More age-care staff report helping care recipients following a brief depression awareness raising intervention

Those working closely with the elderly need to have a good level of awareness of depression because of its high incidence in elderly care recipients [1, 2]. Despite these high rates, detection of depression by staff tends to be low, with different studies showing rates between 15 and 38% for nursing staff (depending on the assessment method used) and 62% for nursing home managers [3]. These low detection rates have been found in a variety of settings, including nursing homes [4] and home care settings [1].

Unlike general practitioners (GPs), age-care staff have regular ongoing contact with care recipients and are well placed to recognize symptoms that could be indicative of depression. Indeed, some data suggest that residents are more likely to disclose depressive symptoms to nursing home staff than to their GP [5]. Early intervention is important as it improves long term outcomes and reduces suffering [6], particularly since depression is a risk factor for dementia [7] and can lead to increased physical health problems and mortality [8, 9]; high health service utilisation [10] and to decline in functional status [11]. Early intervention of depressive symptoms is also warranted since pharmacological and psychological treatments are effective [12].

Recognition rates of depression in older persons have typically been reported to be low [13] although more recent research indicates that the situation may be improving [14]. Recognition in this age group is particularly difficult because of the overlap of symptoms between depression and physical health problems [15, 16] and between depression and dementia [17, 18]).

While it is important for age-care staff to recognize depression in care recipients it is also critical that they know the appropriate course of action to assist a care recipient who may be depressed. Previous research has shown that age-care staff may not be aware of appropriate helping behaviours. For example, an Australian study [19] found that low care and community care staff were unsure of referral procedures, whether to notify a GP or mental health specialist and of what information they should provide. Another study [20] found that even if professional carers did make psychiatric referrals for depressed residents the reasons given usually did not relate to depression but to ‘behaviour problems’ or anxiety.

It is likely that a lack of training in depression awareness is responsible for low detection rates and lack of confidence in knowing what kind of assistance to provide. Studies have found rates of mental health training of between 7.8% and 40% [19, 21, 22]. The latter study also found that staff who had previous depression training had greater self-efficacy scores (that is ‘confidence in working with depressed older people,’ page 1291) but not greater knowledge scores and that personal carers had the least knowledge of late life depression compared to managers and nurses (including responding to depression). Other studies [21] have shown that nurses are no better at identifying depression than other staff members. In addition, length of service has also been shown to be unrelated to level of knowledge about depression [22, 23].

Improving detection rates does not necessarily translate into improved management of depression in terms of help giving behaviours by staff. For example, a meta-analysis [24] found little or no impact of depression screening questionnaires on either the detection or management of depression by clinicians. A recent study [25] investigated staff knowledge and self-efficacy related to recognizing and responding to depression and whether training improved numbers of referrals for depression. While the authors did find significant improvements in knowledge and self-efficacy there were no significant increases in referrals for depression at follow up.

Investment in age-care staff training needs to be inexpensive and take account of the high staff turnover in age-care facilities. The present study looks at a brief staff training intervention which is easy for facilities to implement, inexpensive and consequently can be repeated on a regular basis to counter the effects of staff turnover.

While a number of studies have looked at staff training in depression recognition [26‐28]; staff knowledge of depression [23, 29] and confidence in managing depression [22, 25]; to our knowledge, no other studies have explored unprompted knowledge of appropriate help giving behaviours or examined staff confidence in knowing how to respond to depression in high care environments. For this reason, the present study aims to extend previous research by focusing on staff self-efficacy and knowledge of appropriate help giving responses and their likelihood of providing assistance to potentially depressed care recipients. The study also examines those factors that influence confidence, knowledge and help giving behaviours including:

The study included all levels of age-care, from institutional high care to at home community care (see below) and included all staff who were available to participate in the training program.

Surveys were returned by 102 staff (53.1% of the total staff employed) at BT and AT and by 51 staff at FU (50.0% of BT sample).

The results of this study suggest that a brief depression awareness training program for age-care facility staff is associated with increased confidence in knowing how to help age-care recipients who may be depressed and this change was sustained at the six month follow up. There was also a significant increase at follow up in the proportion of staff who said they provided help to care recipients for four of the six helping behaviours that were examined. Previous research [22] has highlighted that a lack of self-efficacy is a major barrier to age-care staff in recognizing and responding to depression in care recipients. Self-efficacy has been identified as an important factor in the likelihood of staff providing assistance for potentially depressed care recipients. For example, a recent study [32] found that self-efficacy was linked to improved knowledge about depression, care staff taking time to listen to and discuss depression with age-care recipients, and to a greater likelihood of communicating with other staff about depression in age-care recipients. It appears that increasing confidence levels leads to an increase in helping behaviours possibly by making it more likely that staff will act on the knowledge that they have when they were not confident to do so beforehand. It is therefore important that age-care facilities explore ways to increase staff confidence such as by using the training program outlined in this study.

In the present study, prior to training, the nursing staff reported that they were not significantly better at identifying appropriate responses to care recipients with depression than other staff and neither were they more confident in knowing how to respond. This is similar to Bagley et al., 2000 (op cit). In addition, nurses were no more likely than other staff members to help care recipients who were potentially depressed. If this is an accurate indication of their actual clinical responses this would be of concern as it is likely to be the nurses’ role to liaise with GPs and ensure that care recipients receive help. In the current study all of the nurses surveyed worked in high care where they would have a high level of exposure to care recipients with depression so it is of considerable concern that they did not have either greater knowledge of appropriate responses to depression or were no more likely to help than other groups of staff.

Prior to the training no relationship was found between length of service and any of the three outcome measures, which suggests that experience alone is not sufficient for age-care staff to develop a good working knowledge regarding assisting care recipients with possible depression. This finding is consistent with other studies that have shown no relationship between length of service and knowledge related to depression [22, 23]. However it should be noted that the present study only examined length of service in the current position and not overall experience in age-care settings.

Those with previous training in the health field showed significantly higher confidence in knowing how to respond to depression than those without such training but they did not have greater levels of knowledge of appropriate ways of assisting care recipients with depressive symptoms and were no more likely to provide assistance. In contrast, while those with previous training in the mental health field could name significantly more appropriate ways of providing assistance to depressed care recipients and were also significantly more likely to provide help, they were no more confident than those without. This may be a reflection of the type of training they had received, which somehow failed to improve confidence. In contrast, the Davison et al. study (op cit) found that those with prior training in mental health had greater confidence but not greater knowledge to those without prior training. More research into the relationship between confidence and knowledge is warranted and into how each affect the other.

Prior to training, there was a trend (P = 0.061) for those with an education status of certificate/diploma and above to have greater confidence in knowing how to respond to depressed care recipients but they did not have greater knowledge of appropriate ways to respond and were no more likely to provide assistance than those with a lower education status. It is of concern that in the current study, managers were least likely to have an education status of certificate/diploma level and above and none of them reported having had previous training in either the health or mental health fields. Managers need to have good awareness of mental health in the elderly so they can direct staff in appropriate ways of responding. However it should be noted that the size of this group was extremely small.

Age-care staff work in a busy and challenging environment and care solutions need to be practical and not add to already heavy workloads. A study of hospital nurses in Hong Kong [33] found the second most common reason stated for not assessing patients for depression was lack of time (after lack of knowledge or skills). It is also important that depression be treated in the wider context of other chronic health conditions which are typical of elderly health care recipients [34, 35].

There are a number of limitations in the present study. For example, this was not a randomized controlled trial but a single group pre-test post-test design and therefore because there was no comparison group any changes identified in outcome measures may be due to historical, maturation and testing effects. The study needs to be repeated with a control group for an accurate assessment of the benefits of the intervention. The measures used for help giving behaviors were based on staff self-report and recall rather than on objective, prospectively collected measures. It is possible that staff may have exaggerated their helping behaviours to appear depression-aware. However, the proportion of staff who said they provided assistance for each of the helping behaviours was extremely low, so it seems unlikely that numbers were inflated. Although staff in the current study may not have endorsed the six help giving behaviours included in the survey that does not mean that they did not provide some other kind of help for care recipients such as listening to them or recording their concerns in the care recipients’ notes. However, as the facilities used in the current study did not have formalized procedures for responding to depression some measures were needed for assessing helping behaviours. It is also not necessarily the case that the helping behaviour measures used in the current research would be available options for all the staff in all of the age-care facilities investigated which further highlights the need for formalized procedures to assist care recipients who may be depressed and for staff to be aware of and act upon these procedures. More appropriate measures may be determined in future research. In addition, only slightly more than half of staff returned surveys at baseline; a high percentage of staff were lost from the sample at FU, mainly due to high turnover of staff at the participating facilities; and missing demographic data (particularly for carers) at baseline means that results must be interpreted with caution. Those with a higher education status were less likely to have follow up data. These factors and the sampling of staff from only one geographic location limit the external validity of the results.

More research is needed to identify barriers to providing care to age-care recipients with depression, to find the best methods for providing training for staff to assist information retention; to understand the relationship between confidence and knowledge; to increase staff confidence; and to facilitate moving from a theoretical understanding to a practical application of knowledge by staff in their day to day work.

Clearly there is a need for high quality training in depression recognition and management in age-care settings. The present study highlights the potential of a brief training program to increase staff self-efficacy and the number of staff who provide assistance to potentially depressed age-care recipients. The intervention is inexpensive and can be implemented on a regular basis to counter the effects of high staff turnover in age-care facilities.