District Nurses’ Experiences of Practice in Caring for People with Mental Ill-Health in Swedish Primary Care

Abstract

Mental ill-health is one of the greatest public health challenges in Sweden, and it is estimated that every third person seeking primary care in the country suffers from mental ill-health. Without proper treatment at an early stage, mental ill-health may lead to long-term illness and have a significant impact on functional ability. As district nurses are specialists in public health nursing, they have been pointed out as having a key role in the prevention and management of mental ill-health. The aim was to explore district nurses’ practice in caring for people with mental ill-health within primary health care. Individual semi-structured interviews were conducted with district nurses (n = 18) and the transcribed text was subjected to qualitative content analysis. The result was formulated as several subthemes, eventually developed into three themes: Practicing within an organisation where traditional attitudes are impediments, Perceiving mental healthcare as not being an obvious part of district nursing, Working as fellow human beings rather than “professionals”. The findings indicate that district nurses feel uncertainty in their practice in this area. Working independently with mental ill-health was not always considered socially acceptable among district nurses. Despite these challenges they tried to remain involved without becoming emotionally overwhelmed. They also strived to meet the needs of these patients with ‘small things’, that could be effective and a part of recovery-oriented practice, even if they might be defined as unprofessional, and their efficacy negated.

Introduction

Research shows that anxiety has increased in Sweden during the last 25 years and that about a fourth of the population is affected by mental ill-health at some point during their life (Calling et al., 2017). Mental ill-health is likely to coexist with conditions for which general medicine and nursing care are delivered (Read et al., 2017). In fact, it has been estimated that every third person seeking primary care in Sweden is suffering from mental ill-health (Nordström & Bodlund, 2008), a number that is increasing. The results of an evaluation of care for depression and anxiety syndrome based on the national guidelines (National Board of Health and Welfare, 2019) reported that depression and anxiety disorders were among the major public illnesses and caused roughly 40 percent of all sick leaves in Sweden. More than one in three women suffer from depression at some point in their lives, and almost one in four men. The number of girls aged 15 to 17 treated for depression and anxiety disorders in the specialised child and adolescent psychiatry had tripled since 2006. The incomparably largest increase had occurred since 2010 (National Board of Health and Welfare, 2019). Unfortunately, there are almost no data concerning primary care where most people with depression receive care, which is worrying considering this growing vulnerable patient group. Recently, it has been estimated that over 70 percent of all patients with depression or anxiety receive treatment from primary care (National Board of Health and Welfare, 2021). It has also been reported that the number of patients receiving a correct psychiatric diagnosis in primary care is less than 50 per cent and often characterised by unspecified diagnoses, increasing the risk of ineffective treatments (Swedish Council on Health Technology Assessment [SBU], 2012, pp. 93–102). Without proper treatment at an early stage, mental ill-health may lead to long-term illness and have a significant impact on functional ability (McKnight & Kashdan, 2009).

Background

The integration of mental health services into primary care has been carried out in different forms in various countries (Adewuya et al., 2019; Barraclough et al., 2016; Liang et al., 2018). In Swedish health care centres, the care of people with mental ill-health is provided by several professions, such as physicians, social welfare officers, psychotherapists, and registered nurses. In this study ‘mental ill-health’ is an umbrella term including a variety of conditions, from mild symptoms of worry to complex diseases. It includes mental health problems that have a negative impact on the individual even if they are falling short on diagnostic criteria. Most patients with symptoms of depression or anxiety will initially turn to their local health care centre for help. Nurses are generally assigned to take all incoming calls from patients, which is the primary way to get in contact with health care centres (National Board of Health and Welfare, 2021).

Still, patients have expressed concerns about primary care providers’ abilities to provide mental health care (Keller et al., 2016). Mental ill-health is often perceived as stigmatising, and many patients perceive that health care professionals lack understanding and are ignorant (Huggett et al., 2018). Stigma has been linked to reduced help-seeking (Clement et al., 2015). Stigma and negative attitudes related to mental ill-health are well documented among both health care professionals and patients (Hansson et al., 2013; Henderson et al., 2014; Yuxing et al., 2018). These attitudes are related to a low degree of faith in the capability of holding a job and engage in society (Hansson et al., 2013). A study by Ross and Goldner (2009) showed that nurses in general medical settings often held negative attitudes of fear, blame, and hostility towards patients with mental ill-health, which affected their care negatively. Lack of knowledge, less professional experience, and not having a friend or relative with mental ill-health are some of the factors related to negative attitudes towards mental ill-health (van der Kluit & Goossens, 2011).

District nursing in Sweden is a post graduate education characterised by autonomous work in primary health care or in the community including both home care and school health. To become a registered nurse (RN) in Sweden, 3 years of university studies are demanded which is leading to a Bachelor of Science. Several nursing specialties, of which district nursing is one, requires 1-year or longer specialist nurse education leading to a Master of Science. The district nurse specialist education is 1.25 years and is focussing on child health care, school health, as well as prevention in general where health pedagogy is highlighted. Healthy diet, physical activity and normal weight as well as balance in life are core messages that are promoted in all ages (Hörnsten et al., 2014). As Sweden has a growing group of people in higher age with chronic diseases, the assessment, treatment and rehabilitation of people with common illnesses, somatic as well as mental, among adults and elderly is highly focussed in the district nurse specialist education. Clinical assessments e.g., structured assessment of suicide risk and assessments of drug- and alcohol abuse, are included in their education. Since Swedish district nurses also are allowed to prescribe commonly used pharmaceuticals, their education also includes a course about prescription (Swedish District Nurse Association, 2019).

Most district nurses are working at either public or private primary health care centres, driven and financed by the regions in Sweden. Within health care centres, a lot of their time is spent in telephone support of people contacting the health care centres for health problems or advice. District nurses could consult, but most of the time work independently of physicians, and have their own general receptions where people come for health assessments and consultations, often for common infections or wound treatment, taking laboratory tests, getting injections, measuring blood pressures etc. (Boström et al., 2012a). They also have their own nurse-led special receptions with regular visits for people with long-term conditions as asthma, incontinence and diabetes (Boström et al., 2012b), but usually not for people with mental ill-health. Attempts to introduce care managers for this group of patients and their families have though begun in one region in southwest of Sweden (Björkelund et al. 2020), something that is pronounced as prioritised by the National Board of Health and Welfare (2021). However, even if mental ill health commonly is not a special reception, district nurses in general have time appointed to serve people with chronic mental illness and drug abuse with medication, treatment evaluations and laboratory testing. They are often a patient’s first contact in primary care settings and have been pointed out as having a key role in the prevention and management of mental ill-health because of the broad and complex nature of their patients’ care needs (Ekers et al., 2013; Grundberg, 2015). They also meet people in crises or those having anxiety and depression disorders where they simultaneously need to be observant on risks of suicide (National Board of Health and Welfare, 2021). District nurses should play an important role in these assessments, as they are specialists in public health nursing (Swedish District Nurse Association, 2019, 4-8).

As the number of people with mental ill-health increases in primary care, new challenges lie ahead of district nurses (Bjorkman et al., 2018). Previous studies have shown that trained nurses in primary care can identify depression as accurately as physicians (Mitchell & Kakkadasam, 2011), deliver cognitive therapies for symptoms of mental ill-health (Sandlund et al., 2017; Tyrer et al., 2015) and self-management support (Björkelund et al., 2018; Halcomb et al., 2019; Zimmermann et al., 2016). To further understand how district nurses shoulder the increasing public health challenge of mental ill-health, it is important to explore district nurses’ experiences of their practice in the care of people with mental ill-health. Increased knowledge of these experiences might help to motivate district nurses and their managers to prioritise mental health nursing in primary care. The aim of this study was therefore to explore district nurses’ practice in caring for people with mental ill-health within primary health care.

Methods

Design

The study has a qualitative descriptive design, based on 18 semi-structured interviews (Polit & Beck, 2017). These interviews were subjected to qualitative content analysis with an inductive approach, characterised by searching for patterns, moving from the concrete and specific to the abstract and general (Graneheim et al., 2017; Lindgren et al., 2020).

Settings

The study was conducted in 2019–2020 at eight health care centres in one county in Mid Sweden, situated in six municipalities with a population varying between 5,690 and 154,049 inhabitants. The health care centres were run either privately (n = 3) or public by the regions (n = 5). The number of patients listed at each health care centre in this study varied between 5.456 and 19.790 people. Swedish health care centres are staffed with several professions like physicians, nurses, social welfare officers, physiotherapists, occupational therapists and medical secretaries. Nursing staff consist of district nurses, registered nurses and nursing assistants.

Participants

Eight of 27 managers for health care centres in one county approved the study and one nurse manager at each health care centre assisted with recruitment through purposive sampling (Polit & Beck, 2017) and according to set inclusion criteria, implying having a specialist education in district nursing, minimum 1-year work experience from primary care, and having a service grade of at least 50 per cent at the health care centre. Potential district nurses were then provided information by e-mail and orally at staff meetings. Nurses who were interested in participating contacted the first author by email or telephone to agree on a place and time for the interview. Eighteen district nurses participated in the study. All were females between 31 and 63 years of age (mean 43.7 years). Their professional experience as district nurses ranged between 2 and 21 years (mean 7 years). Several participants had responsibility for nurse-led specialist clinics. Two participants had also experience of nurse management at the health care centres. Fifteen participants had a Degree of Master in Nursing. All participants had work experience of encountering patients with mental ill-health in primary care. Participants previous work experiences within the healthcare sector varied widely.

Data collection

Interviews were conducted by the first author (J.L.) in a conversational form to achieve a shared understanding of the study focus (Polit & Beck, 2017). The interviews were based on a topic guide. The guide was tested in two pilot interviews and proved to work well; one of the pilot interviews was later included in the data material. The actual interviews started with general questions like “When talking about mental ill-health, which patients come to mind?”. To encourage participants to speak freely about the topics of the guide, the interviewer used questions such as “How do you feel about it?” and “Can you tell me more about that?” The participants also answered a basic questionnaire about age, length of career, education and previous workplaces in the health care sector. The interviews lasted between 14-67 minutes (mean 37). Data collection took place between September and October 2019. The interviews took place at locations chosen by the participants, which, in all but one case were in a room at their workplace during working hours. One interview took place at the participant’s home.

Data analysis

The interviews were digitally recorded and transcribed verbatim into Swedish. The text was subjected to qualitative content analysis (Graneheim et al., 2017; Graneheim & Lundman, 2004; Lindgren et al., 2020). Qualitative content analysis is a structured but non-linear process and requires that the researchers move back and forth between the original text and parts of the text during the analysis process. Every interview was read through several times, with and without audio to become immersed in the data. To analyse the data, the transcriptions were marked line-by-line to identify meaning units that corresponded with the study aim. Following this, meaning units were condensed and coded into descriptive labels for its content. The codes were abstracted and interpreted and further compared for differences and similarities and sorted into 15 tentative subthemes. Furthermore, to create a wider analytical space and enhance trustworthiness, the authors jointly reflected on and discussed the content and headings of the tentative subthemes whereby eight subthemes finally were agreed upon (Malterud, 2012), and three descriptive themes were formulated to unify the content of the subthemes.

Ethical considerations

In Sweden studies involving healthcare staff in their professional role do not require full approval by the ethics committee. Ethically, there are still several aspects to consider throughout the process of data collection and analysis. As data was collected through interviews, a risk-benefit assessment was made to determine whether the benefits of participation were higher than the risks (Polit & Beck, 2017). As the study aim could be perceived as sensitive, several risks were identified: emotional distress from self-disclosure, introspection, anger against the type of questions being asked, and loss of time. Potential benefits were an opportunity for introspection and self-reflection, the excitement of being part of a study and satisfaction from providing information that might help others. To reduce these risks, the interviewer used a neutral, encouraging approach and active listening. Furthermore, the study adhered to ethical regulations and guidelines according to Swedish Law (2003:460) and the General Data Protection Regulation [GDPR] (2016). To reduce ethical issues, ethical principles were followed in terms of information, consent, confidentiality and utilisation requirements (Swedish Research Council, 2017, 12-18). The participants gave informed consent after being informed orally and in writing about the study. To further adhere to the right of self-determination and autonomy, participants were informed that participation was voluntary, that all data was considered confidential and that they were free to withdraw at any time without an explanation. The requirement of confidentiality was adhered to by de-masking and coding the material to minimise the risk of exposing participants’ identities. The data material was locked in securely in such a way that only the authors had access to it, and after publication of the article destructed, which is in line with regulations of Umeå University.

Results

The district nurses’ experiences of their practice in the care of people with mental ill-health were formulated in three themes and several related subthemes. The three themes were as follows: Practicing within an organisation where traditional attitudes are impediments, Perceiving mental healthcare as not being an obvious part of district nursing, Working as fellow human beings rather than “professionals”. The respective subthemes are described in the text below and exemplified with quotations from the original interviews. An overview of the themes and subthemes is presented in Table 1.

Table 1. Overview of themes and subthemes.

Themes	Subthemes
Practicing within an organisation where traditional attitudes are impediments	Prioritising acute cases over preventive care
	Focusing on physical care interventions in daily work
	Lacking time and resources
Perceiving mental healthcare as not being an obvious part of district nursing	Mental ill-health being within the margins of district nursing
	Intercepting patients and referring them further
Working as fellow human beings rather than “professionals”	Using gut feelings when expert knowledge is missing
	Remaining involved but preferably at a distance
	Helping patients to find solutions on their own

Practicing within an organisation where traditional attitudes are impediments

The district nurses described that their roles as district nurses were constantly evolving, both positively and negatively. This allowed for a potential for specialisation in areas of interest, as well as leading to additional work assignments. It could also mean that work with mental ill-health was overlooked. The traditionally physically oriented nature of district nursing led to a focus on more common and easily treated issues associated with physical illness. Acute problems with mental ill-health were prioritised over preventive care and advice on self-care.

Prioritising acute cases over preventive care

The district nurses described preventive care as the foundation of district nursing. Yet, preventive care and lifestyle changes were generally performed in small scales by the participants. Active prevention of mental ill-health was rarely performed. Participants were unsure how to specifically work with prevention and hesitant to give self-care advice to patients with mental ill-health. Sometimes, advice about basic sleep hygiene, stress reduction and physical activity was recommended. Overall, participants experienced talking about lifestyle changes concerning a high blood pressure more comfortable than concerning mental ill-health. When participants were actively involved, it was usually something out of the ordinary. They described having a big responsibility to assess suicide risk and acute cases of mental ill-health were always prioritised and managed rapidly.

…We’re supposed to talk about physical activity, nutrition… it’s not a lot of talking about how you live your life, it’s more… pass on to social welfare officers or psychotherapists. You don’t have time to go into that, it’s more if anyone comes in acute and just cries, in those situations we handle it well. (p. 9)

Acute cases led participants make themselves available by taking time from administrative work or lunch breaks to give patients with acute symptoms of mental ill-health time to talk.

… It’s my responsibility to ask the questions when their life is at the edge of a cliff. (p. 17)

Focusing on physical care interventions in daily work

Although district nurses perceived mental and physical health equally important, they described their role as traditionally physically oriented. Working autonomously with mental health was not anything that was expected of them by their employer. Participants saw themselves as practitioners, having a clinic and working hands-on with more common causes of physical ill-health (e.g. measuring a blood pressure, treating a wound). They were used to quick results, which made it more natural for them to engage with these practices. Treating physical ill-health was also seen to promote mental health. Mental ill-health on the other hand, especially mild to moderate cases, was described as ambiguous and hard to pinpoint. It could make participants uncomfortable and frustrated to experience that care could not be evaluated as quickly as they were used to.

You’re used to do things well and fast. The hard part about mental ill-health is that it can take such a long time. I prefer doing something and then the problem is solved. (p. 16).

Lacking time and resources

The district nursing role was described as complex and constantly expanding. This was perceived both as a privilege and a burden. Their versatile competence often allowed them to explore and immerse themselves in areas of interest that lead them to have their own clinics at the health care centres. On the other hand, the slim work organisation in health care made them feel pressured to take on additional work assignments, like intravenous drips, from other authorities (e.g. hospitals). This led to feelings of being taken advantage of and loss of focus for their field of competence (e.g. public health). Working with mental health required more time and resources than was currently available. Participants found themselves trying to limit their work and go back to the basics of district nursing, which meant that mental ill-health was diverted to other professions. Thus, a supportive management was seen as important to be able to work with mental health.

It’s the same as always when new things are laid on us in primary care… do we have to do this as well? (p. 14)

Perceiving mental healthcare as not being an obvious part of district nursing

The district nurses were unsure as to what degree mental ill-health was their responsibility and described that they often resort to treating it under a different guise or simply referring the patients further.

Mental ill-health being within the margins of district nursing

Mental ill-health was described as a common reason to seek care at the health care centres. The district nurses encountered patients with mental ill-health daily on the telephone and frequently during appointments for physical matters, essentially making mental health a part of district nursing care. Still, they did not consider themselves an actively independent supportive instance for these patients. Participants were unsure of their responsibilities and scope of practice in the care of people with mental ill-health. For example, it was not always seen as socially acceptable for either patients or district nurses to book appointments to them solely for mental health purposes. Instead, participants would book follow-up appointments for physical matters, mainly to continue talking about mental health with patients:

I noticed she needed to talk to someone. She did not want to see any welfare officers; she did not think that was an alternative for her. So, we mix it together with her diabetes… following it up… but, it’s not really the diabetes she wants to see me for. (p. 3)

Intercepting patients and referring them further

The district nurses described themselves as the front line of primary care: the profession was stationed to take all incoming calls from patients. Besides, patients often met a district nurse for a first evaluation at the health care centre. Intercepting patients with mental ill-health and referring them further was how they were mainly involved with these patients: participants gathered information about physical and mental health and guided the patient to the most appropriate profession by booking an appointment. Intercepting patients was considered something anyone working in health care could do. Mental ill-health was though always considered a serious matter requiring assessment from other professions like physicians, social welfare officers or psychotherapists. Intercepting patients at an early stage was seen as an important step to prevent patients from developing further mental ill-health. The district nurses could assess suicide risk, but a further assessment was risky, possibly harmful to the patient and potentially costing the participants their licences. In this way, passing them on also functioned as a security measure. Usually, patients were referred to a physician to rule out potential somatic reasons for the patient’s symptoms before proceeding to further psychiatric assessment.

… If we don’t intercept them it might lead to psychiatric clinics having to take care of them later, in the end. (p. 12)

Working as fellow human beings rather than ‘professionals’

The district nurses described that utilising their gut feeling was vital as they felt they were missing expert knowledge, and desired further education in this field. To compensate for this gap of knowledge, participants described that they worked as fellow human beings rather than ‘professionals’. Notably, the district nurses consistently referred to other disciplines as professionals, but this term was not used regarding their own profession. When managing patients with mental ill-health the district nurses also found it difficult to balance personal and professional roles in the same way as they would with patients who did not experience mental ill-health.

Using gut feelings when expert knowledge is missing

Detecting mental ill-health was perceived as a challenge. The district nurses experienced both their specialist nursing education and registered nursing degree as insufficient in the area of mental health in general. They described feeling unprepared when starting work at the health care centres, as they were surprised by the number of patients suffering from mental ill-health. To be able to work autonomously within mental health, participants wanted additional knowledge of self-care options and treatment methods. Having insufficient competence caused uncertainty about providing adequate care in the area.

I can’t do so much with my education; I don’t really know what’s right. I mean, you don’t want to make them worse. (p. 6).

Participants described how they were listening to the patient, observing behaviour (e.g. unease), body language (e.g. avoiding eye contact, close to crying) and voice (e.g. silent, monotone). Beyond the assessment of suicide risk, participants primarily used their gut feeling and previous professional experiences. This was perceived as problematic and described as unreliable. Further skill improvement in the area was rarely offered by employers and education given usually focused on solely suicide assessment. Interest played a key role in the care of people with mental ill-health. Participants with a personal interest in mental health had learnt more about the topic themselves and developed skills on their own, whilst participants with a lack of interest were described as not seeking further skills actively:

They are not that interested… they see this group as a burden. (p. 8)

Using gut feeling and previous experiences led participants to manage patients differently. While some participants felt mental health was not a necessary topic of discussion in every appointment, having experienced a first-hand encounter with a suicidal patient had led others to bring up the subject of mental health in situations where it was not obvious.

I had performed a blood pressure control, and right when he was leaving, I asked… but how are you? How are you as a person, I forgot to ask that. He said, ‘Yeah well, I was going to kill myself last week’ (…) If I had not asked that question, he would have just walked away. Now I make sure to ask everyone, even when taking a blood pressure. (p. 4)

Remaining involved but preferably at a distance

Encountering patients with mental ill-health required that the district nurses had to balance their professional and private role well. Participants were involved in mental health cases but believed it was in the best interests of both the district nurses and patients to remain involved at a distance. Participants described themselves often working as fellow human beings rather than district nurses during these patient encounters. This was a way to build a trustful relationship with the patient but could backlash if it became too personal, leading to a co-dependent relationship that affected both the district nurse and the patient in a negative way:

It felt like she hurt herself more to see me again… I became a sort of safe place for her and her history was too close to my own. It tore me up a bit. (p. 13)

Helping patients to find solutions on their own

When encountering patients with mental ill-health, the district nurses preferred using structured, open-ended questions or motivational interviewing, MI. By mirroring a patient’s reflections, the participants could help the patients find solutions to their situation on their own:

I think it helped her that I did not have any answers for her. I bounced her questions back to her, so she had to find the answers herself (p. 5)

Skills that emphasised being observant and attentive were needed, along with having a broad outlook. This included an understanding that physical illness could lead to mental ill-health and being able to see that a physical nursing intervention could promote mental health. Being able to ask about mental health, social network, working life as well as health- and risk factors influencing the patients’ health was important. Participants played a key part in reducing the taboo around mental ill-health and in helping the patients connect their physical and mental symptoms.

I tell them, ´Okay, it’s five days until your doctor’s appointment, think about these resources you have. Use them and think about how you can minimize your risk factors and how you can help yourself until you see a physician.’ (p. 4)

Discussion

The result showed that the district nurses were practicing within an organisation where traditional attitudes are impediments. They stressed that their expertise in preventive care seemed to slip away on behalf of more acute cases, and they experienced a sense of resignation in their work environment. Even though district nurses are known to generally work autonomously, the results of this study suggest that they might feel uncertain regarding their responsibilities and lack knowledge when it comes to the area of mental health. The district nurses also found it easier to hold on to the nursing process in practical interventions such as blood pressure measurements and wound treatments and it was perceived as more in line with the role of district nursing than to promote, prevent or treat mental ill-health. Focusing on physical care interventions in daily work was a way to get a socially accepted chance in the workplace to also discuss mental health issues with these patients, something that may be seen as a stigma. Health care staffs’ negative attitudes towards mental ill-health have also been reported in various healthcare settings and may direct the choice to focus on physical care (Bjorkman et al., 2018; Corrigan et al., 2014; Hansson et al., 2013; Ihalainen-Tamlander et al., 2016; Janlöv et al., 2018; Ma et al., 2018). Stigmatising attitudes are reported being related to lacking education (Abera et al., 2014; Ma et al., 2018; Shahif et al., 2019), something that the participants in this study also experienced.

To work autonomously in the mental health area, the participants desired training in using structured instruments to assess mental health, knowledge of the implementation of treatments and increased knowledge of self-care options to promote mental health. To remember, assessments and implementation of such are already meant to be within district nurses’ scope of practice (Higher Education Ordinance, 1993:100), pointing at potential deficiencies in education.

Our results relating to lacking time and resources for working with mental ill-health, could be connected to our findings about helping patients to find solutions on their own. However, it is important to know more about the motives for this. If it is due to strivings to empower patients in their self-management it is positive, but if it concerns the ongoing cuts and reduction of resources, it is problematic for this group of vulnerable patients, since globally only 2% of health budgets are spent on mental health while suicide is the second-leading cause of death among 15-29 year olds (Vigo et al., 2019).

The results about perceiving mental healthcare as not being an obvious part of district nursing is interesting. The profession often talks about the importance of being providing health services from “cradle to grave”, being generalists, caring for people with various diseases and from all socioeconomic groups, but in relation to mental issues this was not always a reality among the participating district nurses, and it was seen as within the margins of district nursing. Even though promotion of patients’ mental health should be within the district nurses’ scope of practice (Higher Education Ordinance, 1993:100), the district nurses seemed to feel great uncertainty about their nursing practice and responsibilities in this area and often only intercepted patients and referred them further. One reason for this could be related to the regional organisation, but this is likely not the only factor contributing to it. It also appeared that it was not always acceptable in the primary care context for district nurses to manage cases of mental ill-health on their own and making appointments for mental issues. Referring most patients with symptoms of mental ill-health to other professions can be seen as taking mental health as a serious issue, but these actions can also reveal that the participants are task-oriented and avoid to assess and prioritise these patients. This action to refer patients to other professions is also relatable to the novice and advanced beginner stage of Benner’s (1993) “From novice to Expert” theory. According to Benner (1993, p. 38) every nurse entering a new area of practice where they lack experience, may sometimes find themselves in the novice’s level of achievement if the goals and means for nursing care are unknown.

The results showed that the district nurses described their way of acting as working as fellow human beings rather than ‘professionals’. They did not consider themselves ‘professionals’ in this area, while they repeatedly used this term for other disciplines. We argue that when participants consider other disciplines as ‘professionals’, they by implication undermine their own profession and maintain a power imbalance in the culture in which they work. They also described that they resorted to gut feelings and their own previous experiences when supporting people with mental ill health, which made them feel as if they were disregarding evidence-based care and ‘professionality’. Participant further described that they worked with mental health under the radar calling it something else, as control of hypertension or blood sugar, even if they knew that the patients visited them in order to get a chance to talk about their mental ill-health. According to Patricia Benner (1993), intuition and previous experiences are valuable resources in the advancement to expert nursing (p. 42) and could indicate that the participants are advancing in their skills acquisitions. By using previous experiences, nurses can recognise when the expected does not occur, and how to change plans accordingly to the new situation. Relating to gut feelings, Benner describes the expert nurse as no longer leaning towards analytical principles and instead, by intuition, finding the solution. Further, Topor et al. (2018) in their review emphasise that micro-affirmations, i.e. ‘small things’ as words, gestures and actions, even as fellow human beings, could play an important role in improving a person’s sense of self. Such ‘small things’ are often invisible but an effective part of recovery-oriented practice, but they might be defined as unprofessional, and their efficacy negated.

The results also showed that the district nurses tried to remain involved but preferably at a distance. They experienced that there was a risk of becoming too involved in patients’ mental ill-health and thereby a risk of being emotionally overwhelmed themselves. Studies have demonstrated that stress of conscience and related burnout among staff in healthcare contexts may seriously affect their health (Åhlin et al., 2022). The participants also described it hard to find a balance between professional and private life. Regarding sustainable work-life, Matsuo et al. (2021) reported on the striving for work-life balance among nurses and related it to their intention to stay or leave the workplace. Nurses who exhibited less striving for work-life balance behaviour showed higher intentions to leave. Matsuo et al. conclude that securing a comfortable work-life balance would reduce the nurses’ desire to quit their work in health care. To reduce nurse turnover, nurse managers therefore should develop support programs that can help nurses achieve a better work-life balance.

The participants described that they often chose to help patients to find solutions on their own, sometimes due to lack of competence as well as limited time and resources, but also due to their strivings to empower patients by using motivational interviewing. When they experienced limited resources of supporting these patients with mental ill-health, they could support them to help themselves. This could be beneficial since a systematic review and meta-analysis of MI used in primary care demonstrated usefulness and clinical effects and the largest effects were related to weight loss, blood pressure and substance use (VanBuskirk & Loebach Wetherell, 2014).

Methodological considerations

Although measurements were taken to ensure trustworthiness, several aspects need to be discussed. Qualitative content analysis is a systematic method that offer opportunities to analyse both manifest and latent content in data in order to provide new insights (Lindgren et al., 2020) that could be used as a practical guide to action An inductive approach is recommended when former knowledge of the phenomenon is insufficient or fragmented which was the case in the present study. To attain a broad description of the phenomenon, semi-structured interviews were performed (Polit & Beck, 2017). According to Graneheim and Lundman (2004) choosing participants with diverse experiences increases the possibility of providing information about the study focus from various perspectives. Because of this, participants who differed in aspects such as the size of the health care centre and geographic location were chosen. Although all participants worked within the same region, they worked in six different municipalities varying in population size. A limit to the trustworthiness was that all participants were females. However, most of the nursing workforce in Sweden consists of women (Statistics Sweden, 2020). The initial amount of 15 participants was deemed appropriate considering the time frame and information needs. However, to provide a deepened comprehension of the study aim, three additional interviews were carried out. To limit the risk of inconsistency during data collection, all interviews were performed by the one author using a topic guide to make sure all areas were covered. The interviewer gained new insights into the phenomenon during data collection, which influenced follow-up questions and led to deepened data later on in the process. Quotations are presented in the results section to highlight the themes in the content. Finally, to help the reader determine the transferability of the results, context, sampling and characteristics of participants, data collection and analysis process were described thoroughly.

Conclusion

The findings from this study highlight that district nurses worked in a traditional organisation that became an impediment for the quality of care in mental health nursing. Thereby it was hard to view mental health care as obvious parts of district nursing. They experienced lacking knowledge and uncertainty. Despite these challenges they strived to work as fellow human beings, remaining involved but without becoming emotionally overwhelmed. They strived to meet the needs of these patients by using gut feelings, previous experiences and by helping the patients to find solutions on their own. Benner (1993) emphasises that intuition is a part of nurses’ professional development and Topor et al. (2018) mean that ‘small things’ could be effective and a part of recovery-oriented practice, even if it might be defined as unprofessional.

Implications for nursing

Since our findings indicate that district nurses may feel uncertainty in their practice regarding care of people with mental ill-health there are potential for improvements such as education and training. An early study by Haddad et al. (2005) reported that British district nurses’ negative attitudes and involvement in mental health problems could be related to lack of training, since 75% of nurses had received no such training during the past 5 years. We have no such statistics for the Swedish nurses but argue that managers need to recognise the potential district nurses could have in the care of people with mental ill-health, however they need a mandate and adequate education to accomplish it. Shouldering the increasing number of patients seeking primary care with mental ill-health further requires that district nurses form a shared vision of mental health nursing so that they can counteract stigma and work autonomously in this field.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.