The effect of nurse–patient interaction on anxiety and depression in cognitively intact nursing home patients

Gørill Haugan, Siw T Innstrand and Unni K Moksnes

Aims and objectives. To test the effects of nurse–patient interaction on anxiety and depression among cognitively intact

nursing home patients.

Background. 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 community-dwelling older people,

and a large overlap of anxiety is found. Therefore, identifying nursing strategies to prevent and decrease anxiety and depres-

sion is of great importance for nursing home patients’ well-being. Nurse–patient interaction is described as a fundamental

resource for meaning in life, dignity and thriving among nursing home patients.

Design. The study employed a cross-sectional design. The data were collected in 2008 and 2009 in 44 different nursing

homes from 250 nursing home patients who met the inclusion criteria.

Methods. A sample of 202 cognitively intact nursing home patients responded to the Nurse–Patient 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).

Results. The SEM model tested demonstrated significant direct relationships and total effects of nurse–patient interaction on

depression and a mediated influence on anxiety.

Conclusion. Nurse–patient interaction influences depression, as well as anxiety, mediated by depression. Hence, nurse–

patient interaction might be an important resource in relation to patients’ mental health.

Relevance to clinical practice. Nurse–patient interaction is an essential factor of quality of care, perceived by long-term nurs-

ing 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 Bureau 2009) highlights a huge shift to an older popu-

lation and its consequences. Within this shift, the most rapidly

growing segment is people over 80 years old: by 2050, the per-

centage 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).

Authors: Gørill Haugan, PhD, RN, Associate Professor, Faculty of

Nursing, Research Centre for Health Promotion and Resources,

Sør-Trøndelag University College, HIST, Trondheim; Siw T

Innstrand, PhD, Associate Professor, Research Centre for Health

Promotion and Resources Norwegian University of Science and

Technology, NTNU, Trondheim; Unni K Moksnes, PhD, RN,

Associate Professor, Faculty of Nursing, Research Centre for

Health Promotion and Resources, Sør-Trøndelag University

College, HIST, Trondheim, Norway

Correspondence: Gørill Haugan, Associate Professor, Research

Centre for Health Promotion and Resources, HIST/NTNU, NTNU,

SVT/ISH, 7491 Trondheim, Norway. Telephone:

+47 73 55 29 27.E-mail: [email protected]

© 2013 Blackwell Publishing Ltd 2192 Journal of Clinical Nursing, 22, 2192–2205, doi: 10.1111/jocn.12072

For many of those in the fourth age, issues such as physi-

cal illness and approaching mortality decimates their func-

tioning 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 popula-

tion 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 esti-

mated that by 2020, depression is expected to be the high-

est 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, respec-

tively (Stordal et al. 2001, 2003). Worse general medical

health is seen as the strongest factor associated with depres-

sion 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 6–26% and from 11–50% for minor depression.

However, the prevalence rate for depressive symptoms ran-

ged from 36–49% (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 emo-

tional 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, maintain-

ing intimacy through friends and family and managing the

change process associated with older age (Traynor 2005).

Significantly more hopelessness, helplessness and depres-

sion 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 mor-

tality, all of which increases an individual’s vulnerability

and distress; in particular, loneliness and depression are iden-

tified 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 relation-

ships, privacy, self-determination and connectedness.

Because NH patients are characterised by high age, frailty,

mortality, disability, powerlessness, dependency and vulner-

ability, they are more likely to become depressed. A recent

literature review showed several studies reporting prevalence

of depression in NHs ranging from 24–82% (Drageset et al.

2011). Also, with a persistence rate of more than 50% of

depressed patients still depressed after 6–12 months, the

course of major depression and significant depressive symp-

toms 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 anxi-

ety and depression reports a paucity of findings on anxiety

in older people (Byrne & Pachana 2010)