Psychosocial needs

What are psychosocial needs?

Psychosocial needs refer an individual’s emotional and social requirements for wellbeing. [1] Psychosocial needs can be supported by social connection and interaction, recognition and respect for personal identity, culture and spirituality, access to appropriate care to support mental health needs, and autonomy in decision-making. [2]

In care settings, such as residential aged care facilities (RACFs), clinical and physical health information of those receiving care is often prioritised over psychosocial detail in care planning and documentation. [3] Task-based care routines are often prioritised over building relationships with individuals receiving care. [4] 

Why does this matter for rights-based care? 

In a rights-based care (RBC) framework, meeting the psychosocial needs of older people is not optional; it is an ethical requirement. This aligns with the obligation in The Australian Government's strengthened Aged Care Quality Standards, Standard 1, Outcome 1.1 to provide person-centred care and deliver services that foster a sense of safety, inclusion and quality of life. [5]

Psychosocial needs of older people 

Psychosocial wellbeing includes maintaining a sense of autonomy, social connection, and engaging in meaningful activities that enhance quality of life. 

• Wellbeing is fundamentally linked with a sense of autonomy. Older people should receive care in a way that provides reassurance and a sense of acceptance about their limitations and the help they are receiving, rather than a sense of shame. [6] Some studies described care workers completing tasks on behalf of an older person, rather than providing support for the person to complete the tasks themselves. [7] 
• Access to aged care services that enable older people to maintain social connections can have a significant impact on wellbeing. [7, 8] This becomes particularly important as physical health declines and people become more reliant on their caregivers for support. [7] 
• Many of the factors identified as most important to good quality of life for older people in RACFs are aligned with meeting psychosocial needs. Six key identified domains are: independence, mobility, pain management, social connections, emotional wellbeing, and activities. [9] 

Mental health and psychological wellbeing are affected by care practices and care environments.

• The use of person centred care (PCC) approaches have been found to achieve positive psychosocial outcomes, especially by allowing people to maintain independence. [3] 
• Using restrictive practices, including physical restraints can cause damage to psychological wellbeing, and it is essential to have staff trained to provide alternative approaches to help manage behaviours of people receiving care. [10, 11]
• Factors related to the physical spaces, or built environments, where people receive aged care services are important to psychosocial wellbeing. Access to the outdoors, opportunities to engage in meaningful activities and a ‘normal life setting’ leads to better wellbeing outcomes for older people living in RACFs. [9, 12] 
• Factors like low staff-to-client ratios hinder the ability to achieve good quality-of-life objectives for older people in residential care settings. [9]

The ability to meet the psychosocial needs of older people receiving care is also affected by administrative processes and conceptual models of care more broadly.

Patient information forms are often designed for recording more medical information than psychosocial detail about the individual receiving care. Simple tools, such as a card sorting game that asks about an older person’s preferences, and guides to help structure conversations between staff and people receiving care about individual’s values and goals, can be useful. [3]

Models of care focus on clinical routines rather than resident thriving. [13] In RACFs and other high-needs settings, psychosocial needs, including social inclusion, are often neglected. A model of care where thriving, rather than surviving, is the core purpose of care is preferred by aged care stakeholders.  This model can inform evaluation approaches  based on psychosocial dimensions of care which lead to better wellbeing. [13]

Supporting older people with additional mental health needs 

Many older people using the aged care system have additional psychosocial needs including those with a mental health condition, people living with dementia (PLWD), and people who have experienced trauma. 

• Some 23% of those assessed for a home care package and 58% for those entering permanent residential care were recorded as having at least one mental health condition. [14] 
• Mood disorders (including depression) followed by anxiety/stress disorders are the most common mental health conditions recorded. [14] 
• Up to 60% of people living in residential care facilities have symptoms of anxiety that require treatment. [15] 

There is a mismatch in that aged-care facilities are required to provide support for residents’ psychosocial wellbeing, yet they are not required nor funded to provide psychological support. [15]

PLWD also commonly have mental health conditions such as depression and anxiety.[16] Detecting these symptoms can be complicated because of the overlap with some of the symptoms of dementia. [17] Changes in behaviour among PLWD are usually viewed through a medical lens but psychosocial or environmental factors should be considered. [18] PCC approaches have been found to reduce agitation, and improve mood and quality of life for PLWD. [19]

Many older Australians will experience trauma at some point in their lives. Trauma can be caused by many things including war, accidents, abuse, and natural disasters, and can cause ongoing distress. [20] Providing trauma-informed care includes having awareness that some practices and procedures performed in the care setting are in violation of protecting an individual’s human rights, for example, locking doors in attempts to keep people safe. [21] These practices can cause additional distress for those with lived experience of trauma.

Care staff require specialised training and education in providing care that meets the mental health needs of people receiving care, including trauma-informed care. [22]. Using a PCC approach to practice and understanding the person receiving care holistically, including experiences of trauma, will help both clients and care providers get the outcomes they want. [23]

Tensions related to psychosocial needs

There are some tensions between supporting dignity of risk while also protecting the health and safety of the individual receiving care, and the rights and safety of others. The consumption of alcohol in residential care settings provides a good example of this tension. Three frameworks have been identified to guide residential aged care facility policies around alcohol policies: public health, legal and human rights. [24]

Navigating such tensions can also be complicated for workers when providing care for PLWD. For example, inconsistencies have been identified in the views of aged care workers as to whether they would allow residents with dementia to engage in potentially risky behaviours, such as smoking or sexual activities. [25] 

The mental health needs of aged care workers also must be met in a rights-based care framework; this includes providing both physically and psychologically safe workplaces. [26] A safe and healthy workforce underpins the ability of older people to also receive care adequately and appropriately under the rights-based care lens. 

Staff qualified in caring for people with complex mental health needs are required to both meet the sometimes complex mental health needs of those receiving care and to ensure staff are not working beyond their abilities, putting themselves and others at risk. [27]

Acknowledging past failures of the aged care system that have caused moral harms to people receiving care (and their families), such as the use of restrictive practices for people with dementia and ineffective complaint systems, is an important part of moving forward under a rights-based care framework. Identifying how future systems will be changed is part of addressing dignity and justice in applying a rights-based care approach. [28, 29]

Want to learn more?

Supporting psychosocial wellbeing

• The Meaningful lifestyle activities priority topic describes evidence supporting psychosocial wellbeing through social, nature-based and physical activities and person-centred approaches. 
• This resource from PalliAGED provides guidance for providing psychosocial care. This is targeted to people approaching end of life, but the concepts and suggestions can be applied more broadly to anyone receiving or providing aged care services.

Older people’s mental health needs

• The Mental health and wellbeing priority topic describes factors associated with older people’s mental health and approaches and tools to support mental health. 
• This web report by the Australian Institute of Health and Welfare includes information about the mental health needs of older people at the time of their assessment for aged care services and provides links to existing national datasets about the mental health of people using aged care services.
• This bulletin from the Australian Psychological Society provides information about the mental health challenges faced by older people living in residential aged care settings, and ways to support them.  
• Phoenix Australia provides information and resources for people affected by trauma. There are resources available for aged care workers and organisations, and for older people and their families. 

Workforce wellbeing

• Read more about meeting the psychosocial needs of the aged care workforce (link to Workers rights and issues subtheme) 
• The Staff burnout priority topic addresses personal and interpersonal factors that contribute to staff burnout, many of these factors are related to psychosocial wellbeing. 

What can be done?

Support care approaches and environments that contribute to psychosocial wellbeing 

Organisations or policy makers:

• Prioritise psychosocial needs to same level as physical health needs.

Organisations:

• Enable older people to maintain social connections and participate activities that contribute to good quality of life. 
  Use PCC approaches to help older people achieve positive psychosocial outcomes.
• Ensure the environments where people receive aged care services are supportive and comfortable and provide access to meaningful activities. 
• Adapt administrative processes to enable the assessment and monitoring of psychosocial needs of aged care recipients.

Care teams:

• Provide care in a way that reinforces the autonomy and dignity of the older person.
• Avoid using restrictive care practices and train staff to use other approaches to help manage behaviour. 

The evidence: 

• In residential care settings, there is sometimes more focus on clinical routines than resident thriving. [13]
• An organisational culture that lacks adequate administrative processes for prioritising and benchmarking psychosocial needs of care recipients is a barrier to understanding and meeting these needs. [3, 30] 
• Meeting psychosocial needs including enabling older people to maintain social connections and participate in meaningful activities is important to positive wellbeing and a good quality of life. [7, 9, 12]
• A sense of autonomy for those in residential care settings is fostered by involving older people in decision making about their care and providing supportive environments where older people feel a willingness to rely on staff for assistance. [6]

Supporting people with additional mental health needs

Organisations or care teams:

• Recognise that a substantial proportion of people assessed for aged care services have a mental health condition such as depression or anxiety. 
• Consider psychosocial and environmental factors when assessing changes to behaviour for PLWD. 
• Increase awareness of, and training to provide, trauma-informed care.

The evidence:

• Many older people using the aged care system have a mental health condition. [14, 15]
  PLWD often also have anxiety or depression. Changes in behaviour observed in PLWD are not always due to cognitive decline. [16, 18]
• There is a need for staff qualified in caring for people with complex mental health needs. [27]

Managing tensions related to psychosocial needs

Organisations or care teams:

• Consider the individual’s condition and circumstances when determining their capacity to make decisions to engage in risk-taking behaviours. 
• Prioritise the safety and mental health needs of aged care workers who may be confronted with distressing situations or behaviours in the course of their work. 

The evidence:

• A risk-adverse culture in care settings means the safe, routine option is often prioritised over allowing for individual choice. [21]
• The balance of allowing for dignity of risk while maintaining safety can be compounded by other factors, for example, when providing care for a person with dementia. [25]
• Workers in the health and aged care sector are at the highest risk of workplace violence and aggression. [26]

Promote dignity and justice

Policy makers or organisations:

• Admit and work to repair past wrongs that led to moral injury of care recipients and their family members. This can help to restore the belief that aged care services centre the dignity of the individual receiving care.
• Promote dignity of older people by working to correct ageist attitudes in the general culture towards older people in residential care. 

The evidence:

• Research about family members or care partners of people with dementia receiving care found many have experienced moral injury caused by, for example, consenting to restrictive practices due to lack of alternative options or perceived coercion by aged care operators. This should be acknowledged and corrected in order address the guilt and trauma caused by this experience and to restore faith more broadly in the aged care system. [28, 29] 
• The ‘conceptual framework’ many residential care facilities operate within are underpinned by ageist attitudes in the broader culture. There is need to proactively correct for this in order to provide dignified care.