Supervising post-graduate psychology trainees in residential aged care settings: common issues

ABSTRACT Objective There will be an increased need for psychologists to provide mental health services in residential aged care facilities. Experience while training is invaluable to improving both confidence and interest in working in this area. Awareness of potential barriers and ethical situations that may impede good mental health care is necessary when providing supervision. Method This paper reviews issues that supervisors need to be aware of when working with students in this clinical space. Results Barriers and enablers of clinical placements in residential aged care settings are discussed. Models of care, ethical considerations relating to risk, consent and working systemically, multiple clients, practical difficulties of being off-site and clinical aspects of adapting therapy to residential care settings are identified as key issues related to supervising students. Potential solutions, resources and practical approaches to these issues are also highlighted. Conclusions A positive approach to the complexities of working in residential aged care settings can lead to quality supervision and clinical care in this much needed area. Key Points What is already known about this topic: There is a high degree of mental health issues amongst older adults living in residential aged care. Concerns have been raised about how clinical psychologists will meet future workforce demands. There is a lack of supervisors with experience in providing clinical guidance in this area. What this topic adds: Supervising in residential aged care has been enabled by an increased level of funded psychological services available to aged care residents in Australia. Several unique ethical issues can arise within supervision in residential aged care contexts that need to be discussed with students to improve their competence. There are practical approaches to adapting clinical interventions and working systemically that serve to facilitate a student’s placement journey in residential aged care.


Background
Individuals living in residential aged care facilities are classified as one of the most vulnerable in our society, with over 50% experiencing mental health disorders (Amare et al., 2020).The COVID-19 pandemic has amplified the stress, anxiety, depression, and isolation for individuals living in such facilities, with 41% of residents having increased loneliness and 33% increased anxiety in a recent Australian survey regarding the impact of COVID-19 on residents' mental health (Brydon et al., 2022).Such a preponderance of mental health issues in residential aged care underscores the need for a well-prepared workforce to meet the demand.However, there are comparatively few psychologists working with older adults, and even fewer with skills relevant to residential aged care environments (Moye et al., 2019;Pachana et al., 2010), with less than 14% of Australian facilities employing psychologists (Stargatt et al., 2017).
Exposure to quality clinical placements with older adults has been identified as a positive predictor of working in this field amongst psychologists (Koder & Helmes, 2008).Providing clinical placement opportunities can improve access to mental health services for residents, as well as increase exposure of students to the skills required in this unique setting, thus educating the next generation of aged care mental health clinicians.However, not only are clinical placements that focus on mental health in late life comparatively rare (Pachana et al., 2010), but few supervisors have experience in supervising trainee psychologists on placement in these settings (Karel et al., 2012).

Barriers and enablers of clinical placements in residential aged care settings
Lack of appropriately experienced supervisors is a major barrier in accessing practical experience in aged care settings.At present, resident emotional wellbeing is often seen as the domain of leisure and lifestyle therapists (commonly through group programmes such as music therapy and cooking) and pastoral care workers (Stargatt et al., 2017).Whilst the spiritual counselling and stimulating programmes provided by these professional groups are integral to residents' wellbeing, psychologists can provide timely identification and specialised treatment for mental health issues (Davison et al., 2017).Through the inclusion of psychologists and other mental health professions, such as counsellors and social workers, the potential pool of mental health practitioners can be increased in aged care settings.
Professional psychology training programmes have clinical placements within their degree structure which are well placed to service aged care facilities.However, residential aged care settings are less used as a psychology placement setting for experience working with older adults, compared to inpatient and outpatient psychiatric facilities (Pachana et al., 2010).Obstacles include perceptions that training experiences may be inadequate due to difficulties with client communication, lack of interest in working with residential aged care populations amongst students, and post-graduate training mainly focused on specialised mental health settings (McCloskey et al., 2020;Pachana et al., 2010).One factor relating to successful placements from research with nursing students has been cited as having a designated research liaison professional or nurse educator from the university regularly meet with students and relevant facility staff (Xiao et al., 2012).Stakeholder input into placements, namely the administrators and managers of the residential aged care facilities, can also highly influence the creation and quality of a placement.Research has highlighted generally positive reactions to having students within residential aged care facilities, with staff commenting on the positive influence of student enthusiasm (Grealish et al., 2013).
There are financial barriers for psychologists working in residential aged care facilities which may limit

Remote supervision
As residential aged care facilities seldom directly employ clinical psychologists (Stargatt et al., 2017), students on placement in these settings are more likely to have to source supervision that is remote.Whilst remote supervision is not limited to the residential aged care environment and can occur in settings such as prisons and schools, the clinical complexity of resident presentations can lead to students feeling isolated and anxious on site.Furthermore, common mental health conditions, such as depression and anxiety, often have a different presentation in older adults, compared to what is typically taught regarding such symptoms.For example, an older adult with depression is more likely to present with somatic or subjective memory complaints, rather than stating they are feeling emotionally low.Anxiety can often be missed if agitation is present.Medical conditions, such as delirium, have a significant impact on a resident's mental state and understanding the interplay between medical, functional and nursing care needs can be daunting to a student.This feeling of vulnerability may be heightened when clients present at risk of self-harm or suicide.Clear guidelines as to how to access a supervisor, as well as having an established liaison champion in the facility, can decrease a student's sense of isolation.
Learning a structured approach to communicating clinical information to other health professionals, such as general practitioners (GPs) and nursing staff, can lower the perception of being a burden or nuisance that students may feel.In addition to knowing the person responsible on a referral form, having the contact details of key people who would be working with the identified client (for example, Leisure and Lifestyle manager; Clinical Care Co-Ordinator, GP) would be valuable in the absence of an on-site supervisor.There are several resources that describe the various staff roles within residential aged care (Aged Care Guide, 2022) and the role of psychologists working in an aged care facility (Molinari et al., 2021), that supervisors and students can discuss together.
Similar to other settings where direct observation of student performance is less common, session recordings are one way of validly assessing competence (Topor et al., 2017).Specific issues in aged care settings related to using recordings involve gaining informed consent from a resident (or their substitute decision maker) prior to recording.Reactions to such requests may trigger concerns about privacy and confidentiality breaches (Stargatt et al., 2021), hence clear explanations need to accompany any recording requests (for example, the student can explain to the client that recordings help provide the best possible service).Recording sessions in a residential care environment intensifies the impact of common disruptions that can occur (for example, staff bringing the resident their morning tea, administering medication).Disruptions of therapy flow may be distracting for a student, especially when they are being recorded for assessment.Informing key nursing staff about session times and having a sign on the resident's door may help lessen the impact of care delivery interruptions.
Supervisors themselves need to ensure they have up-to-date knowledge within the aged care mental health field and awareness of ethical guidelines for working with older adults (Australian Psychological Society, 2016) to help students avoid outdated practices and to develop students' confidence in supervision.The Pikes Peak Geropsychology Knowledge and Skill Assessment evaluation tool (Karel et al., 2010) can be used with students to help them target and develop key skills in working with older adults, including in residential care.

Dignity of risk versus duty of care
Reporting of suicide risk and other serious threats to client physical and emotional wellbeing (e.g., delirium, client concerns regarding their treatment in the facility, elder abuse) may be discussed in the therapy session but not be known to staff.Reporting potential risk may necessitate breaking the client-therapist confidentiality bond and can be uncomfortable for students.Dignity of risk involves a person having the opportunity to make choices that may necessitate taking reasonable risks, such as walking to the local shops.However, students may be concerned when they are informed of such intentions, fearful they are potentially breaching their duty of care in not acting to avoid harm to the resident.The importance of collective collaboration when weighing up these two principles has been highlighted (Duffy, 2003;Ibrahim & Davis, 2013), by clearly discussing with clients early on in therapy the limits to confidentiality, the amount and type of information communicated to staff either verbally or in progress notes, as well as which staff will be involved.
Supervisors need to emphasise the importance of temporaneous clinical notes and well documented risk assessments.Knowledge of the specific risk management procedures of the facility is also advised and could be a part of a student's orientation.Comprehensive reviews of risk management issues and procedures in residential aged care have been published (Ibrahim et al., 2019).

Working with family and staff: the systemic model
The model of treatment within residential aged care tends to be systemic, with students gaining experience in working collaboratively within the resident's whole network (Bhar et al., 2015;Bhar et al., 2021).Expanding the person-centred care model to the family and staff working with residents has been found to enhance feelings of working in a partnership in the care of a resident in both family members and the residents themselves (Hutchinson et al., 2017).Supervisors need to be aware of this focus on partnerships and how it can apply to psychological therapy programmes.Outcomes can be enhanced by utilising family and residential care staff (for example, working with family members to bring in resources as an aid to behavioural activation, staff practicing exposure exercises with residents in between sessions and family members reinforcing therapy strategies).This model of treatment may be a change for students who are used to working in a more traditional one-on-one model of care.Openness in communication with residents, staff and family members is a principal factor in ensuring ongoing trust between these three groups.
Complex dynamics in the relationship between a resident and their family may not always be known to the student (Andrews, 2022).It is therefore recommended that students discuss with residents about the benefits of involving the family in the treatment plan.Before a family member is contacted, the student must gain the resident's consent.Family members may require their own external psychological support and students are in a strong position to facilitate such arrangements, with the supervisor helping them source family support.The referrer may well be a family member who is concerned about their relative: again, openness with the resident is recommended.Students can at times find themselves in an advocacy role with a resident where choices need respecting.Structured problem solving is also a way to help residents understand their options, as opposed to a therapist being too directive in their approach.All these issues, when discussed in supervision, can shape a student's ability to work in a systemic way.

Adapting therapy to residential care settings
Older adults can have particular attitudes regarding mental health issues, believing them to be a natural part of ageing.Internalised ageist attitudes can lead to older adults blaming themselves for their depression.Similarly, public stigma associated with mental health issues can also influence attitudes towards treatment (Conner et al., 2010).Such implicit negative beliefs influence treatment options, with older adults tending to seek medical treatment or focus on their religion, rather than engage in psychological treatments (Nair et al., 2020).The residential care setting can intensify such beliefs, with residents often being the passive recipients of daily care.
Students need to be made aware of such stereotypes so they can emphasise psychoeducation regarding the nature of depression and that there are evidence-based approaches to treatment that can be used.Research has suggested that older adults have lower levels of mental health literacy, negatively impacting their acceptance of treatment (Farrer et al., 2008).Supervision discussions can focus on how to best approach a resident in considering their view of the world, understanding the issues they may be facing and using relatable language as opposed to jargon.Supervision can also assist in addressing a student's own assumptions of ageing.
Such unfamiliarity with mental health issues and psychological therapy necessitates careful orientation to the therapeutic process.Many factors can influence the outcome of an initial session with a resident and there are resources available for supervisors regarding interviewing older adults (Gerolimatos et al., 2014).
Initial engagement requires easing a client into therapy, especially when taking into consideration generational gaps between a typically younger therapist and older client, compared to working with clients in a university clinic setting (Gallagher-Thompson & Thompson, 2010).Residents may have little idea of why they have been referred for psychological therapy and initially be understandably wary of a new person coming to see them in their room.Identifying and engaging a trusted staff member as an initial introduction can be of help in increasing a resident's comfort and trust.Furthermore, the collaborative aspect of cognitive behaviour therapy may seem unusual for residents used to a more medical model of treatment.Explanations about the active nature of cognitive behaviour therapy and the role of homework/practice in between sessions are important aspects of early sessions.Supervision content may involve targeting practice exercises and therapy tools to suit a resident's abilities.
Students need to be advised that assessments may take longer and that therapy sessions may not necessarily be a predetermined length.Flexibility is essential for rapport building and comfort in this setting, where medical comorbidities can lead to fatigue that impacts on a resident's ability to converse and concentrate for extended periods (for example, pain, respiratory or cardiac conditions).However, less structure and predictability may heighten student anxiety, necessitating supervision discussions regarding what constitutes a "typical" therapy session.Awareness of cognitive and sensory impairments is essential and can be emphasised in supervision (Gerolimatos et al., 2014).For example, ensuring a resident's hearing aids are properly inserted, seating a resident away from bright lights and having sessions in a quiet, private place away from distractions are more likely to lead to successful sessions.Adapting communication to suit the resident's abilities also influences therapy (for example, avoiding double barrelled questions that may overload working memory).
Supervision is an opportunity to examine students' assumptions about their role and the goals of therapy.The treatment goal may not need to be definitive (for example, decrease anxiety), but can be framed in terms of hypothesised benefits (e.g., improve sense of connectedness).Further, perceived goals of the referrer may not align with the goals of the client once counselling has commenced.Students need encouragement that that it may take some time before the issues take form and become clearer.Students will find that over time, and with the development of trust, the resident may disclose more information and raise more concrete goals.A focus on goals in initial sessions is particularly challenging for residents living with dementia with concrete and activity-based goals being more acceptable in a recent review of the uptake of psychological strategies in residential aged care (Chan et al., 2021).Evaluating outcomes can be performed via observer rated instruments such as the Cornell Scale for Depression In Dementia (Alexopoulos et al., 1988) and the Rating Anxiety in Dementia scale (Shankar et al., 1999).
Supervisors need to be familiar with the treatment outcome literature on psychological therapy in residential aged care settings; in particular, that there are successful adaptations of evidence-based therapies such as cognitive behaviour therapy (CBT) (Bhar et al., 2021).A recent systematic review (Chan et al., 2021) highlighted behavioural activation as the most commonly used therapeutic strategy from 18 cognitive behaviour therapy trials with aged care residents.The Pleasant Events Schedule-Nursing Home Version (Meeks et al., 2009) was developed to implement behavioural activation strategies in residential aged care contexts, given the differences in available activities in this setting.
CBT is slowly being validated and adapted for those with cognitive impairment (Spector et al., 2015;Tay et al., 2019) and cognitive impairment should not be an automatic exclusion criterion for treatment.Supervisors need to be aware of any biases they may hold and challenge those of students regarding a person's ability to benefit from CBT when they are cognitively compromised and the use of common adaptations (Koder et al., 1996;Rehm et al., 2017).Research findings on key concerns of health students when working with cognitively impaired residents have included having to reintroduce themselves and impatience in reteaching new activities (Korukcu et al., 2018;Sass et al., 2022).
Supervisors also should be informed regarding approaches specifically suited to older adults in residential care such as reminiscence therapy (Saragih et al., 2022).Recollecting their past can help an older person integrate various aspects of their lives, validating their experiences.Reminiscence approaches have been found to improve mood in residents with depression (Chiang et al., 2010), including those living with dementia (Saragih et al., 2022).However, students may feel that they are not using the structured techniques of established psychotherapies such as CBT, but rather are simply being supportive.Students may also feel a heightening of the well documented imposter syndrome where they feel they are not validly using their training and that their expertise is underutilised during therapy sessions (Bravata et al., 2019).Supervisors can remind students that supportive therapy is a form of therapy in its own right (e.g., Rogerian and non-directive therapies) and that such support is integral to establishing a strong working alliance for more structured therapies to be effective (Kazantzis et al., 2017).Students can be advised that earlier stages of treatment may require more nondirective interactions with a focus on the relationship, compared to later stages of treatment.
At the other end of therapy, when terminating, students may be concerned that they are abandoning residents.Termination requires careful discussion with the resident in advance and needs to be paced out across several sessions.Part of relapse prevention is careful follow up of the resident's situation, level of risk, personal preferences and ongoing symptoms.Supervisors need to be aware of potential services that can be accessed to continue to assist residents maintain gains made in therapy or to further improve residents' mental health (for example, local aged care mental health team, volunteer services).Written relapse prevention plans can also help family and key staff continue to use therapeutic strategies with residents once therapy is completed.
Termination can also occur unexpectedly.A resident dying is often a shock to a student, particularly if it is sudden.Sudden deaths are not uncommon in the residential aged care setting.Personal reactions of students related to grief can be intense and need to be validated and normalised (Ådland et al., 2022).Difficulties balancing personal and professional reactions can lead to suppression of emotions having adverse consequences on a student's wellbeing.Supervisors have a key role in supporting students with reactions to death such as helplessness and identifying any assumptions that may impede emotional processing.Students may feel that expressions of grief are unprofessional and fear negative evaluation from a supervisor.Over emphasis on professionalism may in fact be a protective mechanism to distance oneself from intense emotional reactions (Ådland et al., 2022).Death of a resident can be raised as a possibility in early supervision sessions so reactions are normalised and arrangements for timely support can be discussed if needed.Encouraging a student to talk about the resident and how they were informed of their death is a way of debriefing.There is also the issue of closure, and the supervisor can have a key role in assisting the student to process what has happened and to creatively explore ways of saying goodbye, including completion of outstanding documentation as part of the closure process.

Conclusion
There is a need to be aware of both systemic and cohort related issues when supervising students in residential aged care.Barriers to accessing mental health care relate to attitudes of residents, psychologists and students regarding a resident's ability to benefit from treatment and clinical supervision can address such barriers.Overcoming potential limitations such as remote supervision has the potential to increase supervision possibilities in this underserviced area.
There are specific ethical issues involved when working in residential aged care and supervisors can identify and respond to these in a timely, supportive manner.Awareness of possibly conflicting needs within the resident's community of care can help a student navigate complex relationships between the resident, their family members and staff.Ethical competencies are a major aspect of psychology standards of care and a student gaining experience within residential aged care will enable significant exposure to issues such as confidentiality, multiple relationships, consent, privacy and duty of care.
The literature is supportive of psychological interventions for the treatment of mental health issues in residential aged care settings and increasing placement opportunities can serve as a means of knowledge translation.Supporting students in adapting therapy implementation and content can lead to successful experiences delivering psychological interventions to residents.This can encourage psychologists to both train, work and supervise in residential aged care settings, ultimately increasing the workforce to improve the mental health of one of our most vulnerable populations.