A total of 35 interviews were conducted, including 14 residents, 19 staff, one relative and one volunteer. Residents’ average age was 84.9 years (range: 70 to 92 years), most were female (n=8, 57%) with an average residential aged care stay of 18 months. Staff average age was 36.6 years (range: 30 to 62 years), most were female (n=17, 89%), and comprised residential managers (n=4), personal care workers and nurses (n=4), ‘lifestyle’ staff (n=2), and pastoral care practitioners (n=4). The other five represented staff from quality and customer service teams.
The shared focus of interviews facilitated the collation of all participants’ responses into three broad themes, representing the overall experience of the transition, residents’ mental health needs and strategies to support residents’ mental health. Participants’ experiences and suggestions informed the co-development of practical strategies and resources.
Overall transition experience
In the first theme, participants considered their overall experience of moving into residential aged care. While participants across all groups acknowledged the significance of the move, residents considered their role in the decision-making process, and accepting the need to move to aged care, as critical to a successful transition.
I wanted to come … I like it, I am happy (Jacquie, resident, 70 years)
I decided to go to aged care. This home is the one I chose first and then all of a sudden I was offered a spot (Oliver, resident, 91 years)
Conversely, those who had little time to consider their options, were not involved in the decision-making process or were reluctant to move were less likely to report their contentment with the experience.
It’s a slow process, especially for people who didn’t want to come (Josie, resident, 88 years).
I realised I was going down and would be needing help soon. But it was really challenging leaving my home … I was happy there (Ingrid, resident, 88 years).
Whether the transition had been voluntary or involuntary in nature also had a clear influence on how the residents had come to terms with the move.
We know the effect of an unplanned transition, or a rushed transition … it’s detrimental to people's mental health (Mike, operational manager).
While a significant amount of paperwork was required for the resident’s transition, most participants identified a need for ‘real world’ information to help residents settle in. Real world information, such as information about daily routines and expectations, were identified by relatives as instrumental to helping them support their family member through their transition. Participants explained this information should be given before moving into the home.
It would be handy to be given some sort of booklet … some sort of introduction to the place. Nobody sits down with us to tell us what we can do or get (Sarah, resident, 88 years).
[I’d want to know] what the ‘rules’ are in terms of staff supporting me? Should I expect staff to knock on the door before they come in? Who do I go to if I've got a concern or if I'm not comfortable with something? (Gail, quality manager).
These suggestions resonated with residents, who described difficulties getting used to the new environment and routine. For some, it was evident that the uncertainty associated with the move was stressful and confusing, particularly in the initial post-transition period.
It’s all a challenge when you are new. It takes a bit getting used to … everything is difficult (Yuri, resident, 87 years).
Living to a schedule instead of doing what I like … I am used to it now, but it would have been good to know (Sarah, resident, 88 years)
Someone from the home should tell new residents about the routines and activities (Cathy, resident’s daughter).
Asked what might help new residents settle in, participants confirmed the importance of meeting people and making new friends. New friendships were also a way to get used to the new environment and routine.
I think it is important to promote friendships and relationships, because it gives people the opportunity to have that peer respect, but also the ability to have someone to talk to, or to ask questions (Meryl, pastoral care practitioner).
Despite participants’ knowledge that making new friends in the home supports reducing a sense of loss and loneliness, most participants acknowledged a gap in this process.
We no longer get introduced to new people, which is a shame. It’s nice to be introduced to new people (Alice, resident, 90 years).
We need to improve how we introduce residents (Sheila, pastoral care practitioner).
Staff explained a lack of personal information about new residents was a concern during the transition process. Limited knowledge effected staffs ability to support new residents in their transition.
.I’m not sure what information they get, or how prepared they are. And we don’t know about the resident and their needs until they arrive … it would be good to get something [information] from them [before they arrive] (Penny, personal carer).
Staff, in particular, highlighted the positive effect of setting up new residents’ rooms before they move in, describing how comforting it could be for new residents to have something familiar waiting for them. Although circumstances may prevent this from happening every time, such as due to an unplanned transition from hospital, the benefits of placing items from home in the new resident’s rooms were clear.
If I had a bit of notice, I would ask the family to start bringing stuff in before they moved in. So, I would put photo frames up, some cushions from home, I'd have their favourite music playing in the background (Pauline, quality manager).
It doesn’t always happen, but I always like to see it when families can come in and set up the room before the person comes. I know, myself, that my own pillow and blanket are so comforting … having something there that is very comforting to you (Sheila, pastoral care practitioner).
Residents’ mental health needs
In the second theme, participants described how they might recognise or respond to signs of depression and/or anxiety. For staff, advance knowledge of a new resident’s pre-existing mental health condition allowed them to set up appropriate strategies to support the person, often in collaboration with family members. It was also important to be given timely and accurate healthcare information, including background on the person’s past experiences and triggers.
If we know from the get-go [start] that the person is feeling quite depressed or anxious, maybe the family can help us understand what might be helpful (Sheila, pastoral care practitioner).
We need to find out who the resident has seen for their [depression]. Can we get any copies of reports to try and understand? We don't know what the triggers are. How can we care for someone if we don't really understand what they’ve been through? (Jenny, residential manager).
Clinical care staff and residential managers identified the importance of being proactive in recognising and treating mental health issues. Despite this, participants working directly with residents reported a need to improve this process, with evident gaps in practice.
Mental health is often overlooked … and the pathway to receiving mental health assessment and services needs to improve (Tina, residential manager)
Mental health [treatment] has lacked in aged care for a long time. We had a man, he was depressed, and there was no support for him (Penny, personal carer).
Managers and pastoral care practitioners, in particular, reported that they would refer to doctors or mental health professionals for support.
If [a resident] was suffering with depression or anxiety, I think it would be very helpful to them to have somebody [mental health professional] there (Sheila, pastoral care practitioner).
If somebody has a mental health diagnosis, then we should be thinking about what we need to put in place for them (Tina, residential manager).
For residents, mental health was often related to feelings of loss and loneliness. Often, they first sought support from relatives and other residents.
I had a sense of loss, but I talked to my family … the help from family is very good (Jim, resident, 92 years).
During lunch or dinner, we do notice each other … we notice things, if people are having a problem. Then we talk about it (Sarah, resident, 88 years).
[You need] a friend who can help if you’re getting depressed (Josie, resident, 88 years).
If they felt it was appropriate, residents would encourage others to seek help from the staff. Some had received professional support for their mental health.
I’d tell a team member if I think a resident is depressed (Josie, resident, 88 years).
A few times, I’ve had a bit of a ‘melt-down’ … the staff have been really good. The nurses come in and I can talk with them (Sarah, resident, 88 years).
Despite the evidence in favour of pastoral care support in aged care [24], it was clear that this resource was under-utilised with just one resident accessing support from the pastoral care team.
I’d tell them to talk to somebody … pastoral care is a good start. I talk to them quite often (Jim, resident, 92 years).
Strategies to support residents’ mental health
Reflecting on existing resources to support residents’ mental health, participants highlighted a need to address a common misconception regarding pastoral care. Despite several examples of referring residents to a member of the pastoral care team (see ‘Responding to mental health needs’), more participants reported confusion or scepticism about their underpinning philosophy and function.
I avoid mentioning pastoral care … it’s too religious (Barbara, lifestyle coordinator).
For the generation [residents] here, ‘pastoral care’ means church, it means religion … for some people, it’s a big wolf [frightening] (Julia, pastoral care practitioner).
This misunderstanding frequently resulted in the under-utilisation by residents and staff of an important existing resource, and was particularly frustrating for pastoral care practitioners who are keen to engage with and support residents throughout their transition.
I’ve been here for five years, so people know me as a person, but my title confuses people. It’s a continual teaching and reminding them [what I do], especially when new staff come on board (Sheila, pastoral care practitioner).
I actually sent out an email saying, ‘Pastoral care is not what you think it is’. Basically, just say, ‘Pastoral care is about your wellbeing … it's a holistic view … it is not based on a religious view’ (Julia, pastoral care practitioner).
There was particular potential in enlisting additional pastoral care support at the time of a new resident’s arrival.
There's a lot to do [when a new resident arrives], but it's all the clinical stuff. I don't understand why pastoral care aren't involved right from the start … [new residents] need a friend (Diane, clinical care coordinator).
Pastoral care would help with the transition of our residents … if we could have someone follow them each day of the transition that would be amazing (Holly, nurse).
In so doing, participants noted the importance of understanding and treating each resident as an individual.
[Residents] want the focus to be, ‘This person truly knows about me, they truly care about me, and they're interested in me’ (Mike, operational manager).
Their individuality is important for any transition. I'm a great believer in knowing the history of someone … understanding where there may be speed bumps [challenges] along the way (Jonathan, clinical care coordinator).
Staff described the benefits of knowing as much as possible about the person before they move into the home. This would allow them to focus less on the formal process of the admission and more on the new resident’s individual needs. While processes were in place to manage the transition, potential improvements to practice were identified.
It's not just a phone call, a booking, people filling out paperwork and coming and having a quick look at the room … there's a big piece that follows on from that … making people feel safe and comfortable, how things work here … all that information that we take for granted or just provide in a written format (Gail, quality manager).
The potential of a ‘buddy system’ was raised by several participants, with current residents considered a largely underutilised resource in providing information and support to new residents.
The best thing would be to have a buddy … a welcoming buddy … [and] whatever they [new residents] ask, you would know the answer (Josie, resident, 88 years).
[A buddy system] could work here, because the residents here like to be productive and helpful … I think that they would really love to be a part of something like that (Sheila, pastoral care practitioner).
Potential obstacles to a buddy system were considered, largely by staff, including the different needs and personal capacity of residents. The potential of volunteers to perform this role was raised, as was the need for clear guidelines and processes.
We've done a buddy system, but it can be hard, depending on your demographic in the home … most of the homes are just too high level [of care needs] (Pauline, quality manager).
With the buddy, you need to make sure they are not ‘gate keepers’ … make sure it’s not overdone (Roger, resident, 76 years).
Volunteers could take on the role of a buddy, but this would require significant investment into policy and process updates, and central oversight … you want to make sure that the resident gets the right information about what goes on at the facility (Jenny, residential manager).