Mindfulness practices to increase wellness and wellbeing and reduce rates of depression in clients with normal or impaired cognitive function, their families, and staff of Residential Aged Care facilities
Introduction: In 2021 the Royal Commission Enquiry into Aged Care Quality Standards (RCACQS) published a report that made recommendations to the Australian Government for changes to meet the Aged Care Quality Standards (ACQS, 2015). Since this report one of the changes will be a new aged care act to replace the Aged Care Act of 1997 (Department of Health, 2021). For this project plan the main areas of focus are reducing existing rates of depression and improving wellbeing in residential aged care (RACF) by promoting community participation in Mindfulness Based Stress Reduction (MBSR) programs which will be open to clients, their families, and the staff of RACF.
Background: The Public Health Problem
There is a high prevalence of Depression in Residential Aged Care Facilities (RACF). The Australian Bureau of Statistics (ABS, 2018) states that approximately 52% of people have depression. In 2021, The Royal Commission into Aged Care Quality Standards (RCACQS, 2021) stated that:
“Older people should have the same access to mental health support as all members of the community but they do not (p.69). The current systems do not sufficiently recognise the importance of proactively supporting older people’s social and emotional wellbeing. We have found that Australia’s care system is understaffed and the workforce is underpaid and undertrained” (p. 74,75).
The Australian Government Productivity Commission (AGPC, 2022) has 14 quality indicators for RACF one of which is assisting older people to achieve wellbeing and independence. Reduced rates of depression and increased focus on wellbeing need to occur if this is to be achieved.
Background: The Target Population
In RACF in Australia, 184 000 residents have high care needs in at least one care domain including complex health care (54%); cognition and behaviour (65%); and activities of daily living (63%) (Gen aged care data, 2021). The Aged Care Quality Standards (ACQS, 2015) Standard 4 of 9. Services and support for daily living’ states: “A consumer might have challenges in their health and abilities, but they still have goals they want to achieve. They also have roles that have meaning, and they want to manage their day-to-day lives as well as they can”. Standard 4. refers to the responsibility RACF have in supporting clients to achieve their goals and enjoy life.
The Royal Commission Enquiry into Aged Care
The 2021 RCACQS (2021) highlighted continuing problems in RACF. One statement by RCACQS (2021) called for a shift from a predominantly market lead model of aged care, to one with improved government leadership, and a strong community focus with person centred care at the heart of practice. In addition, many people in aged care communities, from the workforce of 366,000 paid workers (84%) and 68,000 volunteers (16%) (ABS, 2018) contributed anonymous submissions to the RCACQS, 2021 enquiry. The combined amount of submissions from clients, families, and staff made up 47% of the reports which were statements of concern about understaffing, unanswered call bells, high rates of staff turnover, lack of caring, and agency staff not knowing the residents and their needs (RCACQS, 2021). Additional complaints were about more serious aspects of substandard care, neglect, and abuse (RCQCQS, 2021; Senate Affairs Commitee, 2019). Approximately 428 500 people are informal carers for people over 65; the RCACQS acknowledged their value in the care system by reducing burdens on paid staff (RCACQS, 2021; Xerri, et al., 2019). The RCACQS (2021) also made reference to sentiments of an aged care community that expects RACF to be fair and equitable, and to treat clients and their families with dignity and respect, along with promoting quality of life and wellbeing physically, emotionally, mentally, and socially (Hill, 2021; RCACQS, 2021).
Mindfulness Based Stress Reduction for RACF
It is proposed that introducing Mindfulness Based Stress Reduction (MBSR) to RACF for clients, their families, and staff can provide a community focused solution in working together to look after the health of Australia’s Ageing population ‘upstream’. Currently approximately 16% of Australian’s are over 65, with the number expected to steadily increase to 23% by 2066, and the percentage of Australians over 85 is set to double by 2040 (ABS, 2018). Mindfulness Australasia (MAA) currently works with Primary Health Tasmania (PHT) to run MBSR an 8-week program in Tasmanian communities, which is helpful for those participating to improve their quality of life. It is also helpful in managing issues of stress, anxiety, depression, and chronic illness (MAA, 2022; PHT, 2022). Facilitators run the program adapted to the needs of participants, whereby attentional balance is learned through breath work, focusing on thoughts, emotions, behaviours, and the body. The end outcomes of practice can include a renewed perspective on life and improved wellbeing (MAA, 2022). Between sessions participants are encouraged to practice and implement these skills in their daily lives (MAA, 2022).
Purpose
The purpose of this project is to improve the health of RACF communities. The World Health Organisation (WHO, 2022), describes Health as: “A state of complete physical mental and social wellbeing, and not merely the absence of disease of infirmity”. The Global Wellness Institute (GWI, 2022), describes Wellness as multidimensional and more than just physical health, for example most models of wellness include 6-12 dimensions that represent different aspects of life (GWI, 2022). The following statement from the Department of Health (DOH, 2022) further supports a proposal for MBSR in RACF by giving some context to the ‘why’ of this proposal. The DOH (2022) states:
“Wellness and reablement are related concepts, often used together to describe an overall approach to service delivery. Wellness and reablement approaches are based on the idea that, even with frailty, chronic illness or disability, most people want and are able to improve their physical, social, and emotional wellbeing, to live autonomously and live as independently as possible”.
It is therefore worthwhile for RACF to implement MBSR programs to improve health and wellness, reduce rates of depression and assist in meeting ACQS (2015).
Research
For this plan a search of data bases with the keywords, residential aged care, mindfulness, wellness, wellbeing, elderly, dementia, depression, pain, and carers, returned information from universities, academic journals, and government websites. Many studies reported that MBSR for the elderly can support health related quality of life, thereby reducing symptoms of depression and other health problems (Ernst, et al., 2008; He, et al., 2019; Geiger, et al., 2016; Kyoung-Nam, et al., 2014). Dementia related illnesses benefit from MBSR by reduced stress, improved relaxation, sleep, calmer emotions, improved clarity, social interactions and interconnectivity. Carers and family of those with dementia are also able to benefit from MBSR (Berk, et al., 2018; Epstein-Lubow, et al., 2011; McMahon, et al., 2017; Mulquiny, et al., 2022; Oken, et al., 2010; Raab, 2014; Rakesh, 2012). Studies where wellbeing and wellness were looked at in a social context, and or qualitatively assessed through client / staff discussions, or self –reporting utilising questionnaires, were also reviewed. A study by Liu, et al. (2022) utilised the PERMA scale for measuring a person’s wellbeing after practicing mindfulness. PERMA stands for: Positive emotion, Engagement, Relationships, Meaning, and Achievement. A study by Bech, et al. (2003) stated the value of measuring a person’s wellbeing to quality of life, rather than the absence of distress symptoms. In this study the WHO 5 wellbeing scale and the SF-36 wellness scale were utilised. The holistic model of wellness, ‘SPECIES’ which refers to: Social, Physical, Emotional, Career, Intellectual, Environmental, and Spiritual wellness (University of Wiscon, 2021) was highlighted as a tool for the measuring wellness in a report “Wellness, reablement and purposeful ageing” (Conci, 2018). The Cornell Depression Scale, used by an Aged Care Assessment Team (ACAT) assessed clients with and without cognitive impairment on admission to RACF and perdiodically thereafter (DeBelis & Williams, 2008; Department of Health, 2012). In a study by Banks (2018) titled “The Social dynamics of devaluation in an aged care context”, it looked at where aged care workers and clients are devalued, for example, low wages and status for workers may effect their views on the importance of the work they carry out, or for clients, their views on their rights may be affected by RACF protocols. A study from Bauer et al (2018) described ‘Narrative Identity’, or how people frame their life experiences as being an important component of ‘eudamonic wellbeing’, which is happiness or contentment derived from self-actualisation and a sense of meaning and purpose in life (American Psychological Association, 2022). Many more examples were found that highlighted the importance of wellness and wellbeing in RACF.
Wellbeing and Wellness Models
As previously stated, MBSR has been shown to improve wellness and wellbeing and reduce depression and chronic pain, including in those with cognitive impairment. In utilising the SPECIES Model in relation to wellness, participants can gauge where aspects of their lives need attention, or are improving. Observations of the Social, Physical, Environmental, Career, Intellectual, Emotional, and Spiritual domains of life (SPECIES) provide qualitative evidence of efficacy over time (University of Wisconsin, 2021). Examples can include the social, emotional, and intellectual aspects of MBSR which bring communities together to relax and attune with how they’re feeling via participation and discussion, thus fostering inclusivity and connection (Steller, 2022) and in the physical domains MBSR can be effective in helping to manage chronic pain (Morone, et al., 2008). The career aspect may still be acknowledged as clients reflect on their past occupations, gain meaning through reflection, and share wisdom with their families (Steller, 2022). Clients can carry over skillsets past retirement which can inspire confidence in their achievements in life, through a positive mindset (Lindberg, 2005; Steller, 2022). Family members and RACF staff may also find space to breathe and allow the stresses of the work day to wash away, and renewed enthusiasm and focus might occur (Larkey, 2021). Spiritual and environmental insights may be gained as people spend time in quiet reflection and gratitude for the things they appreciate in their lives (Gautam, et al., 2022; Jackson, et al., 2016; Steller, 2022). In addition, people view each other as valued members of a community, rather than in the role of staff member or client (Bergland & Kirkevold, 2006; Brownie & Nancarrow, 2013; Banks, 2018; Conci, 2018; Hartevelt, 2022; Hill, 2021; Meagher, et al., 2019; To Ng, et al., 2021). It’s worthwhile stating that Depression, and or the absence of feelings of wellbeing, can come from a multitude of factors in transition to aged care, including moving from the familiarity of home, grieving the loss of independence, health, dignity, loved ones, pets, and even financial stressors; the transition to care is often not easy despite efforts of providers to make it so. Living permanently in an organisational environment may at times feel institutionalised or limiting (Anglicare Australia, 2022; Baldwin, et al., 2015; Fitzpatrick & Tzouvara, 2019; Gill, et al., 2018; McCabe, et al., 2022). It seems wise to place an emphasis on implementing holistic strategies into existing care frameworks for RACF
Implementation
Goal
RACF providers recruit MAA to hold 8-week MBSR in their facilities approximately 5 times per year to foster continuity and add value to any existing wellbeing and or wellness frameworks. Clients, their families, and staff can participate in MBSR programs.
Objectives
Following are three main objectives: (1) Mindfulness practice surveys are collected and transcribed after each 8-week course (Berk, et al., 2018; Chan, et al., 2020; Ernst, et al., 2008). Client’s responses to the PERMA, SF-36, WHO5 (Bech, et al. 2003) and Cornell depression scale surveys (De Bellis, 2008) are recorded at the beginning and end of the course. A separate SPECIES and WHO 5 survey for week to week responses will also be recorded (Gautam, et al., 2022; Jackson, et al., 2016; Lindberg, 2005; Steller, 2022). RACF may wish to recruit university or nursing students to evaluate the qualitative findings or employ staff who have knowledge of the framework analysis to evaluate the findings. (2) Findings may be shared with permission so that other facilities may learn from the process and decide whether to implement the practice. This practice could potentially be an opportunity for medical staff and community GP’s and Specialists to participate and contribute medical data to evidence based research in MBSR. (3) Outcomes against the ACQS 2015 framework are measurable from the qualitative results derived from client participation, feedback and surveys.
Strategies
It’s suggested that three aspects of planning occur (1) Clients who self-identify as feeling depressed, have cognitive impairment, or alternately are just in need of an activity to improve their wellbeing are encouraged to join the sessions. Those who are able, can sign informed consent and confidentiality forms, and agree to complete wellness questionnaires at the beginning and end of the 8 weeks. Those with cognitive impairment will be encouraged to follow this protocol, families or carers may assist, but it won’t be deemed as necessary as MBSR is still beneficial (2) Families and caregivers are invited to sign up to attend with clients of RACF and will follow the same processes (3) Staff are invited to attend, supported by roster modifications where possible or they may voluntarily attend when not on roster.
Evaluation
After 8 weeks of MBSR in RACF it’s expected there will be measurable improvements in self-reported wellbeing and wellness outcomes including reduced rates of depression in participants without cognitive impairment. For those with cognitive impairment, it’s expected that their responses be recorded with family, or that observations are made by staff or carers. It’s likely there will be instances where MBSR alleviates symptoms of impairment. In conclusion, the above will describe which aspects of the practice have been helpful and this can aid research in the future.
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