Structured pro-active care for chronic depression by practice nurses in primary care: a qualitative evaluation.

Madeleine Bennett,Kate Walters,Vari Drennan,Marta Buszewicz,Christy Elizabeth Newman

doi:10.1371/journal.pone.0075810

Madeleine Bennett, Kate Walters + Show 3 more

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https://doi.org/10.1371/journal.pone.0075810

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Abstract

PurposeThis qualitative study explored the impact and appropriateness of structured pro-active care reviews by practice nurses for patients with chronic or recurrent depression and dysthymia within the ProCEED trial.ProCEED (Pro-active Care and its Evaluation for Enduring Depression) was a United Kingdom wide randomised controlled trial, comparing usual general practitioner care with structured ‘pro-active care’ which involved 3 monthly review appointments with practice nurses over 2 years for patients with chronic or recurrent depression.MethodIn-depth interviews were completed with 41 participants: 26 patients receiving pro-active care and 15 practice nurses providing this care. Interview transcripts were analysed thematically using a ‘framework’ approach.ResultsPatients perceived the practice nurses to be appropriate professionals to engage with regarding their depression and most nurses felt confident in a case management role. The development of a therapeutic alliance between the patient and nurse was central to this model and, where it appeared lacking, dissatisfaction was felt by both patients and nurses with a likely negative impact on outcomes. Patient and nurse factors impacting on the therapeutic alliance were identified and nurse typologies explored.DiscussionPro-active care reviews utilising practice nurses as case managers were found acceptable by the majority of patients and practice nurses and may be a suitable way to provide care for patients with long-term depression in primary care. Motivated and interested practice nurses could be an appropriate and valuable resource for this patient group. This has implications for resource decisions by clinicians and commissioners within primary care.

Highlights

Chronic and recurrent depression are very common [1,2] and are often solely managed in primary care[3]
Three main themes emerged from the thematic analysis: (1) The experience of proactive care reviews, (2) the therapeutic alliance and (3) practice nurses as case managers for depression
Sometimes if patients had not followed up the suggestions made, this could lead to frustration for the nurse and resultant disharmony in the consultation. This qualitative exploration of both patient and nurse experiences highlights the potential role that practice nurses may be able to play in providing on-going pro-active care for patients with recurrent and chronic depression

Summary

Introduction

Chronic and recurrent depression are very common [1,2] and are often solely managed in primary care[3]. The collaborative care approach was developed in the United States (US) as a way to improve the management and outcomes of people with acute major depression in primary care[8,9,10] Central to this approach is the role of the case manager who proactively follows up patients, assesses adherence to psychological and pharmacological treatments, monitors their progress and takes action when treatment is unsuccessful. In contrast to the US approach in which combinations of three distinct professional groups work collaboratively in a primary care setting (i.e. case manager/ practice nurse, primary care practitioner and mental health specialist) [8,9,10] the ProCEED trial focused on the practice nurse as a case manager within a chronic care model This is similar to their widespread role within the United Kingdom (UK) in monitoring and reviewing other long term conditions such as diabetes and COPD, and could be more implemented in primary care settings using existing staff

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