Autonomy and depression: A mixed methods study exploring the experience of decision-making for residents in residential aged care

Abstract

Depression in older adults represents a major and growing global health concern. Statistical evidence suggests the highest risk group for depression in the ageing populace is those living in residential aged care facilities. Several risk factors are associated with depression in this group, particularly loss of autonomy and environmental mastery, which result in reduced self-esteem and self-concept. Despite the prevalence of depression in residential aged care, there is a paucity of identified interventions that result in significantly reducing the symptoms of depression in this group. The purpose of this mixed methods study design was to evaluate the effectiveness of offering residents bedtimes and participation in an evening activity program on reducing depressive symptoms among older adults living in a residential aged care facility. The study also examined whether depression training improved residential aged care staff’s knowledge of late-life depression. In addition, interviews with residents and staff were conducted to explore their experiences of the interventions and to identify factors influencing residents’ autonomy. This research is particularly timely given the introduction of the Strengthened Aged Care Quality Standards (2025) introduced in November 2025, which require aged care facilities to actively promote resident choice and decision-making. The quasi-experimental resident intervention consisted of the assessment of resident participants’ depression scores using the Geriatric Depression Scale-15 (GDS-15) tool at three points during the study; this included at baseline, after the three-month pre-intervention phase, and after the three-month intervention phase. During the pre-intervention phase, a cross-sectional questionnaire of staff knowledge of late-life depression pre and post a short education session was conducted. The 10-Item Knowledge of Late-Life Depression-Revised questionnaire was used for this study. The study concluded with thematic analysis to investigate the resident and staff experiences of the resident interventions, and residents' choices in their daily lives more broadly. The collective voices of the aged care residents and staff, and the thesis researcher's observations, were used for the qualitative study. Thematic analysis was conducted using the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. The interpretation of the findings was guided by the theoretical frameworks of Self-Determination Theory (SDT), Person-Centred Care, and Personhood. The results of the resident intervention study indicated that there were no significant changes in depression scores following the interventions. The results of the staff's responses in the knowledge of late-life depression questionnaires denoted an improvement in staff knowledge following a short education session. Results of the resident interviews revealed four major themes: (1) facility routines impact choice; (2) factors that promote well-being; (3) barriers to engagement; and (4) confinement and isolation. Results of the staff interviews revealed three major themes: (1) confidence in recognising depressive symptoms; (2) experience of the evening program for residents and staff; and (3) catering to residents’ choice. This study adds to the body of research exploring the complexities of supporting autonomy among residents in residential aged care facilities to enhance well-being and alleviate depressive symptoms. The findings highlight the need for organisational reforms, advocating a shift from institutionalised models of care toward more flexible frameworks that facilitate and prioritise individual choice and decision-making. Aged care providers need to be dedicated to a fundamental system structure that enables staff to apply person-centred care principles throughout their care practices.