Registered nurses’ experiences of barriers in providing care for older patients with low mood in Swedish municipal settings: A qualitative study

Abstract

Low mood and depression are common mental states among older people, and are difficult to diagnose and treat, causing suffering and declining functions. The aim of the study was to describe registered nurses’ experiences of barriers in providing care for older persons with low mood in Swedish municipal settings. Ten registered nurses working in municipal settings were interviewed using a qualitative approach. The analysis resulted in two main categories, ‘Professional barriers in the care of older persons with low mood’ and ‘Organisational barriers in the care of older persons with low mood’, and four subcategories. Improvements regarding increased knowledge about the use of assessments tools are suggested. Registered nurses should strive to listen to the older person's desires and needs. Furthermore, suggestions about improved collaboration within the organisation as well as with other caregivers in order to provide quality care to older persons with low mood, are made. COREQ was used as criteria to report qualitative data.

Keywords

content analysis interviews qualitative design

Introduction

Mental ill-health among older people is, apart from an individual problem, also a societal problem.¹ One of the most common mental disorders among people aged 60 years and over is depression, which affects about 7% of the older population globally.²

A core symptom of depression is low mood.³ Low mood may be characterised by sadness, anxiousness, worries, tiredness, low self-esteem, frustration and anger.⁴ Low mood and depression in older people can sometimes manifest as emotional, cognitive and physical symptoms or addiction, which is important for registered nurses (RNs) to be aware of.^1,5 Physical comorbidities in depression are common, e.g. physical illness or vitamin deficiency,^1,6,7 and these affect treatment options, creating a need for the optimisation of treatments of coexisting illnesses and decreasing negative drug interactions.⁸ Low mood and depression causes declining quality of life,^7,9 worsening health and increased dependence.⁵ Depression may also cause increased mortality^5,6 and the suicide rate among older people is high both globally and in Sweden^10,11 – about 23% of suicides in Sweden are committed by individuals aged 65 years or older.¹² Low mood and depression may cause extensive suffering, and RNs have a vital role in prevention of the disease. Studies have shown that various activities, e.g. exercise¹³ and reminiscence,¹⁴ may prevent older adults from developing depression.

Low mood and/or depression are difficult to recognise and diagnose correctly.^1,5,15 However, detection can aided by asking questions and with the support of assessment tools.^6,16 There are several appropriate assessment tools that may be used with older patients, for example the Geriatric Depression Scale and the Cornell Score of Depression in Dementia. Using the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Statistical Classification of Diseases and Related Health Problems (ICD) criteria for depression in adults is usually insufficient because of older persons’ unusual symptomatology.⁶ Available non-pharmacological treatment methods for low mood or depression include psychological treatment¹⁷ physical activity¹⁸ bright light therapy¹⁹ and meditation.²⁰ First choice of pharmacological treatment is selective serotonin reuptake inhibitors because of their tolerability, and decreased risk of adverse side effects and suicide among older people.^6,21

Interdisciplinary teamwork is crucial to ensure that the needs of older persons with low mood and/or depression are attended to in a correct manner and to shape their care.²² RNs working in municipal older people care are in a key position to ensure quality care and their observations of low mood and/or depression are crucial for accurate treatment.^15,16 Previous studies show that care providers are experiencing barriers in the care of older persons with low mood and/or depression, such as knowledge deficits regarding the treatment of older persons with low mood and depression,^23,24 and lack of confidence caring for these patients.²⁴ A study revealed that evidence-based nursing interventions are usually not first-line treatment for depression in geriatric care.²⁵

RNs working in municipal healthcare are responsible for a large number of patients who often suffer from multimorbidity and are in need of advanced care. RNs often work alone and need to rely on their own knowledge and capabilities.^26,27 The majority of RNs lack specialist training in care of older persons, something which is recommended in order to be able to assess the older person's needs and offer qualified nursing.²⁸ Low mood and/or depression are common mental states among older persons, causing a great deal of suffering and declining functions. Studies cited above show that barriers to care may be knowledge deficits and lack of confidence in caring. It has also been shown that low mood and depression are difficult to recognise and treat in older people in conventional ways. Knowledge about barriers in the care of older persons with low mood or depression is important in order to improve nursing care. RNs in municipal healthcare are responsible for care of older persons and are pivotal in securing qualified nursing care for these individuals. However, there is a lack of studies focusing on this area and therefore there is a need to further explore the barriers experienced by RNs.

Aim

To describe RNs’ experiences of barriers in providing care for older patients with low mood in Swedish municipal settings.

Method

A qualitative design was selected for the study, as being suitable to explore and describe RNs’ experiences of barriers in providing care for older persons with low mood. Semi-structured individual interviews were used to encourage RNs to describe their experiences in their own words. The term ‘low mood’ was used in this study as it was impossible to ascertain whether all patients the RNs narrated about had the clinical diagnosis of depression. The term ‘patients’ was used in the findings and discussion when referring to the older persons for whom the RNs provided care. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used in this study.²⁹

Setting

This study was conducted with RNs working in municipal settings in the north of Sweden. The RNs were either working in nursing homes or in home healthcare for older people. In nursing homes, patients rent apartments where meals, laundry, cleaning, nursing care and healthcare are included. In home healthcare, patients are receiving nursing care or healthcare in their ordinary homes, performed by enrolled nurses (ENs)/nursing aids (NAs) or RNs. In nursing homes, ENs and NAs are available to perform basic nursing interventions at all hours; RNs are the persons with the highest degree of medical training and are usually available at the nursing home during daytime.

Recruitment/sample

Information about the study along with a request for permission to allow the researchers to approach RNs within the organisation was initially sent via email to the head of healthcare in a chosen municipality in northern Sweden. After approval, an invitation to participate in the study was sent by email to all RNs within the organisation (N = 165). Five RNs accepted. An additional email was sent one week later, resulting in an additional two RNs joining the study. Thereafter, three additional RNs were contacted directly about participation since it had come to the researchers’ attention that they might have experiences which were important to include in the study. They agreed to participate. The inclusion criteria required RNs who have had the responsibility of caring for patients for at least one year during the last two years. This criterion was chosen to ensure that RNs had been given a chance to gain the required experience of caring for older patients with low mood. Ten RNs participated in the study, nine women and one man, aged 26 to 60 years. The RNs had 2–31 years of work experience and 2–24 years within the organisation. Three of the RNs had specialist training; two were district nurses and one was a psychiatric nurse. Three RNs worked in home healthcare and seven RNs worked in nursing homes. RNs working in nursing homes and participating in this study were responsible for the nursing process of 14 patients on average. In home healthcare, RNs were responsible for the nursing process of 23 patients on average. Care of older persons was designed in teams with RNs and ENs/NAs in key roles, being able to consult with physicians, occupational therapists, physical therapists and different types of department heads when needed. RNs had the opportunity to seek specialist care for older persons through the patient's physician, who could refer the patient to consult with the geriatric ward at the hospital or with the psychiatric home team for older people.

Data collection

Semi-structured and individual interviews with RNs were conducted by the first and third authors by using a predetermined set of open-ended questions designed to encourage the RNs to describe their experiences of barriers in the care for older patients with low mood. The questions were also designed on the basis of their experience to cover several aspects of caring for older patients with low mood, such as assessment and treatment as well as internal and external collaboration within the organisation. The interviews commenced with questions such as, ‘Could you describe a specific situation when it was difficult to provide care for an older person with low mood?’, which were followed up as needed with questions such as ‘How did you experience that?’ in order to clarify the RNs’ views or to gain more information about their experiences. The interviews were conducted individually in places agreed upon by the researchers and the RNs, usually at the RNs’ workplace. The interviews lasted 20–90 minutes (on average 40 minutes), were recorded and later transcribed verbatim.

Data analysis

The transcribed interviews were analysed by the first and third authors using qualitative content analysis, aiming to identifying common themes in the text. The interview transcripts were read several times to create a deeper understanding of the content before identifying meaning units relevant to the aim of the study. The meaning units were then condensed without losing their core meaning and thereafter coded. The coded units were sorted based on their similarities and differences and abstracted into subcategories, which in turn were sorted and abstracted into categories.^30,31 The process of coding, sorting and abstracting was reviewed and discussed by all the authors until consensus was reached. An example of the analysis is provided in Table 1.

Table 1.

Examples of the analysis process.

Meaning unit	Code	Subcategory	Category
It is hard to treat patients with physical symptoms such as shortness of breath and angina when I suspect that it is anxiety symptoms but the patient won't hear of it.	Difficult assessments	Difficulties performing symptom assessment	Professional barriers in care of older patients with low mood
It was the ENs/NAs who alerted me that the patient’s behaviour is changed, something is wrong.	Assessments by others	Difficulties performing symptom assessment	Professional barriers in care of older patients with low mood
Eventually I called the primary health centre and said ‘This is taking way too long, the patient needs a doctor's appointment to evaluate the treatment’. The patient's ordinary doctor was unavailable so they made an appointment with another doctor. It's not satisfying but this is the way teamwork with primary health works.	Deficient teamwork with primary healthcare	Lack of coordination in care	Organisational barriers in care of older patients with low mood
I wish for a much better collaboration with the psychiatric home team for the elderly. Not purely towards individual patients but also to provide help in general to the staff on how to cope with this [elderly patients with low mood].	Deficient teamwork with psychiatric home team	Lack of coordination in care	Organisational barriers in care of older patients with low mood

Ethical considerations

The head of healthcare in the chosen municipality gave written permission to perform the study. All participating RNs were given written and verbal information regarding the purpose and the procedure of the study, and their right to withdraw at any time in accordance with the declaration of Helsinki.³² Participating RNs gave written consent before being interviewed. To ensure confidentiality, the transcribed interviews and the recordings were stored where only the researchers had access, and transcribed interviews were de-identified regarding names and places. None of the participants’ or patients’ identities were disclosed in the transcriptions.

Findings

The analysis resulted in two categories and four subcategories; an overview of the findings is presented in Table 2.

Table 2.

Categories and subcategories.

Category	Subcategory
Professional barriers in care of older patients with low mood	Difficulties to perform symptom assessments
	Difficulties to perform and evaluate care and treatment
Organisational barriers in care of older patients with low mood	Lack of conditions to provide good care Lack of coordination in care

Professional barriers in care of older patients with low mood

RNs described their experiences of professional barriers in the care of older patients with low mood. The barriers were described as difficulties performing symptom assessments and difficulties performing and evaluating care and treatment.

Difficulties performing symptom assessments

RNs described difficulties differentiating low mood and depression demanding treatment from the natural mourning of losses that comes with aging, such as losses of abilities and losses of loved ones. Some RNs experienced challenges detecting low mood in patients whom they had cared for over a long period of time. Sometimes they also experienced a lack of knowledge and difficulties gathering information about the patient's situation. RNs described that they often did not detect low mood in patients themselves but were alerted to the situation by ENs/NAs.

Reservation, anger, apathy, reduced sleep, loss of activity of daily living (ADL) abilities and physical unease were some of the symptoms RNs noticed in patients with low mood. RNs described the challenge of assessing the cause of the symptoms in cases where the physical symptoms of low mood were so strong that the patients themselves were convinced of a physical illness. The patient's situation and needs were assessed mainly through conversations with the patient and his/her close ones. RNs described close ones as an asset when trying to gather information about the patient's needs. Furthermore, RNs examined other possible influences on the patient's mental status by eliminating drug-related or physiological causes of low mood. The use of assessment tools was hindered by several difficulties, namely comorbidity with dementia, strong physical symptoms but also lack of knowledge of existing tools. In cases where assessment tools were used they were described as valuable and contributing to helping understand the patient's situation.

I think using assessments are helpful … it was helpful that one could define that on the basis of the assessments this patient is depressed … that might be what the behaviour is an expression for … (7)

Difficulties performing and evaluating care and treatment

RNs described that their intentions were to provide functional nursing interventions; however, they rarely experienced any effect from nursing interventions which made them feel that it was a challenge to provide good nursing to patients with low mood. RNs described several person-centred interventions, of which the most important for patients’ mental health was being together in a social context. When patients expressed death wishes or threatened to commit suicide, RNs experienced difficulties in knowing how to handle the situation. one RN retold the patient's words in this way:

‘Yes but if I’m only left alone, and if I’m able, I will kill myself’ [the patient says]. Then it feels very difficult for us to be able to do something, to do the right thing. (6)

RNs evaluated nursing interventions by talking to ENs/NAs, by observing the behaviour of the patient and by talking to the patient and his/her close ones. Follow-up on a regular basis was considered important since it gave the RNs the opportunity to re-evaluate and change interventions if necessary. RNs described feelings of frustration and hopelessness when nursing interventions seemed to fail. Some RNs felt personally responsible for the patients’ mental health status and put pressure on themselves not to give up.

RNs had varied experiences of the effect of drug therapy in patients with low mood, describing everything from no effect to significant effect. In some cases, RNs experienced that discontinuing treatment with Selective serotonin reuptake inhibitors (SSRIs) or dose reduction led to the patient's mental health worsening. Continual evaluation and making one change at a time were described as important. Discontinuing treatment with drugs that could cause depression as a side effect and adequately treating other conditions and illnesses could also produce positive effects. RNs described it as challenging to evaluate drug therapies for low mood and depression, especially if the patient also had dementia.

Organisational barriers in care of older patients with low mood

RNs described organisational barriers in the care of the older patient with low mood within the areas of lack of conditions to provide good care and lack of coordination in care.

Lack of conditions to provide good care

RNs expressed that not all ENs/NAs were equipped with the ability to care for older patients with low mood in the correct manner. RNs described difficulties creating a feeling of safety for patients with low mood, and also a lack of good environments and activities to promote mental health. They described a lack of knowledge regarding low mood among ENs/NAs and physicians as well. RNs described difficulties for staff to find the time to perform assigned nursing interventions due to heavy workload. The limited time forced RNs to prioritise and sometimes choose drug interventions instead of nursing interventions, creating feelings of frustration and troubled conscience.

One does not really feel that one has given the utmost, maybe it would be necessary for someone to sit with the patient 24 hours a day to enable the person to feel fairly safe, but there aren't resources to do that for months, but maybe that would have been the answer. (8)

RNs experienced difficulties satisfying the needs of patients with low mood due to financial limitations within the organisation. Freeing up time for ENs/NAs to carry out specific nursing interventions or securing an EN/NA to keep watch over a patient with low mood were described as impossible to perform due to financial aspects. RNs described feelings of powerlessness not being able to influence important factors for the patients’ mental health, mentioning several things concerning the ENs/NAs – for example their continuity, their attitude and the number of ENs/NAs on duty. RNs described frustration regarding not being able to be involved directly in the patients’ care and not having the time to observe normal situations and provide support on a daily basis. RNs wanted fewer administrative duties and more time with the patients.

Lack of coordination in care

Collaborating with the local health centres, hospitals and the intra-organisational dementia team was described as an influencing factor and could lead to feelings of powerlessness and frustration. RNs had the overall responsibility of care for patients with low mood or depression, which included the responsibility to organise and coordinate care, a task that sometimes was experienced as difficult and frustrating. RNs described that the primary care physician prescribed antidepressant drugs based on the RN's description alone without conducting their own assessment, and that drugs were prescribed arbitrarily despite the risk of adverse drug effects. They described difficulties in trying to get the patient referred to a psychiatric clinic and frustration when the psychiatric home team for older people declined to offer help. RNs described a lack of collaboration with the geriatric ward in the hospital, which only assisted with drug therapy, and no support concerning how the staff should interact with the patient. Despite the difficulties in trying to get help for patients with low mood, RNs described the importance of not giving up and of using all possible contacts available in the hope of helping the patient.

I have discussed it with the physician a number of times, I have talked to the ENs/NAs, we have tried to redirect … I have talked to the physical therapist, the occupational therapist; I have talked to both the intra-organisational dementia team and the external dementia team all to no benefit. Eventually I broke down crying because of the frustration // It is impossible to get into contact with the psychiatric home team for older patients. As soon as there is a person with dementia and depression, they are referred to the geriatric ward and that means [that they are prescribed] antidepressants, and possibly some antipsychotic medication. If they have psychomotor agitation it will be treated with sedatives, one gets no support to do anything else [for the patient]. (3)

Discussion

The aim of the study was to describe RNs’ experiences of barriers in providing care for older patients with low mood in Swedish municipal settings. RNs described professional and organisational barriers influencing the care of older patients.

RNs expressed difficulties performing symptom assessments because of challenges in creating an understanding of the older patient's situation. Previous studies have shown similar results.^25,33,34 In our study, RNs expressed the importance of conversation as a tool to gain greater knowledge of the older patient's life story and feelings in order to help create a relationship to older patients with low mood and depression. A previous study found that such conversations can be successful if the older patient experiences that the counterpart is committed and strives to understand.³⁵ RNs in the present study tried to motivate and engage the older patient in various ways, while at the same time respecting the older patient's wishes. A previous study has shown this to be effective in caring for older patients with low mood and depression.³⁶ The present study revealed that RNs had difficulties using assessment tools for various reasons such as access to and knowledge of the tools. A study evaluating assessment tools has shown them to be valuable and useful in detecting low mood and depression and there are a variety of tools available.³⁷ A conclusion is that RNs need increased access to and more training in using assessment tools to recognise and reveal signs of low mood and depression in older patients. It is also important that RNs in conversations with older people show interest and that they are willing to listen in order to build a trusting relationship.

RNs in the present study found it difficult, for various reasons, to care for and evaluate the treatment of older persons with low mood and/or depression. They described that activities could improve the mental health of older persons with low mood and/or depression, which is supported by a previous study,³⁸ and thus prioritised activities as a nursing intervention. The present study revealed that RNs experienced difficulties providing adequate medical treatment to older patients with low mood, and they often felt that a combination of interventions was needed to improve patients’ mental health, which is supported by a review in the area. The review also showed that older patients with depression had a strong need to decide themselves what was best and to take control of their own lives.³⁹ A reflection is that in order to improve the care for older patients with low mood and/or depression, it is of great importance to listen to their desires and needs. In this work, RNs should find inspiration in person-centred care.

The findings revealed that RNs experienced lack of the conditions needed to provide good care, which in turn created feelings of frustration and troubled conscience, as shown in previous studies.^40,41 Having a troubled conscience may imply that RNs are at risk of developing stress-related disorders, e.g. burnout.⁴² The findings in the present study revealed that RNs evaluated nursing interventions by talking to ENs/NAs. A study revealed that RNs described ENs/NAs to be invaluable in the care of older patients, as RNs themselves often only have brief encounters with the older patient.⁴³ RNs in care of older patients often execute their professional role as a consultant and thus work at a distance from patients and ENs/NAs.^44,45 A conclusion is that it is important that RNs are given the organisational placement and opportunity to work closely with the patients and ENs/NAs. This placement may enhance the possibilities to provide a good quality of care to patients with low mood and/or depression, to provide daily support to ENs/NAs and to save the RNs’ own health.

The findings revealed that RNs described a lack of coordination in care regarding patients with low mood and/or depression. They described feelings of an overall responsibility for the patients’ care, with insufficient support from physicians. Communication and collaboration between healthcare personnel from different organisations have previously been described as challenging^25,46 and a well-functioning team is important to facilitate the experience of support.⁴⁷ To be able to give good and safe healthcare to older patients within municipal healthcare, the interorganisational team has to collaborate and find a common decision-making process. The team needs to be designed based on the patient's needs and the full competencies of each profession should be utilised where the RN's responsibility is to lead, prioritise, allocate and coordinate care in the team.⁴⁷ New models for interorganisational collaboration are needed to offer extensive and effective healthcare for older patients with low mood and/or depression. Stricter demands on collaboration between different organisations in relation to patient discharge from hospital have recently been enforced in Sweden.⁴⁸ A conclusion is that RNs need to work closely with ENs/NAs in order to create a well-functioning intra-organisational team and to offer support. RNs need to be part of the larger attempt towards interorganisational teamwork within healthcare in order to provide quality care to older patients with low mood and/or depression. RNs, preferably specialised in older people care, are well equipped to lead this venture.

Methodological considerations

The researchers were aware of the risk of bias because of their pre-understanding of working within the organisation and working with older patients with low mood. They therefore attempted to avoid interpretation of their own experiences and prejudices throughout the process.³¹ To uphold trustworthiness, the researchers attempted to minimise the risk of losing important information by preserving the significant content of the meaning units throughout the analysis process.³⁰ The participants had varied levels of experience in terms of years in the occupation, age and level of educational attainment, which increases the credibility of the results.³¹ One limitation of the study could be that it was performed in only one municipality. To enable transferability, the researchers have closely presented the context, participants, data collection and analysis of the study. Another limitation could be the small number of participants; however, no new findings could be seen in the last interviews.

Conclusion and clinical implications

RNs described both professional and organisational barriers in the care of older patients with low mood and/or depression. More training for RNs in using assessment tools to recognise and reveal signs of low mood and/or depression in older patients is suggested. To support the individual older patient, RNs should strive to provide person-centred care, which in the present study means to listen with interest to the older patient's desires and needs in order to build a trusting relationship. To be able to implement these suggestions, RNs must strive to reach an appropriate organisational placement in the care for older patients with low mood and/or depression, which also may improve teamwork and collaboration internally and externally. Together these improvements may enable RNs to provide a good quality of care.

Footnotes

Acknowledgements

We would like to thank the participants in the study.

Author contributions

NV and PH collected the data. NV, PH, EEL and CJ together analysed the data and drafted the manuscript.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

The authors declare no conflict of interest.

ORCID iD

Eva Ericson-Lidman

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