Current issues, future directions

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By Associate Professor Nancy Pachana FAPS
School of Psychology, University of Queensland

What are the words that most people associate with nursing homes? Lonely? Sad? A place to die? These are the words that my fourth year Honours seminar students, in a course entitled ‘Residential Care: Positive Possibilities', most frequently used to describe nursing homes on their first day of the course. I suspect their views are widely held among the general public, not only in Australia but in many countries around the world. Indeed, I might venture to guess that many psychologists unfamiliar either with older adults or residential care settings might harbour similar thoughts. This is despite the fact that psychologists in such settings have a wealth of knowledge and skills to offer both residents and care staff which would enhance the health and wellbeing of both groups.

Attitudes about long-term care for older adults

Attitudes towards nursing home residents and residential aged care facilities (RACFs) are a surprisingly understudied topic. There is quite a bit of literature concerning the need for improved training of health care professionals working in RACFs, both in terms of knowledge as well as attitudes and negative biases (e.g., Glaister & Blair, 2008). Yet there is surprisingly little research on the general public's attitudes towards long-term nursing care. In a recent review paper on the future of long-term care in the US, changing not only professional attitudes but also the attitudes of the general public towards residential care were cited as essential to realise much needed improvements in the system (Miller, 2008). In his article, Miller identifies the need to go beyond empirically supported, best practice concepts such as person-centred and consumer directed care, to point out the need for culturally responsible, innovative and comprehensive care. Miller writes, "The challenges facing long-term care must be addressed by both government and private citizens alike if long-term care recipients' lives are to improve and the increased demand for services is to be met" (p. 450).

Negative public image and poor understanding of residential aged care were cited by Miller as barriers to improving nursing home care. A common response in discussions of nursing homes often includes phrases such as "I'll never go into a home" or "I'd never put my parent/spouse/loved one into a nursing home". The reality is that residential aged care placement is often necessary for an individual whose medical and/or psychiatric care needs exceed home care capacity, or who lacks the family support networks necessary to continue living in the community. If attitudes towards child care were the same, if people stated unequivocally "I would never put my daughter/son into a child care facility", the resources, standards and accreditation, and community interest in providing high standards of child care might arguably be quite a bit lower than they are now. Psychologists might not be attracted to work with children if there was a negative attitude towards the care of children in facilities rather than in the family home. Parents might feel unsupported and stigmatised if they required assistance or even more permanent care for their children if this was the current state of the world.

While the analogy between child care and residential care for older adults has limits, the fact that nursing homes are viewed by many as ‘God's waiting room' does nothing to improve care in such facilities, ease the mind of the family and friends of residents, or support those who work in such facilities.

Role of psychologists in long-term care facilities

Certainly the current situation in Australia with respect to psychologists working in long-term care is bleak. Snowdon and colleagues (1995) reported that psychology had the lowest ratio of service delivery to older adults of the mental health disciplines. While this data is in the process of being updated, informal data from the APS Psychology and Ageing Interest Group (PAIG) suggest that this situation has not improved in the dozen years since Snowden's study, and that the actual number of psychologists working in RACFs probably does not exceed a handful. This is in stark contrast to other countries such as the United States or the Netherlands (see boxed story next page), where psychologists have a large presence in clinical nursing home care, have contributed significantly to research in residential aged care, and thus have a strong voice in best practice directives and local and national policy decisions and direction in residential care.

Why would a psychologist choose to work in a nursing home? You would only choose to work in a nursing home if you had a very high level of clinical assessment, formulation and treatment skills, if you relished the challenges and high rewards of operating in a multidisciplinary environment, and if you derived satisfaction from having your particular skills in understanding and addressing interpersonal and person-environment challenges valued enormously. To work in a nursing home as a psychologist is to provide a vital psychological perspective to care staff, family and the residents themselves, so that the physical and mental health of all concerned has a chance to be optimised. The opportunity to practice a range of empirically validated interventions, with diverse client groups and treatment modalities, including exercise programs, social skills training, staff education and a variety of individual and group interventions would be part of your daily routine.

It is unfortunate that more psychologists are not clamouring to work in nursing home settings, but given demographic trends, it is particularly vital that we excite psychologists in training about working with older adults in general and in residential settings in particular. Given our lack of an existing workforce in residential aged care, are there resources available to universities, practitioners and students?

Fortunately the answer here is a resounding yes! Similar to the familiar Boulder scientist-practitioner model of psychology, the Pikes Peak model of training, developed jointly by Divisions 12/II and 20 of the American Psychological Association, offers an aspirational model for training programs and for individual psychologists and psychologists in training seeking guidance in how best to prepare for working with older adults (Knight, Karel, Hinrichsen, Qualls & Duffy, in press). Within this model, psychological work in residential aged care settings is cited as among the most complex and challenging for psychologists, a sentiment echoed by the group Psychologists in Long Term Care (PLTC), an independent organisation of psychological practitioners in the US which has contributed to specific standards for psychological services in RACFs (Lichtenberg et al., 1998). The unique challenges of psychological work in nursing homes is also acknowledged in similar Australian guidelines for the provision of psychological services to older adults (Pachana, Helmes & Koder, 2006). Gallagher-Thompson and colleagues (2000) point out that the mental health needs of residents in long-term care are overwhelmingly unmet, while the training of psychologists lags behind this growing need. Miller (2008) cites an inadequate workforce in RACFs as among the top barriers to improved care.

Importance of training and research efforts in residential aged care settings

Most disciplines within health and mental health provide their students with only minimal exposure and training to undertake research or practice with older populations. A concerted effort to provide all students with basic ageing competencies, such that they have the basic skills to more effectively meet the needs of older people, is crucial (Rosen, Zlotnik & Singer, 2002). Numerous authors (e.g., Kovner, Mezey & Harrington, 2002) have called for health professionals across the disciplines to receive mandatory training in geriatrics to help avert a crisis in care for older adults. Older adults treated by practitioners with specialised knowledge and clinical skills have improved outcomes (e.g., Cohen et al., 2002). The interdisciplinary model has long been the best practice standard (Zeiss & Steffon, 1996) and this too should be an essential component of clinical training for work with older adults.

The World Health Organisation defines health as "...a state of complete physical, social and mental well-being, not merely the absence of disease or infirmity" (WHO, 1948). Sadly, care in nursing facilities often falls woefully below this standard, and I believe that the increased presence of practising psychologists in nursing homes, and psychologists carrying out research in RACFs, could begin to redress the issues at hand. Consider this small sampling of research on facets of residential aged care:

  • Studies have shown that nursing home staff can be more accepting of sexual expression in handicapped or residents with psychiatric illness than in residents of nursing home facilities (Hajjar & Kamel, 2003).
  • Although the quality of nursing staff-resident relationships is a key variable in patient care quality and many studies have demonstrated problematic aspects in such relationships, few studies addressing this issue have been conducted (although one Australian intervention study by Malins, Couchman, Viney & Grenyer (2004) has been published).
  • Even though psychosocial and behavioural interventions are deemed more effective in many instances than pharmacological interventions, 40 per cent of people with dementia in care facilities in the developed world are taking neuroleptic drugs (Margallo-Lana et al., 2001).
  • While there is a national Aboriginal and Torres Strait Islander Aged Care Strategy and 39 specialised Aboriginal aged care facilities in Australia (Australian Department of Health and Ageing, 2006), such facilities in rural and remote districts lack resources and issues of cultural safety (Williams, 1999) remain.
  • Rates of elder abuse in facilities as high as 50 per cent are still in evidence (Hawes & Kayser-Jones, 2003).
  • As many as five per cent of Australian nursing home beds are occupied by persons under age 65. While many of these people have conditions such as early onset dementia, there are persons as young as nine years old placed in RACFs (Senate Community Affairs Committee, 2005).

The way forward

How can we begin to address these issues? Other authors (e.g., Lomranz & Bar-Tur, 2001) have provided detailed outlines of what clinical geropsychology services in a nursing home environment might look like. Key aspects of Lomranz and Bar-Tur's model which are noteworthy include recognising the zeitgeist of individual RACFs which need to be acknowledged, the importance of family and staff-focused interventions in this environment, and the potential to forge links with university training programs and clinics. The authors, in looking towards the future, state:

The major goal of the clinical geropsychologist in nursing homes should be to contribute to a fundamental change which would render the various institutions as authentic ‘homes' in which residents could actualise their potentials for positive mental health, live with dignity, enhance their well-being, and live creatively. (p. 495)

When my students finished their course on residential aged care, what were the words they now thought of when asked about nursing homes? The words they wrote on their index cards in their last class had changed - ‘potential for improvement', ‘fixable', ‘important', ‘under-researched', ‘hopeful'. On the back of these cards the students wrote about what they would take away from this class into their lives after university. This is what they said:

  • "I want to work in this field / volunteer in a nursing home" (most frequent response)
  • "I am no longer ignorant"
  • "I will have greater respect for the elderly"
  • "I will talk to more people about this interesting area".

What will you take away from this series of articles on residential aged care? Will you think differently about the role of psychologists in long-term care? Will you suggest ways to introduce ageing content, including nursing home content, into your university's curriculum? Will you explore ways to liaise with a local RACF in your practice area? Will you be more mindful of psychologists' roles in residential aged care settings?

Perhaps you will simply think of ageing in another light, as does Longfellow in Morituri Salutamus:

Age is opportunity no less,
Than youth itself, though in another dress,
And as the evening twilight fades away,
The sky is filled with stars, invisible by day.

The author can be contacted at

Nursing home care in the Netherlands: A prominent role for psychologists

Psychologists in the Netherlands usually have a Master's level qualification in order to practice. However, if they wish to practice in a nursing home, they receive an extra year of training and supervised practice within a residential aged care facility. These psychologists then practice as ‘nursing home psychologists' along with similarly trained ‘nursing home nurses' and ‘nursing home physicians', either as consultants or as part- or full-time staff in residential care facilities.

Within such facilities these three disciplines - medicine, nursing and psychology - form the core of the care teams that oversee day-to-day care in such facilities. The role of psychology is viewed as particularly important for addressing day-to-day management of challenging behaviours of residents, but their role is also to help care staff to better anticipate difficult situations and be prepared to address them with appropriate communication, behavioural and interpersonal skills. Care staff also use the nursing home psychologists to address their own needs for debriefing and stress management.

Nursing home psychologists in the Netherlands are taking a leading role in research into psychological symptoms, assessment and intervention in these settings. They are also addressing less frequently studied topics such as anxiety in residential aged care (Smalbrugge et al., 2005). In their study Smalbrugge and colleagues found significant anxiety symptoms in 30 per cent of their nursing home sample. This research serves to highlight just one area among many where assessment and treatment options offered by psychologists might meaningfully address important mental health and wellbeing issues in this setting.

Finally, it should be noted that in the Netherlands an innovative approach to residential aged care extends beyond professional specialist training and multidisciplinary collaboration. Dutch nursing homes offer a variety of creative and empirically tested solutions to address issues of quality of life for residents and working conditions for care staff. Their small group living option for residential care has been shown to increase job satisfaction and decrease burnout for care workers (te Boekhorst et al., 2008). Larger scale facilities still try to keep groups of residents within facilities relatively small, and some facilities (such as the excellent Leo Polak complex in Amsterdam) combine high-tech home automation to assist residents with dementia to safely maintain the highest possible level of autonomy.



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