Person-centred care during treatment with nasal esketamine — a qualitative study

This study had a qualitative design and employed semi-structured interviews, focusing on capturing and describing the experiences of patients receiving ESK treatment for TRD at a psychiatric out-patient clinic in Sweden. As ESK treatment is administered by a registered nurse, in this study, the term “nurse” signifies a registered nurse.

A consecutive recruitment strategy was employed. All patients eligible for inclusion had been diagnosed with TRD by a psychiatrist and had received at least eight treatments of nasal esketamine, the minimum standard of treatment for induction and evaluation. They had no known aneurysmal vascular disease, hypertension or cardiovascular incident within the six weeks preceding the treatment start. The patient’s blood pressure had been controlled before initiation of the treatment. Information letters and consent forms with pre-paid envelopes were sent to 32 patients with TRD treated with ESK. After one week, patients were contacted by non-treating staff from the out-patient clinic via telephone and allowed to ask questions. In all, 22 patients agreed and provided written consent. The researcher contacted the patients who agreed to participate in the study by email or text message, to schedule an interview. Two patients who provided consent did not reply to messages or emails, resulting in 20 interviews conducted, with 11 women (55%) and 9 men (45%). The patients were aged 19–72, with an average age of 46. Fifteen patients had studied at university, four at secondary school, and one at primary school. Professions ranged across diverse fields, such as teaching, IT, and engineering. Sixteen patients were born in Sweden, while the remaining four were born abroad. Eleven lived with a partner, while nine lived alone or with their parents. The duration of the depression varied from between 1.5 and 42 years.

The data were collected by way of individual, semi-structured interviews – a suitable method for exploring people’s thoughts and opinions. Such interviews involve the interviewer writing a guide with relevant questions about the subject under investigation, while allowing patients to express themselves in their own words, in order to provide a comprehensive account. An interview guide was developed by the research team, pilot-tested and subsequently used for all the interviews (see supplementary file A). The interviews were conducted between November 2023 and February 2024. LK conducted nineteen interviews, and one was done by KHW. Five interviews were held face-to-face at the psychiatric clinic, four via phone, and 11 interviews were done digitally, using ZOOM or Teams. Interview length ranged from 29 to 89 min (Median = 48), with a total interview length of 15 h and 9 min. All interviews were digitally recorded and transcribed verbatim.

The collected data was analysed using thematic analysis [20], with an abductive approach [21]. The analysis was done in steps (see Table 1), beginning with familiarization of the material, and open and inductive coding, performed by author LK. The codes were sorted into the various PCC constructs and compared within each construct. Sub-themes were identified and arranged on the basis of McCormack and McCance’s four constructs: prerequisites, care environment, person-centred processes, and expected outcomes [13]. The analysis was done in AtlasTi © (2002–2024 – ATLAS.ti Scientific Software Development GmbH, v8.7.1-2024-09-30). Coding was performed by one member of the research team (LK), with analysis and close collaboration between the research team. Two members of the research team were mental health credentialled nurses with several years of experience, whereas the third member had clinical experience primarily from the area of rheumatology, but extensive experience in methodological issues and nursing research within mental health. The background and expertise of the research team enhance the trustworthiness of this study.

During ESK treatment, prerequisites for PCC were described in terms of the importance of meeting nurses who were competent and engaged. Patients also stressed the importance of being treated with respect.

During treatment with ESK, patients described the importance of the care environment in PCC feeling comfortable, having a private space, and adapting care to individual needs.

Patients receiving ESK emphasized the person-centred process in PCC with nurses supporting individuals, valuing their unique identity and involving them in decision making.

Expected outcomes in PCC meant patients wanted to feel cared for and achieve their treatment goals.

The findings demonstrate that patients perceived nurses at the psychiatric clinic as competent in psychiatric treatments and experienced in dealing with ESK. Research shows that meeting competent nurses who demonstrate caring abilities is fundamental to building patients’ trust [22], which in turn is a key factor in achieving positive health outcomes [23]. Nurses with knowledge and experience in treating individuals with mental health issues tend to have less stigmatized attitudes, which promotes a good patient-provider relationship [24]. The quality of the relationship between the nurse and the patient mainly depends on the nurse’s skills, such as self-awareness, communication ability, and the ability to show empathy [25]. Nurses must be skilled in communicating with patients as unique individuals, employ active listening, and ask questions [26]. Insufficient information about medication, inaccessible care, an unprofessional attitude, and a lack of professional counselling can be barriers to recovery from TRD [27]. This entails that nurses involved in treatment with ESK must have relevant knowledge of all aspects of the medication; pharmacokinetics, pharmacodynamics, potential side effects and expected treatment effect, to instil trust and promote recovery.

Patients in the current study also felt that nurses were engaged and had a genuine desire for their well-being, which made them feel more comfortable dealing with uncomfortable experiences associated with ESK. In PCC, nurses’ competence in communication and the ability to build relationships and recognize patients’ unique needs is essential to providing safe and secure care. It is also important for nurses to be diligent in their work and have a desire to provide the best care for the patient [14]. In the current study, patients identified that soft, friendly, kind, and calm personal qualities of nurses were associated with receiving good treatment. This conforms with the research on showing patients respect and providing good treatment, and the multifactorial nature of recovery according to patients’ beliefs [28]. Respectful treatment from nurses may be based on personal attributes such as caring, empathy, insightfulness, respectfulness, and competence [29]. However, personal attributes are also closely linked to organizational factors, such as support and flexibility, ultimately providing favourable conditions for good nursing care. The organization, or care environment, according to the PCC nursing framework, also needs to provide an opportunity for nurses to develop and safeguard their competence.

The importance of the physical care environment, also a part of the PCC construct, was stressed during treatment with ESK. Several patients appreciated that the clinic had a home-like environment, rather than a traditional hospital setting. An environment that instils calm and comfort promotes the patient’s well-being and health [13]. Patients wanted to be able to sit or lie comfortably while under the influence of ESK. It was important that the room was quiet and that they had the opportunity to sit alone, but using the same room for every treatment was not emphasized as necessary. This entails that clinics using ESK should enable patients to have access to private and quiet rooms with comfortable seating. The patients’ preferences for a private space need to be balanced with clinical supervision requirements for the safety of the patient during treatment. The rooms should be easily accessible for the nurses, with blood-pressure apparatus for monitoring possible hypertension and other side-effects such as vomiting and loss of consciousness. The rooms should also provide means for the patient to call for attention. The need for a private room might limit treatment of multiple patients simultaneously due to restrictions of space.

Some patients in the current study appreciated the flexibility in terms of arranging appointment times. According to Brand and Pollock [30], being flexible in the organization means adapting to, and meeting the patients’ specific needs, which also inspires trust. Thus, a supportive and flexible organization is essential as routines, power structures, attitudes, physical environment, and standardized procedures may be factors that otherwise limit the implementation of PCC [31]. Other studies show that time constraints and policies prevent nurses from interacting with patients in a meaningful way, and the focus is on the patient’s diagnosis rather than a holistic view of the patient and the care surrounding the patient. With no chance to take part in the patient’s experiences, values, and opinions, individual care and participation become unattainable [32‐34]. Developing a culture of care that values the relationship between nurses and patients can improve the quality of care and promote patient recovery from depression [28].

In the current study, patients noted that the ways in which nurses relate to, and treat patients, plays a significant role in patients’ well-being, and how patients perceive their treatment’s effectiveness. This is particularly true in PCC, where building a good relationship between nurses and patients is crucial. According to a study by Chambers et al. [35] and DeCou & Vidair [36], nurses must be non-judgemental, open-minded, good listeners, nice, calm, and accepting, and treat patients as whole humans and not cases. A good relationship is built when nurses commit to their patients and consider them to be equal partners in the decision-making process. In the current study, during the monitoring period, patients had varying preferences regarding frequency of supervision, and room environment, such as sound and light. Most patients felt that they had a say in how they wanted it and that the nurses adapted accordingly. This flexibility in supervision entails that nurses must have time assigned for each patient receiving treatment, as supervision will be more frequent at times and less frequent at other times. A few patients felt that they were unable to influence their care in some respects, such as wanting a dose or interval of treatment or wanting treatment at home, which went against the guidelines for the administration of ESK. Ensuring the patient understands the rationale behind guidelines, particularly from a safety perspective, is important for the relationship and ultimately, the treatment outcome. According to PCC, participation is a crucial aspect and involving the patients, and adapting to their needs, is essential for high quality in person-centred processes, and ultimately to achieving desired treatment outcomes. In the current study, patients described participation as being involved in decision-making processes regarding their care, where they were asked what they thought was best for them, and the nurse accommodated their preferences. They felt respected and valued when they could participate in their care, and that their opinions mattered. When patients are involved in their own care, they trust nurses more and are more likely to comply with treatment [28]. According to Sheldon [37], the ability of nurses to listen to the patient is an important aspect of involving the patient in decisions. Barriers to participation may arise when carers have a poor attitude, do not take the patient seriously, or are short of time [27]. In the current study, several patients highlighted the importance of having time to talk, not only about their illness, but about life in general. They appreciated it when nurses took the time to listen and made them feel seen as individuals. This is supported by Ekman et al. [11], who argue that the opportunity to talk about one’s well-being, life, and experiences is the basis for a good relationship between patients and nurses. It is likely that the substantial and recurring time spent together by nurse and patient during ESK contributes to high-quality, person-centred processes. Thus, ESK treatment and administration must be regarded as an encounter allowing interaction between patient and nurse, and not a quick and mechanical handing over of medication. This is also in line with the PCC processes, which emphasize the importance of the relationship between patient and nurse in establishing trust.

Patients stated that feeling secure during their treatment with ESK is critical, as the medication can cause unpleasant side effects. Thus, it is essential for patients to feel secure in their environment and with the nurse. Patients identified several factors that contributed to their sense of security, such as a comfortable and welcoming environment, seeing the same nurse at each visit, receiving care from professional and empathetic nurses, and having a say in their treatment. This aligns with Mollon’s [38] description of security as an emotional state that is impacted by memories and experiences. A peaceful and inviting care environment is crucial for patients’ sense of security, as both the physical and social environment impact their sense of security [39]. Building a robust relationship with a nurse involves continuously meeting the same nurse, which fosters trust and confidence, as long as the nurse is competent, responsive, and skilled in communication [40]. Continuity of care, such as seeing the same nurse at each visit, was perceived as fostering a sense of security and enabling individualized interactions. When the nurse knows the patient, it’s easier to pick up on non-verbal communication, such as mood, and facial expressions, and be able to identify any concerns and fears, thereby resulting in more effective care for patients [41, 42]. Today’s healthcare organizations struggle with providing continuous contact with the same healthcare professionals for patients, which potentially prolongs the effective recovery of TRD [43]. Clinics using ESK should prioritize staff continuity and strive to ensure that patients meet the same nurse to enhance the recovery process.

Patients in the current study reported positive outcomes from ESK, including reduced anxiety and improved ability to cope with daily activities, which helped them avoid negative thoughts and feelings. It is worth noting that some patients were uncertain whether their increased well-being was due to the medication per se or the nursing care and interactions with nurses. This underscores the importance of a person-centred approach to patients’ recovery.

As this study aims to describe patients’ experiences, a qualitative approach is advantageous, because it provides a nuanced picture of their experiences. The quality of qualitative studies is reviewed based on credibility, dependability, transferability, and confirmability [44]. A detailed description has been made based on the selection and analysis to enhance credibility. Twenty interviews were deemed sufficient for the purpose of the study, to discover similarities and variations in patients’ experiences. One limitation may be that most interviews were conducted digitally or over the phone, meaning that facial expressions and body language were missing. However, there are advantages to conducting interviews digitally, as it can be easier to share private information when there is a sense of anonymity and distance from the interviewer. Although two members of the research team had considerable experience as psychiatric nurses, the interviewer, LK, who conducted most of the interviews, had no prior experience of treating patients with ESK, nor any personal knowledge of the out-patient clinic – which enhances credibility. This study used an interview guide to ensure consistency in the questions asked and encourage participants to share their experiences freely, thus increasing dependability [45].

Diversity in terms of gender, age, and illness duration in this study encourages a breadth of experiences, which strengthens transferability [46, 47]. The study was conducted in a single clinic, which can affect transferability. Interviewing patients from multiple clinics with diverse environments, policies, and nurses would increase transferability [44]. Most patients responded well to treatment and had positive experiences with the care they received, expressing gratitude for the opportunity to try the treatment method. Therefore, it can be questioned whether critical perspectives, such as poor treatment outcomes or negative experiences, are underrepresented, and perhaps those who chose not to participate in the study opted out for this reason. TRD is a difficult condition to evaluate, as aspects such as compliance, other life events, the experience of previously failed treatments, the mood at interviews, etc., affect the patient’s experience of treatment and its effectiveness. Quotations are included in the Results section, to strengthen confirmability [46, 47].

To ensure trustworthiness, the study is reported in accordance with the Consolidated Criteria for Reporting Qualitative Research 32-item checklist [45].