic: A mixed-methods systematic review. Int J Environ Res Public Health. 2022;19(15):04. 
100. Krzyzaniak N, Scott AM, Bakhit M, Bryant A, Taylor M, Del Mar C. Impact of the COVID-19 pandemic on the Australian residential aged care facility (RACF) workforce. Aust J Adv Nurs. 2021;38(3):47-58. 
101. Kyler-Yano JZ, Tunalilar O, Hasworth S, Kohon J, Winfree J, Wilton R, et al. "What keeps me awake at night": Assisted living administrator responses to COVID-19. Gerontologist. 2022;62(2):190-9. 
102. Giebel C, Hanna K, Marlow P, Cannon J, Tetlow H, Shenton J, et al. Guilt, tears and burnout—Impact of UK care home restrictions on the mental well-being of staff, families and residents. J Adv Nurs. 2022;78(7):2191-202. 
103. Nyashanu M, Pfende F, Ekpenyong MS. Triggers of mental health problems among frontline healthcare workers during the COVID‐19 pandemic in private care homes and domiciliary care agencies: Lived experiences of care workers in the Midlands region, UK. Health Soc Care Community. 2022;30(2):e370-e6. 
104. Franzosa E, Mak W, O RB, Hokenstad A, Wiggins F, Boockvar KS, et al. Perspectives of certified nursing assistants and administrators on staffing the nursing home frontline during the COVID-19 pandemic. Health Serv Res. 2022;57(4):905-13. 
105. Bielderman A, Nieuwenhuis A, Hazelhof T, van Gaal BGI, Schoonhoven L, Akkermans RP, et al. Effects on staff outcomes and process evaluation of the educating nursing staff effectively (TENSE) program for managing challenging behavior in nursing home residents with dementia: A cluster-randomized controlled trial. Int J Nurs Stud. 2021;120:103982. 
106. Dichter MN, Trutschel D, Schwab CGG, Haastert B, Quasdorf T, Halek M. Dementia care mapping in nursing homes: Effects on caregiver attitudes, job satisfaction, and burnout. A quasi-experimental trial. Int Psychogeriatr. 2017;29(12):1993-2006. 
107. Halek M, Reuther S, Muller-Widmer R, Trutschel D, Holle D. Dealing with the behaviour of residents with dementia that challenges: A stepped-wedge cluster randomized trial of two types of dementia-specific case conferences in nursing homes (FallDem). Int J Nurs Stud. 2020;104:103435. 
108. Westermann C, Kozak A, Harling M, Nienhaus A. Burnout intervention studies for inpatient elderly care nursing staff: Systematic literature review. Int J Nurs Stud. 2014;51(1):63-71. 
109. Zhao Y, Liu L, Chan HY. Dementia care education interventions on healthcare providers' outcomes in the nursing home setting: A systematic review. Res Nurs Health. 2021;44(6):891-905. 
110. Zwakhalen SM, Hamers JP, van Rossum E, Ambergen T, Kempen GI, Verbeek H. Working in small-scale, homelike dementia care: Effects on staff burnout symptoms and job characteristics. A quasi-experimental, longitudinal study. J Res Nurs. 2018;23(2-3):109-22. 
111. Zwijsen SA, Gerritsen DL, Eefsting JA, Smalbrugge M, Hertogh CM, Pot AM. Coming to grips with challenging behaviour: A cluster randomised controlled trial on the effects of a new care programme for challenging behaviour on burnout, job satisfaction and job demands of care staff on dementia special care units. Int J Nurs Stud. 2015;52(1):68-74. 
112. Dreher MM, Hughes RG, Handley PA, Tavakoli AS. Improving retention among certified nursing assistants through compassion fatigue awareness and self-care skills education. J Holist Nurs. 2019;37(3):296-308. 
113. Akugue P. Evaluating the effectiveness of BREATHE for nurse practitioners during COVID pandemic. J Nurse Pract. 2022;18(7):778-81.