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Aims and objectives
To test the effects of nursepatient interaction on anxiety and depression among cognitively intact
nursing home patients.
Depression is considered the most frequent mental disorder among the older population.
Specifically, the depression rate among nursing home patients is three to four times higher than
among communitydwelling older people, and a large overlap of anxiety is found. Therefore,
identifying nursing strategies to prevent and decrease anxiety and depression is of great importance
for nursing home patients' wellbeing. Nursepatient interaction is described as a fundamental
resource for meaning in life, dignity and thriving among nursing home patients.
The study employed a crosssectional design. The data were collected in 2008 and 2009 in 44
different nursing homes from 250 nursing home patients who met the inclusion criteria.
A sample of 202 cognitively intact nursing home patients responded to the NursePatient Interaction
Scale and the Hospital Anxiety and Depression Scale. A structural equation model of the
hypothesised relationships was tested by means of LISREL 8.8 (Scientific Software International Inc.,
Lincolnwood, IL, USA).
The SEM model tested demonstrated significant direct relationships and total effects of nurse
patient interaction on depression and a mediated influence on anxiety.
Nursepatient interaction influences depression, as well as anxiety, mediated by depression. Hence,
nursepatient interaction might be an important resource in relation to patients' mental health.
Relevance to clinical practice
Nursepatient interaction is an essential factor of quality of care, perceived by longterm nursing
home patients. Facilitating nurses' communicating and interactive skills and competence might
prevent and decrease depression and anxiety among cognitively intact nursing home patients.
With advances in medical technology and improvement in the living standard globally, the life
expectancy of people is increasing worldwide. The document An Aging World (US Census
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Bureau 2009) highlights a huge shift to an older population and its consequences. Within this
shift, the most rapidly growing segment is people over 80 years old: by 2050, the percentage of
those 80 and older would be 31%, up from 18% in 1988 (OECD 1988). These perspectives have
given rise to the notions of the ‘third’ (65–80 years old) and the ‘fourth age’ (over 80 years old)
in the lifespan developmental literature (Baltes & Smith 2003). These notions are also referred to
as the ‘young old’ and the ‘old old’ (Kirkevold 2010).
For many of those in the fourth age, issues such as physical illness and approaching mortality
decimates their functioning and subsequently lead to the need for nursing home (NH) care. A
larger proportion of older people will live for shorter or longer time in a NH at the end of life.
This group will increase in accordance with the growing population older than 65, and in
particular for individuals older than 80 years. Currently, 1·4 million older adults in the USA live
in long‐term care settings, and this number is expected to almost double by 2050 (Zeller &
Lamb 2011). In Norway, life expectancy by 2050 is 90·2 years for men and 93·4 years for
women (Statistics of Norway 2010).
Depression is one of the most prevalent mental health problems facing European citizens today
(COM 2005); and, the World Health Organization (WHO 2001) has estimated that by 2020,
depression is expected to be the highest ranking cause of disease in the developed world.
Moreover, depression is described to be one of the most frequent mental disorders in the older
population and is particularly common among individuals living in long‐term care facilities
(Choi et al. 2008, Karakaya et al. 2009, Lattanzio et al. 2009, Drageset et al. 2011,
Phillips et al. 2011). A linear increase in prevalence of depression with increasing age is
described (Stordal et al. 2003); the three strongest explanatory factors on the age effect of
depression are impairment, diagnosis and somatic symptoms, respectively
(Stordal et al. 2001, 2003). Worse general medical health is seen as the strongest factor
associated with depression among NH patients (Djernes 2006, Barca et al. 2009). A review that
included 36 studies from various countries, reported a prevalence rate for major depression
ranging from 626% and from 1150% for minor depression. However, the prevalence rate for
depressive symptoms ranged from 3649% (Jongenelis et al. 2003). Twice as many women are
likely to be affected by depression than men (Kohen 2006), and older people lacking social and
emotional support tend to be more depressed (Grav et al. 2012). A qualitative study on
successful adjustment among women in later life identified three main areas as being the main
obstacles for many; these were depression, maintaining intimacy through friends and family and
managing the change process associated with older age (Traynor 2005).
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Significantly more hopelessness, helplessness and depression are found among patients in NHs
compared with those living in the community (Ron 2004). Jongenelis et al. (2004) found that
depression was three to four times higher in NH patients than in community‐dwelling adults.
Moving to a NH results from numerous losses, illnesses, disabilities, loss of functions and social
relations, and approaching mortality, all of which increases an individual's vulnerability and
distress; in particular, loneliness and depression are identified as risks to the well‐being of older
people (Routasalo et al. 2006, Savikko 2008, Drageset et al. 2012). The NH life is
institutionalised, representing loss of social relationships, privacy, self‐determination and
connectedness. Because NH patients are characterised by high age, frailty, mortality, disability,
powerlessness, dependency and vulnerability, they are more likely to become depressed. A
recent literature review showed several studies reporting prevalence of depression in NHs
ranging from 2482% (Drageset et al. 2011). Also, with a persistence rate of more than 50% of
depressed patients still depressed after 612 months, the course of major depression and
significant depressive symptoms in NH patients tend to be chronic (Rozzini et al. 1996,
Smalbrugge et al. 2006a).
Moreover, studies in NHs report a large co‐occurrence of depression and anxiety
(Beekman et al. 2000, Kessler et al. 2003, Smalbrugge et al. 2005, Van der Weele et al. 2009,
Byrne & Pachana 2010). A recent review concerning anxiety and depression reports a paucity of
findings on anxiety in older people (Byrne & Pachana 2010). Hence, more research is urgently
required into anxiety disorders in older people, as these are highly prevalent and associated with
considerable disease burden (ibid.).
Depression and anxiety in NH patients are associated with negative outcomes such as poor
functioning in activities of daily living and impaired quality of life (QoL)
(Smalbrugge et al. 2006b, Diefenbach et al. 2011, Drageset et al. 2011), substantial caregiver
burden and worsened medical outcomes (Bell & Goss 2001, Koenig & Blazer 2004,
Sherwood et al. 2005), increased risk of hospital admission (Miu & Chan 2011), a risk of
increased dementia (Devanand et al. 1996) and a higher mortality rate (Watson et al. 2003,
Ahto et al. 2007). Accordingly, efforts to prevent and decrease depression and anxiety are of
great importance for NH patients' QoL.
Social support and relations to significant others are found to be a vital resource for QoL and
thriving among NH patients (Bergland & Kirkevold 2005, 2006, Drageset et al. 2009a,
Tsai et al. 2010, Tsai & Tsai 2011), as well as the nursepatient relationship (Haugan
Hovdenes 2002, Cox & Bottoms 2004, Franklin et al. 2006, Medvene & Lann‐Wolcott 2010,
Burack et al. 2012). The perspective of promoting health and well‐being is fundamental in
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nursing and a major nursing concern in long‐term care (Nakrem et al. 2011,
Drageset et al. 2009b). However, low rates of recognition of depression by staff nurses is found
(Bagley et al. 2000, Volkers et al. 2004).
Through the last decades, the importance of establishing the nursepatient relationship as an
integral component of nursing practice has been well documented (Nåden & Eriksson 2004,
Arman 2007, Carpiac‐Claver & Levy‐Storms 2007, Granados Gámez 2009, Rchaidia et al. 2009,
Fakhr‐Movahedi et al. 2011). Excellent nursing care is characterised by a holistic view with
inherent human values and moral; thus, excluding the patient as a unique human being should be
regarded as noncaring and amoral practice (Haugan Hovdenes 2002, Nåden & Eriksson 2004,
Austgard 2008, Watson 2008). NH patients are in general extremely vulnerable and hence the
nursepatient relationship and the nursepatient interaction are critical to their experience of
dignity, self‐respect, sense of self‐worth and well‐being (Dwyer et al. 2008,
Harrefors et al. 2009, Heliker 2009). NH patient receiving self‐worth therapy showed
statistically significantly reduced depressive symptoms relative to control groups members
2 months after receiving the intervention (Tsai et al. 2008). Self‐worth therapy comprised
establishment of a therapeutic relationship offering feedback and focusing the patient's dignity,
emotional and mental well‐being (ibid.).
Caring nurses engage in person‐to‐person relationships with the NH patients as unique persons.
Good nursing care is defined by the nurses' way of being present together with the patient while
performing nursing activities, in which attitudes and competence are inseparately connected.
‘Presence’, ‘connectedness’ and ‘trust’ are described as fundamental cores of holistic nursing
care (McGilton & Boscart 2007, Potter & Frisch 2007, Carter 2009) in the context of the nurse
patient relationship in which the nursepatient interaction is taking place. Trust is seen as a
confident expectation that the nurses can be relied upon to act with good will and to secure what
is best for the individuals residing in the NH. Hence, trust is the core moral ingredient in nurse
patient relationships; even more basic than duties of beneficence, respect, veracity, and
autonomy (Carter 2009).
Caring is a context‐specific interpersonal process that is characterised by expert nursing practice,
interpersonal sensitivity, and intimate relationships (Finfgeld‐Connett 2008) which increases
patient's well‐being (Nakrem et al. 2011, Hollinger‐Samson & Pearson 2000,
Cowling et al. 2008, Rchaidia et al. 2009, Reed 2009). The relationship between NH staff
attention and NH patients' affect and activity participation have been assessed among depressed
NH patients, showing that positive staff engagement was significantly related to patients'
interest, activity participating, and pleasure (Meeks & Looney 2011). These results suggest that