Definition, transition to, scope of practice, social work relevance, social work practice on transition, social work practice with residents
Three sections follow:
1. Background Material that provides the context for the topic
2. A suggested Practice Approach
3. A list of Supporting Material / References
Feedback welcome!
Background Material
Introduction
A residential aged care facility can be defined as a “special-purpose facility which provides accommodation and other types of support, including assistance with day-to-day living, intensive forms of care, and assistance towards independent living, to frail and aged residents" (Hardy et al., 2020, p. 450). Key to entering residential aged care is the need for support and assistance with daily care and, in Australia, it is estimated that 52% of people have a diagnosis of dementia. Not for profit (60%) and private organisations (30%) are the primary providers of residential care in Australia (Hardy et al., 2020).
Transitioning into a residential aged care facility is an incredibly stressful life event for older adults and can potentially increase feelings of helplessness and psychosocial distress. On admission, older people find themselves in an unfamiliar environment, adapting to living with multiple people, changed routines and diets, and a group-based approach to lifestyle activities. The admission often occurs during a crisis, such as following an acute medical event, hospitalisation or the death of a carer or family member. In other words, older adults are probably experiencing multiple losses related to loss of family home, relationships, community roles, health, finances, and decision-making autonomy (Wood, 2022).
There is usually extraordinarily little time to prepare for such a significant life transition, and there are also times when older adults may be admitted against their wishes. There is the potential for family conflict during this time, especially when there are differences of opinion regarding the future care of the older person. Furthermore, older people are confronted by death and dying. Firstly, they may have a greater perception of dying from their illness rather than living with it. Secondly, they are more exposed to death and dying in the facility given the frail population (Wood, 2022).
Therefore, it is advisable to prepare for the transition well in advance of residential care being needed. The publication by Cutter Law P.C. (2024) suggests five steps to consider when choosing an aged care facility. One of the suggestions made is for people thinking of entering aged care to explore various aged care facilities (point 4 of 5). An effective way of doing this in Australia is through staying in an aged care facility for a week or so as a way of providing respite for their carer. In this way the older person gains some understanding of how the facility works and may be able to explore other points of the Cutter P.C. article.
The current Australian situation regarding social workers in aged care
Social workers are already employed across various settings, offering evidence-based support for older people. These include hospitals, palliative care services, aged care assessment teams, rehabilitation services, mental health services, disability services, primary health care networks and private practice (Wood, 2022). The AASW (2015) suggests the scope and practice in aged care includes:
Assessments: psychosocial, risk, care needs, accommodation, as part of aged care assessment teams
Counselling, therapy and mediation: grief and loss, adjustment to illness, transition to residential care, palliative care, inter-family relationships
Mediation and conflict resolution
Practical assistance with transition to and aspects of residential care
Case management and service coordination: advanced care planning, support networks, referrals
Education and resources: navigating health and welfare systems, specialist aged care education
Hospital discharge planning
Advocacy work: supporting older people’s rights to self-advocate, advocating on older people’s behalf.
Policy and research
Specialist expertise in the psychosocial aspects of elder abuse, neglect, mental health, family dynamics, transition trauma, palliative care, ethical decision making.
Overall, social work with older people focuses on the preservation and/or enhancement of functioning and quality of life (AASW, 2015).
In spite of this social workers are absent as practitioners in residential care facilities (Wood 2022). Few Residential care facilities employ social workers as core team members of the multi-disciplinary team to provide integrated care. Moreover, research suggests there is limited focus on psychosocial support in residential care facilities, with research showing individuals experience reduced quality of life when compared to those living in their community. In addition, there is evidence that staff in residential care facilities experience considerable stress from the high emotional demands placed on them because of the nature of the work and the frequent occurrence of resident decline and death (Lee et al., 2022). In Australia, the recently concluded Royal Commission in Aged Care found that ageism (a process of systematic stereotyping and discrimination against people because they are old) is entrenched in an aged care sector that is failing to meet the needs of old people. Social work is missing as a core, allied-health team member in private and NGO Residential care facilities, yet is ideally placed to provide more holistic approaches to contribute to the overall wellbeing and quality of life of people. This has contributed to a "thin" construction of care that lacks a multidimensional, holistic approach to, and investment in the overall health and wellbeing of older people (Hardy et al, 2020).
Transitioning into residential care facilities
While ageing in place is a major focus of ageing-relating policies, older adults face a number of barriers to doing so. (i) Ageing is often accompanied by declines in physical or cognitive functioning that can restrict health, quality of life, and independence. (ii) Higher participation of women in the workforce and increased longevity can mean family and friends are not available to provide informal care. (iii) The long-term care systems in place (e.g. home care packages) may be unable to meet the needs of many older adults who seek community-based alternatives to nursing home care. (iv) There may be limited housing alternatives for older adults who wish to remain in their community but have difficulty maintaining a larger single-family home (Lehning et al., 2017).
The transition to an aged care facility can be either a positive or negative experience. For older people who choose to make this transition it will often be positive. However, if the transition is forced on older people, or occurs suddenly through illness or a change in life circumstances, it can be quite traumatic and lead to loneliness. In the worst-case situation, it can result in depression, anxiety and suicide (Lee et al., 2022).
To put this in context with the material above, the culture of independence that drives the desire to age in place can impact on an older person’s need or wish to move into aged care; he or she may perceive a stigma associated with such a move. The transition leads to a redefinition of self, and people need support to manage this (Soderberg et al., 2013).
It is important that older people are supported through the process as the older person may push limits to stay in place as far as possible, lay claims for assistance for as long as possible but feel bad when not fully corresponding with the expectations of others. Older people can oscillate between justifying a continued life in ordinary housing and providing reasons why they should move to a residential home as outlined below (Soderberg et al., 2013).
Justifications for not moving to a RACF can include:
Referring to the advantages of staying at home
Emphasising remaining capacities, and skills obtained in earlier working life
Claiming the ability of making autonomous decisions
Arguing there have been reversed roles over the years; now it is time for the carer (older person) to be cared for
Claiming own achievements are better than those of the home help service
Stating not being in such a bad shape as residents at residential homes
Not pleased with the residential home offered (Soderberg et al., 2013)
Reasons for moving to a RACF can include:
Referring to old age and disability
Explaining why family members cannot assist
Declaring a desire of not being a burden
Regarding the home help service as an intrusion
Criticizing the achievements of the home help service
Not having the strength to supervise the home help service
Referring to the right to withdraw after a life-long working life (Soderberg et al., 2013)
In other words, the transition to an aged care facility needs to be managed. Suggestions about how to best manage this transition are outlined in the Practice Approach section below.
Social work and Residential care facilities
In Australia, as with other countries, residential care facilities are primarily based on bio-medical models of care, focusing principally on illness, disease and incapacity, and positioning service users as submissive service recipients. The relationships between care professionals and service users are often paternalistic; the service provider is seen to hold expert knowledge about treatment for the person who is referred to as a “resident”, which can propagate a loss of independence and autonomy through a culture of “doing for” rather than “being with”. Social work is missing as a core, allied-health team member in private and NGO residential care facilities, yet is ideally placed to provide more holistic approaches to contribute to the overall wellbeing and quality of life of people (AASW, 2015; Hardy et al., 2020).
Social work is especially relevant because of the relocation stress many older people experience on transitioning to residential aged care: heightened confusion, anxiety, depression and loneliness, all of which can lead to significant decline in mental health. According to the Australian Institute of Health and Welfare, up to 75% of aged care residents have symptoms of depression. Whether long-term or only recently diagnosed, depression and/or anxiety in older adults are associated with a decline in overall wellbeing, daily functioning and independence, increased disability, suicidal ideation and mortality. There are also indications of a reciprocal link between depression and cognitive impairment, including dementia (Polacsek & Woolford, 2022).
The social work code of ethics articulates that social workers strive to enhance individual and collective wellbeing and protect vulnerable individuals from oppression and abuse. Social workers are acutely aware that human beings live and exist within a context. Individual behaviour is often the result of complex interrelationships between family, the broader cultural context, and individual life events and traumatic experiences. The unique lens social workers adopt is ideally suited to working in the complex aged care system (Wood, 2022), including in residential care facilities.
Practice Approach
On Transition to Residential Care
As Lee et al. (2022) point out, while the transition process can be positive for people who choose to move to residential care, it can also be a negative experience, especially if the transition occurs suddenly through illness or changed life circumstances. For this latter group, loneliness, depression, anxiety and even suicide can eventuate. By supporting the older person and the family of that person, social workers can play an important role in putting in place practical measures to make the transition process is as smooth and supportive as possible.
Social work can involve assisting both families and the prospective resident by:
Assisting older people, and in some cases their families, to make significant life decisions based on the best aged care related information and resources available (AASW, 2015).
Using mediation and conflict resolution skills to provide expert psycho-social interventions to residents, families, and staff. Early intervention can defuse problem situations. (Lee et al., 2022).
Providing staff with relevant background information about the person so the person can be treated as an individual, e.g. able to set their own routines and pursue their own interests (gardening, help out, leave for walks, etc.). These strategies are known to support mental health (Polacsek & Woolford, 2022).
Providing staff with comprehensive information about new residents (needs, likes and dislikes, relevant life experiences); residents can feel unsupported when staff are not aware of their personal information (Polacsek & Woolford, 2022).
Ensuring older people (and their family, friends and carers) are very clear on the ‘nuts and bolts’ of how the facility works in real world language, e.g. the daily timetable, type of meals, choice of activities, privacy arrangements, ability to come and go, descriptions of daily routines and expectations, the rules around staff support, where to go with concerns, visitor arrangements, facilities outside the home, and laundry arrangements (Polacsek & Woolford, 2022).
Teaming the person with a ‘buddy’ where appropriate (Polacsek & Woolford, 2022).
Demystifying the role of those who offer help to residents as part of their role in the facility, e.g. volunteers, visiting pastoral care practitioners (Polacsek & Woolford, 2022).
Organising with family and staff the personalising of the new resident’s room before arrival (photos, cushions, pillows, etc.) so the person can identify with some aspects of their former home (Polacsek & Woolford, 2022).
Sourcing a person who will accept the responsibility of supporting the new resident in the transition process; otherwise the new resident may meet a wide array of new people whose roles may not be clear to them and whose availability may be inconsistent. This can limit opportunities to know care staff and be introduced to new residents (Polacsek & Woolford, 2022).
Informing staff of pre-existing mental health needs so appropriate strategies can be put in place to provide support, in collaboration with family members. It is also important for staff to be given timely and accurate healthcare information, including background on the person’s past experiences and triggers (Polacsek & Woolford, 2022).
Social workers also have an important role to play with families who are placing a member into residential care. A study by Graneheim, Johansson and Lindgren (2014) examining the experiences of 180 family caregivers from six different countries found family caregivers who placed a family member into care often passed through four phases: making the decision, living with the decision, adjusting to a new caring role and adjusting to changed relationships. Not everyone passed through all phases and not everyone came to peace with their decision. The key to successful resolution appeared to occur if the family caregivers were recognised as partners in the care of the family member.
Looking at the findings in more detail suggests the following strategies are appropriate for family caregivers who have to cope with a decision to relinquish care of their family member and place him or her in residential care.
1. Recognise the phases that family caregivers will go through.
i. making the decision, often with a feeling of guilt and shame,
ii. living with the decision – oscillating between feeling relief and questioning the decision,
iii. adjusting to the new caring role, i.e., monitoring someone else’s care, and
iv. forming a new relationship with the family member and staff
At the same time family caregivers need to realise
o not everyone passes through these phases,
o the phases do not occur in a fixed order, and
o the phases can overlap.
2. Keep occupied.
3. Engage in physical activity.
4. Seek professional or informal external support if the process is becoming too much personally or as a family. Informal support often comes from family and friends who have had the same experiences.
5. Avoid friends who express negative opinions about residential care.
6. Look at the positives that have occurred or will occur as a result of the family member being placed in care, both for the person concerned and the family as a whole.
7. If possible, visit the family member regularly.
8. Create positive relationships with the staff
Be positive with staff, recognising and commenting on efforts to help the family member adjust to changing circumstances.
Engage with staff about family member’s needs in a non-threatening and collaborative manner. If possible, offer to assist in any changes to care.
Remain actively involved with the staff and seek to inform them of the family member’s interests and ongoing needs. Ask to be involved in any review of family member’s needs.
Within Residential Care
A social worker’s role is to ensure that appropriate support systems are in place, engaged and utilised to their full extent. Person-centred health care and wellbeing outcomes are central to this support. Social workers have a unique appreciation of the importance of social support systems, and the isolation experienced by any older persons (AASW, 2015). The social worker should challenge narrow scopes of physical care, reveal the person behind the resident, and assist the person in achieving the best possible life for themselves (Hardy et al., 2020). In other words, responding to older people in residential care should support the concepts of ‘positive ageing’ and ‘ageing in place’:
Ageing in place linked to a sense of attachment and social connection Facilitate among residents and staff: friendliness, feeling safe, good access to services, connection to neighbours, familiarity of place, social connections.
Ageing in place linked to sense of security and familiarity Facilitate among residents and staff: security and safety, familiarity with residents, people to look out for residents.
Ageing in place tied to sense of identity, linked to independence and autonomy Facilitate among residents and staff: making one’s own choices, maintaining one’s own budget, maintaining good relations with other residents and workers as well as the local health services (Trewren, 2017; Wiles et al., 2011).
Various authors suggest practical approaches for social workers in Residential care facilities. These include:
Use of interventions such as reminiscence therapy, life review, dignity therapy, narrative therapy and legacy creation to encourage conversations that highlight strengths and resilience and nurture connections with family and carers (Wood, 2022).
Use of advocacy and crisis intervention skills by highlighting the unmet needs of older adults and families (Hardy et al., 2020; Wood, 2022).
Assist with the management of depression and other mental health concerns through counselling, education, and case management with other healthcare professionals (Lee et al., 2022).
Ensure staff have relevant background information about the person and can treat the person as an individual (Hardy, et al., 2020; Polacsek & Woolford, 2022). This is achieved by:
Provision of holistic, person-centred care – a person-in-environment approach that considers the individual and their relationships with their family, carer and support networks.
Biopsychosocial assessments - social workers are often the only member in the multidisciplinary team who can identify psychosocial problems and emotional distress.
Social work’s emphasis on the importance of autonomy, self-determination, strengths, and possibilities are crucial to improving quality of life and wellbeing.
Acknowledging and responding to residents’ and families’ experiences: being with people where they are at; encourage them when appropriate, and when they are not feeling positive, do not force them to be.
Supporting other staff members and health professionals; develop partnership models of care.
Supporting decision making—ask people what they want (AASW, 2015; Hardy et al., 2020; Trewren, 2017).
Identify residents’ strengths: though a person might not be physically able to cook anymore, this does not mean that they do not remember the recipes they used. Just because residents cannot walk, does not mean they cannot garden, cook, knit or partially dress themselves (Trewren, 2017).
Learn to know the person, their likes and dislikes. Find creative ways to enable residents to do things within the scope of their abilities (Trewren, 2017).
Helping people die well by making the lives of residents and family members as positive and meaningful as possible (Trewren, 2017).
Develop culturally appropriate models of service delivery (AAASW, 2015; Polacsek & Woolford, 2022).
Respect privacy (AASW, 2015).
Supporting Material / References
(available on request)
AASW: Australian Association of Social Workers. (2015). Scope of social work practice: Social work in aged care. AASW. https://www.aasw.asn.au/document/item/8305
Cutter Law P.C. (2024). 5 steps to choosing the right nursing home for your loved one. https://cutterlaw.com/how-to-choose-the-right-nursing-home/
Graneheim, U. H., Johansson, A., & Lindgren, B-M. (2014). Family caregivers’ experiences of relinquishing the care of a person with dementia to a nursing home: insights from a meta-ethnographic study. Scandinavian Journal of Caring Science, 28, 215-224.
Hardy, F., Hair, S. A., & Johnstone, E. (2020). Social Work: Possibilities for Practice in Residential Aged-care Facilities, Australian Social Work, 73(4), 449-461. doi: 10.1080/0312407X.2020.1778051
Lee, J. L., Splawa-Neyman, M., & McDermott, F. (2021. The role of social work in residential aged care facilities: Evaluation of a pilot program in Australia. The Qualitative Report, 27(1), 64-78. https://doi.org/10.46743/2160-3715/2022.4761
Lehning, A., Nicklett, E., Davitt J., & Wiseman H. (2017). Social work and aging in place: A scoping review of the literature. Social Work Research, 41(4), 235-246.
Polacsek, M., & Woolford, M. (2022). Strategies to support older adults’ mental health during the transition into residential aged care: A qualitative study of multiple stakeholder perspectives. BMC Geriatrics, 22, 151- 161. https://doi.org/10.1186/s12877-022-02859-1
Söderberg, M., Ståhl, A., & Melin Emilsson, U. (2013). Independence as a stigmatizing value for older people considering relocation to a residential home. European Journal of Social Work, 16(3), 391-406. https://doi.org/10.1080/13691457.2012.685054
Trewren, C. (2017). Ageing in an aged care facility. Social Work Focus, 2(2), 24-25.
Wood, J. (2022). Social Work Focus, 7(4), 24-26. https://www.aasw.asn.au/document/item/14033
Wiles, J. L., Leibing, A., Guberman, N., Reeve, J., & Allen, R. E. S. (2011). The meaning of “ageing in place” to older people. The Gerontologist, 52(3), 357-366. doi: 10.1093/gerontgnr098