Experiences of Eldercare Staff Working With Older People With Severe Mental Illness
Abstract
In Sweden, older persons living with severe mental illnesses (SMI) increasingly live independently in the community with support from informal and formal carers and welfare services. A proportion of this group is older people with SMI who, due to age or disability, receive municipal eldercare services such as home care in their ordinary housing, or in residential care. The situation and needs of this group demand that eldercare staff have an understanding for the older person’s situation and the tools to provide appropriate care. The aim of this present study is to explore the experiences of eldercare staff working with older people with SMI. Focus group interviews were conducted with staff from three residential care facilities and two home care teams in one mid-sized Swedish municipality. To analyse the interviews, qualitative content analysis was used. The overarching theme from the analysis was “Doing the best they can,” which was unpacked in two categories: “Working with fragmentary knowledge” and “Finding the right approach.” We could also see differences between the experiences of staff in residential care and in home care. The eldercare staff in our interviews faced lack of formal training, insufficient information and skills concerning mental illness and its treatment. Nevertheless, they tried to make the situation of the older people with SMI as good as possible using experiential and tacit knowledge. Our results also point to system level barriers that hinder effective care for older people with SMI.
Summary
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What is known about the topic
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In Sweden, as in many other countries, health and social care moved from institutions to homes and residential care in communities. Eldercare now includes care of older people with SMI who previously lived in mental institutions.
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Older people with SMI may require different kinds of supervision and personal care, as well as more care hours than older people with long-term somatic conditions.
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The complex needs of older people with SMI mean that staff working in eldercare should have education, information and tools to provide appropriate care.
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What does this paper add
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Eldercare staff face lack of formal training, insufficient information and skills concerning mental illnesses and their treatment.
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Eldercare staff strive to improve the situation of the older people with SMI through mobilizing various forms of knowledge and experiences to meet the group’s diverse needs.
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Organizational resources and barriers in providing quality care for older people with SMI differ between home care and residential care, in this study.
1. Introduction
Deinstitutionalization signified a shift in perspective regarding the locus of care for people with disabilities. The concept total institution [1]–manifested in places such as special schools, mental hospitals and institutions for older people–was replaced by disability acceptance and the concept of normalization [2],community-based psychiatric care through outpatient services [3], and residential choice and the principle of ageing in place [4, 5]. Today, persons with disabilities increasingly live independently in the community with formal care and welfare services as well as help from informal caregivers. This move from closed institutions to community care has also touched the lifecourse of people with severe mental illness (SMI). SMI is often defined through a psychiatric diagnosis with an illness duration of more than two years and causing a substantial impairment in functioning and in major life activities [6]. As with people with physical disabilities, many people with SMI now receive support for independent living at home or different forms of supported housing [7–9].
Following the era of deinstitutionalization, the life expectancy of people with SMI has increased [10], raising the important issue of community care for persons ageing with SMI. Older people with SMI not only face health challenges due to ageing but also specific challenges due to their illness [11]. They may also have difficulties in engaging in community social care [12]. Meanwhile, it is not uncommon for eldercare services to be offered even to “young-old” people with SMI because of premature biological ageing [13] and the higher risk of dementia [14]. Residential care has also had an increasing role for older people with SMI [15]. Some argue that this may lead to a kind of re-institutionalisation, as older people with SMI are often admitted despite a low need for residential care [16, 17]. Nevertheless, eldercare staff are more likely to have contact with older people with SMI. The situation and needs of this client group demand that eldercare staff have an understanding for the older person’s situation and the tools to provide appropriate care. However, research also shows that both eldercare staff and welfare professionals feel poorly prepared to work with older people with SMI [18, 19].
In Sweden, the organization of eldercare is decentralized and municipalities provide both residential and in-home care and service (“Health Care Act [20]”; “Old Age Care Reform Act [21]”; “Social Services Act [22]”). Municipalities are free to design different forms of support, but in practice tend to offer standardized old age care services such as personal security alarms, meals on wheels, escort service for mobility outside the home, daycare centres, short-term assisted living, home care and residential care. Often, the staff in home care teams and residential care consist of nurse assistants with a high school education who perform personal care, social care and domestic assistance [23]. In recent decades, the decrease in the number of places in residential care facilities and hospitals has led to an increase in older people receiving home care [24, 25]. Consequently, municipalities now provide social and health services to a population with diverse needs at home, and a population with more complex needs in residential care.
As for meeting the needs of people with SMI in Sweden, this has remained the responsibility of county councils after the Psychiatric Care Reform of 1995, while the responsibility for residential and social care belongs to municipalities in the same way as eldercare. In Sweden, 1% of the population, or about 80,000 people of different ages, have SMI [26]. Among adults with SMI in Sweden, there is a high rate of independent living in rented or owned housing [27, 28]. Municipal social services at home can include residential support for everyday activities [29, 30] and day centres for meaningful occupation [27]. Different forms supported housing, such as group homes, are also provided and run by municipalities [8].
This study is part of a larger project about the living conditions of older people with SMI (SMI-O) 25 years after the Psychiatric Care Reform in Sweden. Besides quantitative register analysis, the project involved qualitative studies where we have interviewed older people with SMI, representatives of mental health support organizations, and eldercare staff in one Swedish municipality. Using focus group interviews, the aim of this study was to explore the experiences of eldercare staff working with older people with SMI. Through learning their experiences—both the practice and challenges of providing care for older people with SMI—we hope to contribute to the long-term goal of improving the quality of services for the relatively invisible group of older people with SMI.
2. Methods and Materials
2.1. Recruitment of Participants
A purposive sampling of eldercare staff who work with older people with SMI was possible through a series of gatekeepers. After the Psychiatric Care Reform, Swedish municipalities were tasked to create registers over individuals in their area that had SMI and received care from the municipality, to map the group’s unmet needs in the community. We obtained permission from the Regional ethical review board (Ref. 2016/7–31) to access anonymized data on the ages and living situations of persons with SMI in one Swedish municipality. We then contacted the Head of Social Services in the municipality to help identify home care teams and residential care facilities that provided care for older people with SMI. First-line managers of two home care teams and three residential care facilities confirmed that they recently or currently have contact with older people with SMI. These sites were recruited into the study. The first-line managers, in turn, acted as gatekeepers to identify staff who could contribute to our research question. Twenty-one participants, all nurse assistants, gave their informed consent to participate in the study. The participants were all women, with between 1 and 37 years of experience in working in municipal eldercare.
2.2. Data Collection
Five focus group interviews were conducted, each with three to five participants from the same workplace. Two focus groups consisted of staff from home care teams and three focus groups consisted of staff working in residential care. One of the residential care facilities had a profile towards older adults with mental illnesses, although not all residents there had mental illness.
Focus group methodologies have developed in sociology and social psychology as a way to study social groups and group behaviour and have been used to study social interaction patterns, decision making, cohesiveness and other group dynamics [31]. Compared to individual interviews, participants in focus groups talk and interact in different capacities—sometimes talking as a member of the group and sometimes talking as one who shares a common ground with other groups [32]. The interactive data also lends itself to analysis, creating “a complex view of the social representations, opinions, arguments and positions of the focus group members” (Ibid, p. 320).
As a moderator in the focus groups, the researcher is far from a “witness” who observes facts, but rather takes part in the creation of interaction. To create a narrow focus and a rich discussion within a limited time, researchers can sometimes employ stimulus material to encourage group dialogue. Stimulus material could be objects, films, vignette cases, newspaper articles or even activities that provoke reflection about a topic that may otherwise be difficult to approach in a traditional interview setting. Depending on the stimulus material used, it could simulate an artificial situation within the group, encourage participants to take a standpoint or probe contrasting or different perspectives on a topic [33, 34].
Our focus group interviews began by letting participants read and discuss a newspaper article on an issue regarding mental illness and eldercare. For the focus groups in residential care, we chose a newspaper article debating whether residential care facilities exclusively for persons with mental illnesses should be established [35]. For the home care teams, we chose a debate article challenging the lack of focus on mental health within eldercare [36]. Our aims with the stimulus material were to allow participants to reflect about the topic in advance, and to provide a discussion platform open to multiple standpoints. Discussion questions about the stimulus material included: “What are your thoughts about the author’s argument that there should be specialized nursing homes for older people with SMI?” and “How do you feel about the author’s argument that ‘psychological illnesses come as second priority’ in eldercare?”
Additionally, a semistructured interview guide was used that focused more on the participants’ own experiences with older people with SMI in their workplace, as well as their strategies for identifying, reporting, preventing, or mitigating challenges related to the older person’s mental illness. Questions about participants’ own experiences were, for example: “How often do you meet clients with psychological distress, illness or SMI?”; “How do you find out if a client has psychological illness or SMI?”; “In home care, you meet many types of clients. How is it working with groups with different kinds of somatic and psychological support needs?”; and “Do you receive support or training in supporting older people with psychiatric illness?”
Two researchers were present in each focus group: one as moderator and the other as observer. This allowed the observer to take field notes, and the two researchers could also discuss preliminary insights with each other before discussing with the larger group. MA and PHB, with backgrounds in Social Work, were involved in the interviews with residential care staff. CJT and MEB, with backgrounds in Gerontology, were involved in the interviews with the home care teams. The focus group interviews lasted from 48 to 80 minutes. All focus group interviews were tape-recorded and transcribed verbatim by professional transcribers.
2.3. Data Analysis
We used qualitative content analysis [37] to analyse the data. This method involves repeated reading of the transcribed interviews, identification and condensation of meaning units, and labelling these meaning units into codes that represent an aspect of the phenomenon studied. CJT, MA and MEB discussed the transcribed interviews among themselves and brought their preliminary observations and insights to the whole research group. Condensation and initial coding were then done by CJT and MEB, with help from the other research group members when needed. Emerging codes were regularly discussed within the research group, whose members have varying backgrounds in Social Work, Gerontology and Psychiatry. This step is similar to peer debriefing [38], as it allowed other researchers to question and explore aspects of the emerging analysis. Similar codes were abstracted and merged into categories using a columned file and a mind-map, until all authors were in consensus about the categories. Finally, a theme was developed that runs through the categories and express the researchers’ interpretation of the underlying meaning [37].
2.4. Ethical Considerations
Recruitment using gatekeepers meant that the researchers had no knowledge about the participants’ level of experience with older people with SMI prior to meeting them. To ensure trustworthiness of the studied group and to gather informed consent, oral and written information about our study was provided to the individual participants again before the interviews. All participants confirmed their experience with older people with SMI and agreed to participate in the study. The researchers did not have any knowledge about the older people with SMI with whom the participants worked with, prior to the interviews. To maintain confidentiality, this article refrains from going into detail about incidents and diagnoses. Instead, we have chosen passages that convey a common meaning across participants’ experiences. The study and its design were approved by the Regional Ethical Board in Linköping (Ref. 2016/7–31).
3. Results
The overarching theme that emerged in the analysis was the notion of doing the best they can. This theme should be understood in the backdrop of the difficulties experienced when meeting older people with SMI. ‘Doing the best they can’ in this context could be interpreted in two ways. On the one hand, it was a way of presenting a professional attitude and code of conduct guiding professional practice regardless of the situation. On the other hand, it was a way of expressing a degree of frustration and helplessness while working in conditions that were not entirely favorable. These two different readings of ‘doing the best they can’ are further developed under two main analytical categories: Working with fragmentary knowledge and Finding the right approach (Table 1).
| Theme: doing the best they can | |
|---|---|
| Categories | Subcategories |
| Working with fragmentary knowledge | Working with missing facts |
| Partial knowledge, partial support | |
| Finding the right approach | Using experiential and tacit knowledge |
| Never having enough time | |
3.1. Working With Fragmentary Knowledge
The analytical category Working With Fragmentary Knowledge deals with the staff’s expression of frustration and helplessness over the lack of information and knowledge about mental illness of older people they meet in their daily work. They expressed that the mental illnesses of older clients were often undocumented in official case documents. Very often, instead of open communication and information, knowledge about mental illness was acquired through guessing and making judgments based on the interactions with and observations of the older persons.
3.1.1. Working With Missing Facts
When we meet a new client, it doesn’t really say anything [in the person’s information] about mental health or that they suffer from a mental illness, if it is not very apparent. We often get just a little background. And then once you start working and come into the person’s life, it’s then that you start to understand more and more that there is [an illness]. (Focus Group 5, Home care team)
The only information that we had was that [the client] has had psychiatric illness since being a 20-year-old. Yes, that was the only thing that was written there for us to see. (Focus Group 1, Residential care)
When the mental illness was documented, the participants also experienced that this was often written in a way that made it seem like a “cured disease,” with the history of previous contacts with psychiatric care but often no details on the current need for outpatient psychiatric care. Confidentiality between healthcare organizations and municipal organizations was given as one of the reasons for the absence of information, since medical records were not available to the municipal eldercare staff. The participants also felt that the stigma of mental illness may be an additional reason for why information was withheld. They reasoned that knowing about someone’s ongoing illness might lead care staff to feel uncomfortable, or have a prejudice that the older person might be difficult to care for. For example, one participant said that it might be good that she did not receive the information about the client’s mental illness beforehand and thus get “coloured by these impressions about the person.”
It’s also the case that relatives feel shame about their mother or father having a mental illness. But for us, it is hard to deal with it, when we don’t know anything about it. If we did, we could maybe have learned a little bit more about that diagnosis and made sure that the relatives also get good support. But they don’t talk about it, they feel shame (Focus Group 3, Residential care).
The [symptoms] of the mental illness–how should I say it–gets triggered by something and I would really like to know what it is, so [the person] doesn’t ever have to be in that situation. But I have no idea. (Focus group 1. Residential care)
Participants reported that sometimes, the older person openly told them about their diagnosis and experiences as a psychiatric patient, but only after a time. Other older persons, however, did not want to talk about their mental illness at all.
3.1.2. Partial Knowledge, Partial Support
In all focus groups, the participants conveyed that they often met individuals with mental health conditions that did not appear to have been properly diagnosed or treated by the appropriate medical staff. Depression and anxiety disorders are frequently underdiagnosed in older adults [39], including in those with SMI for whom mood and anxiety disorders may co-occur with mental illness [40]. While the staff suspected untreated disorders, they were often unsure of what to do and where to report their worries. Some said that they often meet a general assumption that eldercare staff “just know” how to deal with symptoms of mental distress, even though their actual training varied.
I know that many years ago, there was a psychiatric team that went here. But I mean that was a long time ago. A small group went here, and they talked to the person, and they talked to us, and they trained us. But I haven’t seen that happening for many, many years now. (Focus group 1, Residential care).
I wish that we had a staff meeting on mental illness, because now I’m thinking about the situation with [a client with SMI] and we need to talk about this together, as a staff. If I were newly employed here, I would want to have that. (Focus group 3, Residential care)
I think I need mentoring in psychiatry. Sometimes there are tricky situations, and I don’t have enough training. We don’t have any, in fact. I wish we had more knowledge and more mentoring in specific situations, like how to approach and react. (Focus group 4, Home care team).
Participant 1: We don’t really have the education for everything we face. In home care, we have all sorts of clients [and situations]. Mental illness, co-morbidity, disabilities, substance abuse. All sorts of things.
Participant 2: And it’s as if we are expected to know about all these
Participant 1: Yes, it’s as if we are expected to know about all these. (Focus Group 5, Home care team)
In this case where [the older person with SMI] is refusing any help, we could maybe talk to our boss about it because I don’t know how to reach out to [the client], I really don’t know. (Focus group 4, Home care team)
When I’ve just come back [to our headquarters] from a difficult situation and a colleague comes in, I think that I’d really appreciate talking to someone about [this particular client]. But you know, it’s break time. So I think, “take it easy, don’t bring it up.” Besides, we should prepare by getting keys [for the next client] ready, and have time to eat (Focus group 5, Home care team).
3.2. Finding the Right Approach
The challenging working conditions resulting from the lack of adequate and coherent information about mental illness as well as the overall lack of skills regarding care of mental health patients did not however prevent the staff from trying different strategies and solutions to challenges experienced in their daily work activities. Both individual and collective approaches were underpinned by notions of professional conduct and use of various types of knowledge.
3.2.1. Using Experiential and Tacit Knowledge
I’m pretty good. I am [the client’s] contact person among the staff. And I’ve become good at finding ways to encourage her to take her meds. But today she just refused and said no, and the situation turned, and things started to happen. The situation calmed down just a while ago. (Focus Group 3, Residential care)
It can be in the care plan, the contact with psychiatric care. For example, that someone was admitted in the hospital, or is suffering from something. But how to approach that person in the best way? It’s really hard. We [in the home care team] are all different, and the [client] needs specific help and we get very little information. Just “now you will go to Karl, and then you will go to Pete” and there is so little written information, you know. So often it boils down to your own competence, however little or big your experience is. We try to share our knowledge with our colleagues. Like, “we did this and that, and that seems to work well. We did this other thing, and you shouldn’t do that.” It’s more like tips and tricks on how to have the best approach and it’s really very hard, a lot of times. (Focus Group 4, Home care team)
We talk to each other about these different “keys” and finding the right one in different situations. So we talk and say, “That went well for me,” and “Sure, I can test that next time” and it goes well. So you have to find the right key to bring out [the client with SMI’s] motivation (Focus group 2. Residential care).
It’s a kind of tacit knowledge. You start to read the body language. And when you’ve had many years of experience on your back, you can see it almost directly when you open the door: “Whoops, it’s not her good day.” I can’t explain it sometimes, but I know when something’s not right. And often, the gut feeling is correct. So I know how to respond and how to act. It’s not the kind of knowledge that’s easy to teach to others. You can’t always say that the situation will be the same another time. This knowledge just sits with you somehow. After many years. (Focus group 4, Home care team)
3.2.2. Never Having Enough Time
Participant 1: It takes a lot of time to sit and drink coffee with someone to calm them down, but you have to. It can also be that you’re about to do something simple, like help [the client with SMI] with dressing up, but it becomes a very big task suddenly because he is not feeling well. We do what we can in all situations, we do our best.
/. ./
Participant 2: You notice it after a while. [The client] is not feeling so well and then it just escalates, and it clear that he needs help. And in those situations, well it often helps just to make him a sandwich and a coffee, let him talk it out, and I’ll just be there, listening. (Focus group 2, Residential care).
The participants said, however, that it was not always possible to make time to meet the psychosocial and mental health needs of people with SMI. Home care visits are often time-constrained, and participants could not leave the next client waiting. Situations like these sometimes placed the home care staff in a dilemma about how to best leave the older person with SMI. Even in residential care, other residents with multiple diseases required medical help and daily care from the staff. Some participants reported that residents experiencing psychological distress would sometimes ring the emergency alarms repeatedly, which added to the staff’s work stress.
Participant 1: We used to have 15 minutes of staff meeting before starting the day, but they took that away.
Participant 2: They took it away so we could be as effective as possible. We stamp in at 8:30AM and preferably be at the door of the client at 8:36. So there’re only just time to pick up the client’s keys and such.
Participant 1: Yes, so it is our own responsibility to find time to read the client’s file in the electronic system, here at the computer. It was better before when we had a whole 15 minutes to prepare. There’s only that computer, so sometimes we queue for it.
Participant 3: It came creeping. They started shortening the morning meeting first, and then they took it away for good.
Participant 1: So now we just try to catch each other when we’re on our way to the bike stands, and “Wait up, I have something to tell you about that client yesterday…” (Focus group 4, Home care team).
Participant 1: I think that staff from disability services would have an easier time reaching out [to clients with SMI]. They are often a small group, not 30 people like in our team. And they have more training in this area and more time.
Participant 2: Yeah, more time. We go in and out [of different people’s houses]. We’re often there just 15 minutes at a time. I don’t think disability services have that time limit.
Participant 3: And that way, the person can get another kind of support. We don’t have the education; we’re not used to dealing with people with mental illness. The disability services surely have people with the right education and training. We don’t. Instead, it’s like “Here you are, go inside the door and do what you can.” (Focus Group 5, Home care team)
As the above quote is an example of, the participants often recognized their own and their organizations’ limitations. Unfortunately, participants also reported that self-insight has not always led to changes in their work situation, and they pointed to larger organizational problems that needed to be addressed.
4. Discussion
In this study of eldercare staff’s experiences of working with older people with SMI, participants shared experiences of working with fragmentary knowledge, with missing facts about the older person with SMI and only partial knowledge and support. The eldercare staff interviewed in this study nevertheless demonstrated that they mobilized different solutions to the challenges they experienced in their daily work activities. Finding the right approach, through experiential knowledge, was important to give personalized care. The overarching theme we found was that the eldercare staff were doing the best they can, using tacit experience to navigate a work landscape with different knowledge, resource and organizational barriers.
4.1. Knowledge Work Requires Time
The categories from our analysis were found across all focus groups, but we also found differences between the experiences of staff in residential care and home care teams, for example, regarding knowledge sharing. Tacit knowledge gained through interpersonal relationships and long experience with clients is often overlooked in assessments in quality of care [41]. The situations of different care staff as described in this article provide more evidence of the potential and use of tacit knowledge in care contexts [42]. The participants’ descriptions of “tuning in” and different types of knowledge “sitting in” serve as examples of using bodily practices for the purpose of learning and creating new knowledge. This, as Kontos and Naglie [43] point out, is an important component for understanding how tacit knowledge is experienced, shared and learned. The collective process of knowledge sharing can partly explain the differences between the experiences of residential care staff and home care staff.
Quinlan [44] introduced the concept of knowledge work to recognize the primacy of knowledge in care work. Knowledge work is a concept used to explicate a collective process, including formal and informal interactions, whereby new knowledge is created, transferred, and applied. Crucial to that process is an exchange and open communication that makes it possible to use various forms of tacit knowledge for the purpose of building new knowledge (ibid.). The residential care staff in our interviews reported having more training and more collegial dialogue than home care staff. Because of a more collective approach in work meetings and because they worked closely in the same building, they had more opportunities to draw on collective knowledge. In contrast, the home care staff often performed care duties on their own in the clients’ homes. They also experienced more time constraints and less opportunities for sharing their experiences, especially after their morning team meetings were eliminated by the administrators. This hampered teamwork and made the home care staff feel that they were left to their own resources.
4.2. Differences in Home Care and Residential Care
Previous research has questioned whether residential care facilities are appropriate places of care for people with SMI or whether these housing forms represent re-institutionalization in old age, rather than full integration of people with SMI in the community [45]. We did not see evidence of re-institutionalization in our study. However, our study showed that receiving home care as an older person with SMI can likewise be problematic. Working within home care in Sweden has been likened to precarious work characterized by shift work, low pay, insufficient time for scheduled tasks, limited possibilities for skills development and job control, and a worry that clients do not receive adequate care [46]. The job content of home care has moved—as our participants also confirm—towards more instrumental care within very short windows of time, at the expense of emotional aspects of work [47]. A Swedish study previously showed that differences in leadership and work shift structure between home care and residential care have an impact on the quality of care [48]. In our study, this could be seen in the differences in the residential and home care staff’s access to training, mentoring and time for care planning and care turnovers. Accordingly, the home care staff in our study felt especially unable to meet the psychosocial and mental health needs of older people with SMI as they worked in an organization characterized by working alone, short home visits, short handovers and lack of support.
4.3. Mental Health in Eldercare
Regardless of whether the participants worked in home care or residential care, they agreed that the focus on daily time-constrained instrumental tasks overshadowed older individuals’ social and psychological needs. Repeatedly, the interviews pointed to system-level barriers that limited the effectiveness of the eldercare staff in providing quality care. Some of these system-level barriers concern the lack of visibility of mental health issues in eldercare, which still seems tightly bound to caring for somatic illnesses and focused on everyday instrumental care. The fact that mental illness was not described in the clients’ care plans is an indication of this. The invisibility of mental illness was also compounded by stigma experienced by relatives and the larger problem of lack of coordination and communication between healthcare and social care services. Because the eldercare staff did not have access to medical records, there was sometimes no way of knowing about the client’s SMI, hindering an understanding of the older person’s situation. There is also a lack of integration between eldercare services and disability services, which was pointed out by several participants. All this suggests a wider issue of the “absence” of prioritization of mental health issues within eldercare. Our participants identified their need for more training, more workplace support and more time, indicating awareness that knowledge through experience—although important and valuable—was not enough.
4.4. Implications for Practice
Regardless of whether care is provided in a person’s home or in residential care, an important implication that we draw from our results is the importance of providing eldercare staff with education about mental illness and its treatment. Information about the specific mental health condition of a client and the difficulties that this may involve in the person’s daily life is an important prerequisite for a sense of coherence for the staff, but also for providing appropriate care for the older person with SMI. Our participants thought working with older people with SMI was challenging, not because of how that group of people were, but because of lack of information that hampered their preparedness for working with their clients. Besides education on specific diagnoses, there should also be an increased awareness that older people in eldercare can experience mental illness and poor mental health, which require specific forms of action from the staff.
Another important implication for practice that could be gleaned from our results is the importance of allowing sufficient time for the social and psychological aspects of care. To increase the quality of care for older people with SMI, eldercare staff must have sufficient time to meet and plan services, and sufficient time to meet client mental health as well as basic residential care during home care visits. These require organizational changes that would prioritize quality of care relationships over efficiency within eldercare. Previous studies have criticized how diminishing time resources, together with the expectation to do ever more minute care tasks in eldercare, negatively affect care staff’s work environment [47, 49]. From the interviews, there is reason to believe that eldercare staff working with older people with SMI face similar, if not more difficult, challenges and ethical dilemmas. We mentioned in the beginning of the article that Swedish municipalities have a flexibility to design different forms of care, even though the services offered have become more or less standardized in practice. With eldercare staff facing new populations with complex needs such as older people with SMI, a future challenge would be to further integrate disability and psychiatric perspectives within eldercare.
5. Methods Discussion
In each focus group, the participants were colleagues belonging to the same workplace. An advantage of such a constellationg is that it allows participants to talk about problems and situations that they all could relate to. A disadvantage may be that the focus group may reproduce the hierarchical communication structures in the workplace and that shared understandings could prevail over information not agreed upon by all group members [50]. In all focus groups, the participants were all nurse assistants, but there was a wide difference when it came to the number of years in the profession, which may have influenced the discussion based on a feeling of “seniority.” Inevitably, the participants talked about their length of experience when talking about strategies they used. However, this also gave us the advantage of being able to compare experiences of new and old staff in the same workplace.
In focus groups with members that are familiar with each other, another disadvantage may be that participants become self-conscious of what they share. They may be less likely to talk about difficult issues or feel pressure to sound positive about how they handled their own experiences. Our intention in using stimulus material was that these articles could bridge some of the difficulties of talking about sensitive issues such as the appropriateness of caring for people with SMI in residential care, without first asking participants to reveal their experiences. Our impression was that the focus groups were characterized by an open discussion. The researchers tried to ensure the spread of the group discussion between members. Overall, it is hard to judge how participants could have affected each other’s answers.
6. Conclusions
Eldercare staff in home care and residential care are more likely to work with older people with complex needs. Our study, based on the experiences of eldercare staff working with older people with SMI, underlines that there needs to be better integration of mental health issues in eldercare across the board. Although tacit knowledge was an important tool used by participants in order to give personalized care, our study revealed problems linked the stigma of mental illness, the staff’s feelings of inadequacy and incompetence, and the lack of training, communication and support. Differences in the organization of work between residential care and home care also reveal the importance of making time for the planning, discussion and execution of social and psychological aspects of care of groups such as older people with SMI. Despite the important role of experiential and tacit knowledge, our participants identified their need for more training, more workplace support and more time, indicating awareness that knowledge through experience was not enough. Coordination between healthcare, social care and disability services in training, supervising and planning care, could be a way forward.
Conflicts of Interest
The authors declare no conflicts of interest.
Funding
This work was supported by FORTE, the Swedish Research Council for Health, Working Life and Welfare (Grant number STYA-2015/0003) during 2016-2021.
Open Research
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
