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Issues in Mental Health Nursing

ISSN: 0161-2840 (Print) 1096-4673 (Online) Journal homepage: https://www.tandfonline.com/loi/imhn20

Increased Mental Illness and the Challenges ThisBrings for District Nurses in Primary Care Settings

Annica Bjorkman, Kajsa Andersson, Jenny Bergström & Martin Salzmann-Erikson

To cite this article: Annica Bjorkman, Kajsa Andersson, Jenny Bergström & MartinSalzmann-Erikson (2018) Increased Mental Illness and the Challenges This Brings for DistrictNurses in Primary Care Settings, Issues in Mental Health Nursing, 39:12, 1023-1030, DOI:10.1080/01612840.2018.1522399

To link to this article: https://doi.org/10.1080/01612840.2018.1522399

© 2019 The Author(s). Published with Taylor& Francis Group, LLC

Published online: 09 Jan 2019.

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Increased Mental Illness and the Challenges This Brings for District Nursesin Primary Care Settings

Annica Bjorkman, PhD, RNa,b , Kajsa Andersson, RN, MScb, Jenny Bergstr€om, RN, MScb, andMartin Salzmann-Erikson, RN, PhDb

aDepartment of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden; bFaculty of Health and Occupational Studies,University of Gavle, Gavle, Sweden

ABSTRACTPatients with mental illness generally make their initial healthcare contact via a registered nurse.Although studies show that encountering and providing care to care-seekers with mental illnessmight be a challenge, little research exists regarding Primary Care Nurses’ (PCN) view of the chal-lenges they face. The aim of this study was to qualitatively explore PCNs’ reflections on encounteringcare-seekers with mental illness in primary healthcare settings. The results consist of three themes:constantly experiencing patients falling through the cracks, being restricted by lack of knowledgeand resources, and establishing a trustful relationship to overcome taboo, shame, and guilt.

Introduction

Mental illness is common within all countries and cul-tures, and almost 20% of all cases of illness are related tomental illness (Aczon-Armstrong, Inouye, & Reyes-Salvail,2013; World Health Organization, 2016). The term“mental illness” is an umbrella term including a widerange of diseases from minor symptoms of anxiety tocomplex diseases such as psychosis, bipolar disorder, andmajor depression. The prevalence of mental illness isincreasing in all age groups and among both women andmen. Mental illness is more frequent among younger,female, and unemployed persons (Alonso et al., 2004;Koochaksaraei, Mirghafourvand, Hasanpoor, & Bani,2016). The prevalence of anxiety in Sweden has grownduring the last 25 years, and �25% of the population isaffected by a psychiatric illness at some point (Calling,Midl€ov, Johansson, Sundquist, & Sundquist, 2017). Thereis a vast amount of unmet needs regarding mental healthproblems among all ages, placing great demands on thehealthcare system and its organization (Abel, 2018).Patients suffering from mental illness are at risk of long-term illness and at greater risk of relapse anddeterioration of their functional ability if they do notreceive proper treatment at an early stage (Hunter &Storat, 1994; Jansson & Fridlund, 2016). Early detection ofmental illness is crucial, as it enables early treatment andbetter prognosis (Allison, Nativio, Mitchell, Ren, &Yuhasz, 2014). Nurses play an important role in this, asthey are often a patient’s first contact with the health-care system.

Background

In Sweden and many other Western countries, the care ofpatients with psychiatric illness is provided by a number ofprofessions such as physicians, sociologists, psychologists,and registered nurses (RNs)/PCNs. Many patients with psy-chiatric illness will initially contact their primary healthcare(PHC) provider for help. These contacts are commonlymade via telephone, and the calls are answered by RNs.PHC providers are regarded as the proper provider of men-tal healthcare (Cleary et al., 2014; Luoma, Martin, &Pearson, 2002). However, patients with depressive problemshave expressed concern about PHC providers’ ability tomeet their mental health needs (Kravitz et al., 2011). Studieshave shown how patients with mental illness experience anumber of obstacles when seeking care (Ali et al., 2017;Barney, Griffiths, Jorm, & Christensen, 2006; Gulliver,Griffiths, & Christensen, 2010; Kravitz et al., 2011). Theyperceive problems related to mental illness to be stigmatizedor even taboo, and are afraid of the reaction they will havefrom the healthcare provider when seeking care for mentalillness. Some patients state that they would have preferredto have a somatic disease, as this would have made it lessembarrassing to seek care (Kravitz et al., 2011).

Several studies have shown how both healthcare profes-sionals and patients perceive mental illness as stigmatizing,taboo, and difficult to talk about (Bj€orkman, Angelman, &J€onsson, 2008; Dardas, Bailey, & Simmons, 2016; Natan,Drori, & Hochman, 2015; Oates, Drey, & Jones, 2017;Tharaldsen, Stallard, Cuijpers, Bru, & Bjaastad, 2017). Bothhealthcare professionals and patients with mental illness

CONTACT Annica Bjorkman anaerr@hig.se Faculty of Health and Occupational Studies University of Gavle, Gavle, Sweden.� 2019 The Author(s). Published with license by Taylor & FrancisThis is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/),which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon inany way.

ISSUES IN MENTAL HEALTH NURSING2018, VOL. 39, NO. 12, 1023–1030https://doi.org/10.1080/01612840.2018.1522399

report negative attitudes towards mental illness (Hansson,Jormfeldt, Svedberg, & Svensson, 2013; Mittal et al., 2014).These negative attitudes are related to a low degree of faithin the opportunities that people with mental illness havewithin society, such as possibilities to have a job and a sociallife. Healthcare professionals working within somatic careexperience patients with mental illness as being unpredict-able, frightening, and more demanding than other patients(Bj€orkman et al., 2008). A lack of knowledge can result innurses working within somatic care being afraid of patientssuffering from mental illness (Mavundla, 2000). Studies haveshown how nurses with a specialist degree in psychiatricnursing have a more positive attitude towards patients withmental illness compared to nurses with no specialist degree(Bj€orkman et al., 2008; Natan et al., 2015), and also perceivemental illness as less stigmatizing. Nurses, as the largest pro-portion of healthcare personnel, play an important role asthey are uniquely situated to facilitate care for care-seekerswith depression, and are able to restore, maintain, and/orpromote mental health and wellbeing (Dardas, Bailey, &Simmons, 2016). A majority of RNs working in PHC arePrimary Care Nurses (PCN); that is, RNs with an advancedspecialist university education in public health (TheAssociation of Swedish District Nurses [DSF], 2008;Lepp€anen, 2010). In Sweden, the specialist nursing programin PHC nursing is an advanced academic degree including aMaster of Science in Nursing and entails 75 credits at theadvanced level. To become a PCN, aspirants must be a RNand have a Bachelor’s degree in Nursing before entering thespecialist education program (The Association of SwedishDistrict Nurses, 2008). The 75 credit education consists ofcourses in public health diseases, pharmacology and patho-physiology, nursing science with focus on prevention andhealth promoting among elderly, children and adolescents.

In Sweden, nurse education comprises approximately 2weeks of theoretical education in mental illness and 5 weeksof clinical education in psychiatric wards. However, nursingstudents report lacking theoretical knowledge during clinicalpractice, especially within psychiatric care (L€ofmark &Wikblad, 2001), and there is a gap between theory and prac-tice (Jons�en, Melender, & Hilli, 2013). The specialist educa-tion program for PCN in Sweden does not have specificcourses on psychiatric illness; the subject of psychiatric ill-ness is included in public health diseases. Haddad et al.(2005) reported that PCNs found their training in encoun-tering patients with mental issues limited. Even though theparticipants expressed an ambition to develop their skills,three-quarters had not received any training during the pastfive years. Nurses’ lack of knowledge regarding how to com-municate with, encounter, and care for patients with mentalillness might mean that patients risk receiving inappropriateor inadequate care (Kerrison & Chapman, 2007). Followingtheir specialist education, PCN are supposed to be respon-sible for leading and developing care within their PHC.PCN report that �16% of their patients suffer from mentalhealth problems (Haddad et al., 2005).

Mental illness is a common problem in today’s society, andits incidence is increasing, especially among adolescents and

women (Calling et al., 2017). It leads to many and lengthy peri-ods of sick leave (World Health Organization, 2013). InSweden, mental illness accounts for �44% of all sick leaveacross genders, but women are overrepresented, with 48% ofall sick leave due to mental illness compared to 36% amongmen (Swedish Council on Technology Assessment in HealthCare, 2004). Early treatment is important for successful treat-ment, and continuity is important for a caring relationship(Kane et al., 2015). Encountering and providing care to care-seekers with mental illness problems is not easy, and know-ledge of PCNs’/RNs’ experiences and reflections regarding thisdemanding work is scarce.

Aim

The aim of this study was to explore PCNs’ reflections onencountering care-seekers with mental illness in primaryhealthcare settings.

Method

A descriptive qualitative study design was chosen to addressthe aim and research questions.

Participants

Five health centres in the close geographical surroundingwere selected based on a purposive sample (Creswell, 2002;Polit & Beck, 2008). A written request for permission toconduct the study was sent to the section manager forapproval. The healthcare managers at each health centreassisted with recruitment by identifying potential partici-pants who met the eligibility criteria. The PCNs who wereinterested in participating then contacted the researchers byemail or telephone to agree a time and place for the inter-view. Inclusion criteria for participation were being a spe-cialist PCN, having worked at the health center for at least 6months, and having experience of meeting patients withmental health problems in their work at the health center.Recruitment of participants was based on a purposeful sam-ple selection aimed at targeting interviewees with long-termand in-depth insights from their experience in the area ofinvestigation (Creswell, 2002). Eight PCN, all of whom werewomen, agreed to participate. They worked at five differenthealth centres in the selected municipality, and their agesranged from 27 to 62 years (mean¼ 46.6 years). The back-ground variables are further presented in Table 1.

Table 1. Description of participants’ background variables.

Age

Time worked asundergraduatenurses (years)

Time workedas district nurse

Time worked atthe health center

27 5 0.5 0.537 12 0.5 0.537 10 3 340 18 6 449 27 10 1060 40 13 561 18 14 1462 30 27 23Mean 46.6 9.2 7.5

1024 A. BJORKMAN ET AL.

Data collection

Data were collected from individual semi-structured inter-views based on an interview guide designed according to thepurpose of the study. The guide was used to ensure that allparticipants were asked the same core questions, while leav-ing the interviewer the option of posing additional probingquestions based on the interviewees’ answers. The interviewguide included open questions addressing the participants’experiences of encountering patients with mental healthproblems in telephone counselling, reception desk encoun-ters, and personal visits. All interviews ended with the ques-tion “Do you have something more you want to add?”, toallow the participants to provide further information anddevelop their experiences and reflections (Polit & Beck,2008). During the interviews, a number of follow-up ques-tions were asked with the aim of getting as comprehensiveanswers as possible, such as “Can you tell me more?” and“How do you think and feel about it?” A number of back-ground variables concerning among other things the sex,age, and occupational experience of the participants werealso obtained.

Data analysis

Conventional (inductive) content analysis was used for dataanalysis. In conventional content analysis, coding themes arederived directly from the text data (Hsieh & Shannon,2005). Transcripts of interviews were read and reread severaltimes, with and without the audio, to become familiar withthe content. Following this, each interview was coded line-by-line to identify meaning units that corresponded to thepurpose of the study. The meaning units were then con-densed by shortening the text, and each condensed meaningunit was given a code; that is, a descriptive label for its con-tent. All codes were sorted into themes based on similaritiesand differences, as the purpose of creating themes was todescribe the phenomena and to increase understanding. Thethemes were based on the researchers’ interpretation of thefindings. Data analysis was conducted by all of the authors,and themes were re-read, reviewed, and discussed until con-sensus was reached.

Ethical considerations

Studies involving healthcare staff in their professional roledo not require full ethics committee approval in Sweden.The ethical regulations and guidelines according to SwedishLaw 2003:460 (CODEX, 2004) were followed. The nursesgave their informed consent to participate after receivingboth written and verbal information about the study. Theywere informed about their rights to withdraw from the studyat any time without giving an explanation, and assured thatthey as individuals would not be identifiable in quotations.

Results

The narratives of the nurses were interpreted as describingtheir being exposed to impossible demands. The results con-sist of three themes: “constantly experiencing patients fallingthrough the cracks, being restricted by lack of knowledgeand resources, and establishing a trustful relationship toovercome taboo, shame, and guilt.” These themes illustratethe PCNs’ reflections on encountering care-seekers withmental illness in primary healthcare settings. The partici-pants described a number of challenges they faced whenencountering such patients and these challenges led to diffi-culties in their daily work with this patient group. Theyshared their reflections on the underlying causes, anddescribed the thoughts and feelings arising fromthese challenges.

Constantly experiencing patients falling throughthe cracks

The participants spoke about the need for collegial cooper-ation, including both internal and external cooperation,when encountering patients with mental illness. Theydescribed both positive and negative experiences of this typeof cooperation, and emphasized the importance of referringmental health patients to the right care provider. Externalcooperation with other care providers was sometimes prob-lematic and inadequate. The participants noted that patientsrisked falling through the cracks as they were referred backand forth among different caregivers.

“They… very often they fall through the cracks… and they’rereferred to the social services – they’re referred here, they’rereferred there, but it’s like they… it doesn’t work… somebodyneeds to take charge.” (Nurse 1)

The participants stated that no care provider had theoverall responsibility for these patients, which led to frustra-tion among the PCN. Their experiences of cooperation withpsychiatric healthcare had been problematic, as rules andregulations hindered the patients’ reaching the most appro-priate and competent care provider. The participants hadfound support among colleagues at the district medical cen-ter, and cooperation with colleagues from other professionssuch as physicians, psychologists, and social workers hadbeen helpful to support them. Even so, they said that thelack of routines regarding patient follow-ups was a problem.

“… there’s no good system right now for case follow-up… sowe’re left with a completely full appointment book and no ideawhere to send the patient, so it’s a big problem for us.”(Nurse 7)

The participants also said that they were able to consult apsychosocial team at the health center for advice on how toapproach mental illness and the patient’s needs.

As PCNs, the participants were the ones who initiallyencountered the patients via the telephone or at drop-inappointments. While a nurse might not be the most appro-priate profession to initiate care and treatment, it was theirresponsibility to gather a complete anamnesis and generalpicture of the situation, to be able to refer the patient

ISSUES IN MENTAL HEALTH NURSING 1025

further. Due to this initial contact, the participants consid-ered it to be of utmost importance for them to acquire thecompetence to assess the patients’ needs. They had severaloptions for referring patients for further care; they couldrefer them to a psychiatric emergency department, schedulean appointment with the 24-hour on-call staff at the districtmedical center, or arrange an emergency interview with thepsychosocial team.

Being restricted by lack of knowledge and resources

All the nurses said that mental illness was a very commonreason for people to make contact with the health center,and that they encountered these patients several times a day.There was a general opinion among the participants thatmental ill health was a cause of contact that had growngreatly, especially among children and young adults.

“As I mentioned, if I compare the situation with what it waslike before, I do think we’re getting more and more of thesepatients, and especially the young ones, who are often extremelysick.” (Nurse 8)

Nevertheless, mental illness was not only restricted toyounger patients; the participants confirmed that they saw itin all age groups. When they reflected upon the causes ofthis development, based on their experience, one suggestionwas the general strain that patients are experiencing fromthe societal pressure to be successful and able to perform.

The nurses believed that the enlarged number of patientscontacting the health center due to mental illness risked adecreased quality of care due to long waiting lists. They alsodescribed how visits due to mental illness were time con-suming and did not fit into the restricted time they hadavailable for each visit. This posed challenges, and resultedin a stressful work situation.

“At the same time we’re working under time constraints, so wedon’t always have time to do exactly what we might want to…because I’ve got my twenty minutes, and I’m supposed to…meet with the patient, take some action, and document it, sothat…” (Nurse 7)

The participants said that many of their patients withmental illness had struggled with their problems for a longtime before seeking help. Due to their awareness of this, thenurses often felt that they wanted to help the patient assoon as possible, but their restricted time meant that thepatients were put on long waiting lists. This knowledgecaused a sense of frustration.

“Plus, it’s appalling that people who are so sick have to waiteight weeks before they can be seen at a district medicalcentre… it’s just crazy…” (Nurse 5)

During the nurses’ narrations of their experiences, theyexpressed the difficulty of defining mental illness.

“It’s hard to define it… it’s about what the patient experiences… if they say they’re not feeling well then that’s a mentalhealth issue… because I can’t judge… actually.” (Nurse 3)

Another challenge described by the nurses was the highlycomplex and divergent nature of mental illness. They saidthat mental illness among patients could manifest as

anything from mild symptoms to a long-term psychi-atric diagnosis.

“I see that as possibly being anything from… anxiety todepression to bipolar to, so… a huge range… OCD, and justthis thing about being down… it can of course be ordinaryphysically healthy people who have just had too much to dealwith in life, or… we have, you know… it’s extremely broad.”(Nurse 6)

As exemplified in the quotation above, mental illness wasseen as divergent since it stemmed from numerous causes,such as divorce, psychiatric conditions, or other severe dis-eases. Mental illness was also described as complex, since itsometimes originated from physical ill health. The nursessaid that there were times when patients contacted thehealth center for a physical disorder, but during the visit themental illness became more prominently in focus. Mentalillness was described to be a highly individual experiencefrom the patient perspective. This affected the nurses’ carestrategies, in that they could not decide on specific advice,methods, or treatments in advance, but had to provideadvice that was more individually and situationally created.Most of the participants said that they lacked knowledgeabout mental health, and that this restricted them whenencountering patients with mental illness. They said thatthey had not had any educational programs training themto encounter patients with mental illness. Most of themdescribed how their skills had been developed from clinicaland private experiences, and said that they used these expe-riences when encountering future patients.

“I had a patient once… he was having a really rough time, andhe actually opened up to me, and afterwards he said he wasreally glad he had made that call and was very grateful to mefor the way I talked to him… and you know, that’s anexperience I can use next time… that I must have donesomething right.” (Nurse 5)

The participants believed that there was a need for fur-ther competence at the health centers regarding mental ill-ness. One of the health centers had developed a flowchartfor these patients, which the nurses described as a good sup-porting tool, which facilitated their work.

Establishing a trustful relationship to overcome taboo,shame, and guilt

Providing nursing care for patients with mental illness wasdescribed in terms of challenges that were exclusive to thesepatients. The participants said that many of the patients haddifficulty opening up and talking about their issues, as theproblems were of a sensitive nature. It was the nurses’ per-ception that these patients felt that mental illness was associ-ated with shame and guilt, grounded in the idea that mentalillness is more taboo than physical illnesses. Hence, theybelieved nursing care should normalize mental illness toguide patients to improve their mental health. Based ontheir experiences with this patient group, there was fullagreement among the participants that initially establishinga confident and trustful relationship between them and thepatients was vital for the forthcoming encounter.

1026 A. BJORKMAN ET AL.

“You have to listen more, too, and you have to… always…we’re always empathic, but in these cases you have to be evenmore empathic and more understanding, because otherwise thepatients can lose their trust in you, if you don’t give them agood initial reception… you mustn’t rush, because then they’lllose their trust.” (Nurse 4)

As shown in the quotation above, being responsive to thepatient’s narrative was spoken of as a strategy for creating atrustful relationship. Responsiveness meant not interruptingthe patient, giving them time, and conveying a sense ofbeing present for them by taking a respectful and gentleapproach. However, the nurses were concerned by their lackof time to spend on each patient.

“So I think it’s extremely important that you yourself stay fairlycalm, that you don’t start to push it, even if you’re under stressand are in a hurry… it’s incredibly important and… thepatient feels that there’s time here… because otherwise you’redeceiving them in a way, if you start a conversation and thenstart checking the clock or doing something else… then it’slike, then you’ve… you’ve lost that patient.” (Nurse 1)

During these encounters, the nurses found it necessary topose concrete questions to the patients even though thequestions might be of a sensitive nature, for example, ques-tions about self-harm and/or suicidal thoughts.

“Any concrete plans, if they’ve thought about how they’d do it,if they’ve made any previous attempt, and so on… you mightthink that would be provocative at first, but it’s not provocativewhen you talk about it with them, because you’re showing themyou’re familiar with the problem, you understand, and youcare.” (Nurse 6)

Another strategy that the nurses shared was to be flexibleand make individual adjustments based on the patients’needs. For example, since the patients were in need of moretime, they took the time needed. This need for extendedtime was explained partly by the complexity of the patients’life situations, but also by their need for more extensiveinformation or more detailed advice.

“Um, but as I said before, it’s more that… that you might haveto explain in a little more detail and maybe you’ll decide towrite it down as well – ‘This is what you need to do’ – or drawa picture… I’ve done that sometimes because… it was hardto… sort of remember and understand.” (Nurse 7)

Discussion

The PCNs participating in this study encountered patientswith mental illness on a daily basis, but perceived themselvesas lacking the competence to provide proper care to thisgroup. This poses a number of challenges for PCNs, as thenumber of citizens with mental illness is rising. The partici-pating PCNs reflected on how mental illness problems hadincreased within the younger population. They describedboth positive and negative experiences of internal and exter-nal collegial cooperation when working with care-seekerswith mental illness. They stressed their responsibility forobtaining a proper anamnesis of the care-seeker’s problems,to facilitate a correct assessment regarding need of care andthus be able to refer the care-seeker to the proper healthcareprovider. They also stressed the importance of being

perceptive, daring to ask questions, and trying to have apatient-centered approach.

PCNs are often a care-seeker’s first contact with thehealthcare system, and are responsible for triaging the needof care and referring to the appropriate healthcare providerwhen necessary. However, encountering care-seekers hasbeen shown to be a challenge for nurses (Koekkoek, vanMeijel, & Hutschemaekers, 2006). As described by the par-ticipants in this study, many care-seekers with mental ill-ness are “high consumers” of healthcare, and research hasshown how they are at risk of not receiving proper carebased on their care-seeking habits (Hansagi, Edhag, &Allebeck, 1991). Another challenge described by the nursesin our study is the limited availability of resources for thisgroup of care-seekers. Studies (Bj€orkman et al., 2008) haveshown how healthcare personnel within somatic care experi-ence care-seekers with mental illness as unpredictable,frightening, and more demanding than other care-seekers.The participants in this study did not describe feelings ofbeing frightened by care-seekers with mental illness, but diddescribe the group as more demanding than other care-seekers. Several previous studies (Ali et al., 2017; Barneyet al., 2006; Bj€orkman et al., 2008; Bluhm, Covin, Chow,Wrath, & Osuch, 2014; Bristow et al., 2011; Hansson et al.,2013; Kravitz et al., 2011; Natan et al., 2015; Pagura, Fotti,Katz, & Sareen, 2009; Rao et al., 2009; Shattell, McAllister,Hogan, & Thomas, 2006; Svedberg, Jormfeldt, & Arvidsson,2003) have shown how care-seekers with mental illness areoften subjected to stigma, and are discriminated against andnot provided with the care they are entitled to since theyare perceived as frightening and unpredictable by healthcareprofessionals. The most negative attitudes among healthcareprofessionals are directed against care-seekers with drugaddiction, alcohol addiction, and schizophrenia; and care-seekers with drug addiction are regarded as particularly dan-gerous. The nurses in the present study reflected on howstigma and shame contributed to individuals with mental ill-ness avoiding seeking care, and they also perceived that thisgroup had difficulty talking about their thoughts and feel-ings. According to Lester, Tritter, and Sorohan (2005) andEriksen, Arman, Davidson, Sundfør, and Karlsson (2014), itis easier for care-seekers with mental illness to talk abouttheir problems if they have trust in the caregiver, and con-tinuity in their contacts with the healthcare system facilitatestrust between the care-seeker and caregiver.

Primary healthcare has been shown to be of greatestimportance for care-seekers with mental illness, and thechallenge for healthcare is to provide easily accessible care.However, nurses express insecurity, lack of training, andlack of expertise with this group of care-seekers (Lesteret al., 2005). This insecurity and perceived lack of compe-tence was also described by the nurses in this study, and itwas clear that they desired more competence and educationregarding mental illness, as they believed they did not havethe proper education to attend to these patients and providesufficient care. They also described how a major part oftheir competence was based on previous clinical experiences.Hence, personal life experiences were described as valuable

ISSUES IN MENTAL HEALTH NURSING 1027

when encountering care-seekers with mental illness. Shattellet al. (2006) found that patients with mental illness appreci-ated it when nurses used their own personal experiences oflife and showed their personality in the meeting, and thesestrategies contributed to care-seekers’ experiences of a goodcaring relationship. According to Reed and Fitzgerald(2005), knowledge regarding mental illness is essential fornurses to feel secure in encountering care-seekers with men-tal illness. Lack of proper knowledge led to insecurity andfear of asking the wrong question or saying something thatcould be regarded as offensive by the care-seeker with men-tal illness. However, support contributed to nurses feelingboth more enthusiasm and increased security in their work(Reed & Fitzgerald, 2005).

It is worth noting that care-seekers with mental illnessreport preferring healthcare providers’ continuity and good lis-tening skills over expertise and knowledge within the subject(Lester et al., 2005). This shows a discrepancy between whathealthcare professionals believe care-seekers desire and whatcare-seekers actually desire. The participants in this studyreported having a lack of competence to provide care forcare-seekers with mental illness, but according to care-seekersthemselves this knowledge is of less importance (Lester et al.,2005). Patients with mental illness desire trust, reciprocation,and to be acknowledged and seen. They want nurses to beavailable, engaged, affirmative, and hopeful (Svedberg et al.,2003). The PCNs in this study described how they tried tocreate a feeling of trust by listening and showing empathy.Other studies have shown how patients with mental illnessdesire treatment to be initiated without delay when they seekcare, and wish that healthcare was more easily accessible(Bristow et al., 2011; Lester et al., 2005; Oud et al., 2009).These patients also prefer to come into contact with the per-son responsible for their treatment at an early stage. Theirpreferred type of care is counselling, which as shown in thepresent study is also considered important by PCNs. This pla-ces a great demand on the PCN, who have limited possibilitiesto refer care-seekers to counselling. The participants in thisstudy said that care-seekers with mental illness often also havephysical illnesses, and hence mental illness is regarded as com-plex. Roberts, Roalfe, Wilson, and Lester (2007) showed thatdoctors tend to focus too much on the mental illness, andeventually physical issues will be at risk of not being properlyaddressed. The PCNs in our study stressed the importance ofa holistic perspective when encountering care-seekers withmental illness. They said they tried to facilitate good care forcare-seekers with mental illness, but felt insufficient as theybelieved they did not have the proper education and know-ledge. However, when comparing this to what care-seekerswith mental illness desire from nurses—that is, empathy andgood listening skills—perhaps these nurses contribute morethan they are aware of.

Methodological considerations

Conventional content analysis poses a number of issuesregarding trustworthiness (Creswell, 2002; Hsieh &Shannon, 2005). To facilitate credibility, the data analysis

was performed by two of the authors and recurrent discus-sions took place among all four authors until consensus wasreached. Quotations are presented in the findings section toelucidate the content of the themes. All interviews were per-formed by two of the authors (blinded for review) togetherusing a semi-structured interview guide. In order tostrengthen dependability, we chose participants who variedin aspects such as size of health center, geographic location,and form of management. Finally, to help the reader decidethe transferability of the results, we have described the par-ticipants’ demographics, the data collection, and the analysis.

Conclusion

PCNs encounter care-seekers with mental illness on a dailybasis. This poses challenges for these nurses, as they perceivethat they lack the competence and resources to provideaccurate care for this vulnerable group of care-seekers. Thisstudy found that the nurses used their own personal experi-ences of life and made use of their personalities whenencountering the patients in order to establish a caring rela-tionship. To facilitate a patient-centred approach, it isimportant that PCNs are perceptive of care-seekers’ needsand dare to ask questions, even though the questions mightbe of a sensitive nature.

Implications for clinical practice

Mental illness is rapidly increasing, and primary healthcare pro-viders are often the first points of contact for care-seekers withmental illness. The PCNs in this study felt insufficient, believingthat they did not have the education and experience to facilitategood care for these care-seekers. However, according to previ-ous research, there is an incongruence between what nursesbelieve that care-seekers desire and what care-seekers reallydesire. It is therefore important for PCNs to be provided withsufficient support and opportunity for coaching sessions, tostrengthen them in their demanding and exposed position.

Ethical approval

According to Swedish legislation this study this kind of non-intervention study do not require ethical approval. However,guidelines of the Helsinki declaration was followed; partici-pation was voluntary and all participants provided writteninformed consent.

Acknowledgments

The authors are thankful to the participating telenurses for sharingtheir time and experiences.

Disclosure statement

The authors report no conflicts of interest. The authors alone areresponsible for the content and writing of the article.

1028 A. BJORKMAN ET AL.

ORCID

Annica Bjorkman http://orcid.org/0000-0001-9513-3102Martin Salzmann-Erikson http://orcid.org/0000-0002-2610-8998

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