Introduction
Older adults, 65 years of age and older, living in long-term care (LTC) frequently experience anxiety symptoms and disorders (Creighton, Davison, & Kissane, Reference Creighton, Davison and Kissane2016). Anxiety can result from disorders such as generalized anxiety disorder, may present as a neuropsychiatric symptom in dementia, or could represent an acute response to an event (Cerejeira, Lagarto, & Mukaetova-Ladinska, Reference Cerejeira, Lagarto and Mukaetova-Ladinska2012; Creighton et al., Reference Creighton, Davison and Kissane2016; Fagundes et al., Reference Fagundes, Costa, da Silva Alves, Benício, Vieira and Carneiro2021). In residents of LTC, anxiety is associated with negative outcomes including poorer well-being and higher use of health care services (Goyal, Bergh, Engedal, Kirkevold, & Kirkevold, Reference Goyal, Bergh, Engedal, Kirkevold and Kirkevold2018; Smalbrugge et al., Reference Smalbrugge, Pot, Jongenelis, Gundy, Beekman and Eefsting2006).
Anxiety in residents of LTC is often under-detected and under-treated (Bor, Reference Bor2015; Creighton, Davison, & Kissane, Reference Creighton, Davison and Kissane2018; Koychev & Ebmeier, Reference Koychev and Ebmeier2016). The medical complexity of residents resulting from advanced age, frailty, and medical co-morbidities can make anxiety difficult to detect and, as a result, difficult to treat (Canadian Institute for Health Information, 2020; Pifer, Segal, Jester, & Molinari, Reference Pifer, Segal, Jester and Molinari2020). The lack of evidence supporting approaches to anxiety detection and treatment in LTC was identified as a gap in knowledge (Katzman et al., Reference Katzman, Bleau, Blier, Chokka, Kjernisted and Van Ameringen2014).
In response to the lack of guiding evidence, two systematic reviews were first completed to (1) identify all anxiety detection tools validated against established diagnostic criteria (i.e., Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classifications of Diseases) within LTC (Atchison, Shafiq, Ewert, Leung, & Goodarzi, Reference Atchison, Shafiq, Ewert, Leung and Goodarzi2022), and (2) identify all treatments for anxiety trialled in LTC (Atchison, Watt et al., Reference Atchison, Watt, Ewert, Toohey, Ismail and Goodarzi2022). The Geriatric Anxiety Inventory (GAI) (Creighton, Davison, & Kissane, Reference Creighton, Davison and Kissane2019) and the Hospital Anxiety and Depression Scale-Anxiety (HADS-A) (Creighton et al., Reference Creighton, Davison and Kissane2019) had adequate sensitivity and specificity for use in LTC (Atchison, Shafiq, et al., Reference Atchison, Shafiq, Ewert, Leung and Goodarzi2022). Many low-risk, non-pharmacological treatments but few pharmacological treatments for anxiety management in the LTC population were identified (Atchison, Watt, et al., Reference Atchison, Watt, Ewert, Toohey, Ismail and Goodarzi2022).
After identifying evidence-based detection tools and treatments for anxiety, it is critical to understand the behaviours that may influence how evidence-based care is implemented. Behaviour change theories are an important resource that can inform behaviour change interventions for implementing evidence-based practice (Abraham, Kelly, West, & Michie, Reference Abraham, Kelly, West and Michie2009). The Theoretical Domains Framework (TDF) is a validated behaviour change framework with 14 behavioural domains that address intervention implementation (Cane, O’Connor, & Michie, Reference Cane, O’Connor and Michie2012). Each behavioural domain has related constructs and interview questions. The interview questions address the behaviours underpinning actions and can be used in qualitative work to identify and understand problems behind a given practice (Cane et al., Reference Cane, O’Connor and Michie2012). All TDF domains and related behaviours can be directly linked to the Capability, Opportunity, Motivation, and Behaviour (COM-B) model of the Behaviour Change Wheel (BCW) (Michie, Van Stralen, & West, Reference Michie, Van Stralen and West2011). The BCW maps each COM-B source of behaviour to intervention functions and policy categories (Michie et al., Reference Michie, Van Stralen and West2011). The BCW can be used to select tailored interventions that address identified behaviours, allowing for evidence-informed implementation strategies (Michie et al., Reference Michie, Van Stralen and West2011). Mapping behaviours to the domains of the TDF is the first step in understanding behaviours that are barriers to implementing evidence-based anxiety management strategies and developing interventions that improve the implementation of these strategies (Michie et al., Reference Michie, Van Stralen and West2011).
Having synthesized the existing evidence for anxiety management in LTC, it is important to understand why particular interventions may or may not be used in practice. It is essential to understand the barriers to and facilitators of anxiety detection and treatment in LTC in order to identify behaviour change interventions that can improve the implementation of evidence-based care for anxiety. The purpose of this study was to understand care providers’ perspectives on the barriers to and facilitators of anxiety management in LTC to inform future behaviour change interventions.
Methods
Population and Context
LTC was defined as facility living with 24/7 registered nursing support (Government of Alberta, 2017). Residents of LTC have care needs that exceed that of those accessing in-home or designated supportive living (e.g., assisted living) services. For this study, nurses included advanced practice nurses, registered nurses, licensed practical nurses, or health care aides. Physicians were defined as general practitioners, general practitioners with a care of the elderly designation, geriatric psychiatrists, geriatricians, palliative care physicians, or nurse practitioners. Allied health professionals included social workers, occupational therapists, physiotherapists, or recreation therapists.
Interviews took place during the second wave of the COVID-19 pandemic in Alberta, between January and March 2021. Participants were asked to speak about anxiety management in LTC generally but were able to discuss how the COVID-19 pandemic had altered typical procedures.
Participant Recruitment
Care providers were recruited using purposive snowball sampling methods (Green & Thorogood, Reference Green and Thorogood2018; Patton, Reference Patton1990). The study team identified clinical managers who distributed recruitment materials via e-mail within their networks. Participants were also encouraged to share the study within their respective networks (Green & Thorogood, Reference Green and Thorogood2018; Patton, Reference Patton1990). Recruitment e-mails included the research team’s contact information, the study poster, and a one-page description of the study.
All interested participants contacted the study team directly via e-mail to receive more details about the study and complete the informed consent process. Interviews were scheduled for a day and time selected by the participant. Eligible participants were care providers in LTC settings, fluent in English, and able to provide informed consent. No restrictions were placed on the location within Alberta or the characteristics of the LTC facility in which the participant practiced. All participants who contacted the research team completed interviews included in the analysis.
Data Collection
The semi-structured interview guide was informed by findings from the anxiety detection (Atchison, Shafiq, et al., Reference Atchison, Shafiq, Ewert, Leung and Goodarzi2022) and treatment in LTC systematic reviews (Atchison, Watt, et al., Reference Atchison, Watt, Ewert, Toohey, Ismail and Goodarzi2022) as well as the interview questions within the TDF to address specific sources of behaviour (Michie et al., Reference Michie, Johnston, Abraham, Lawton, Parker and Walker2005). The interview guide addressed how anxiety is detected, diagnosed, and managed with pharmacological and non-pharmacological treatments in LTC. The interview guide was reviewed by knowledge users to ensure that questions sufficiently addressed anxiety management in LTC.
Demographic and interview data collection was completed by one researcher. Interviews were audio-recorded, took place over the phone, and lasted 30–60 minutes. Before each interview, demographic data were collected to describe the participants’ age, gender, role in LTC, time spent working both in their role and in LTC, and whether they practiced in multiple LTC facilities. Interviews were transcribed verbatim with identifiable information removed. Transcripts were reviewed for completeness by one researcher.
Data Coding and Analysis
A framework analysis approach was selected to facilitate comparison across and between cases as well as to produce practice-oriented findings (Gale, Heath, Cameron, Rashid, & Redwood, Reference Gale, Heath, Cameron, Rashid and Redwood2013; Green & Thorogood, Reference Green and Thorogood2018). The five steps of framework analysis (familiarization, identification of a thematic framework, indexing, charting, and mapping and interpretation) were followed (Gale et al., Reference Gale, Heath, Cameron, Rashid and Redwood2013; Green & Thorogood, Reference Green and Thorogood2018).
First, interview transcripts were read to promote familiarization with the data. During thematic analysis, interview transcripts were inductively coded line by line and then reviewed by two independent reviewers. A third reviewer independently confirmed coding using a sub-sample of transcripts. Lines could be assigned multiple codes to capture the meaning in the data. Initial interview coding occurred independently of the TDF.
Interviews were coded in NVivo© as they were completed (QSR International Pty Ltd., 2020). Participant sampling ceased when there was repetition in the codes identified and no new codes were identified within progressive interviews (Green & Thorogood, Reference Green and Thorogood2018). Codes were classified within the TDF and labelled as a barrier to or facilitator of anxiety management. Codes were assigned to the TDF by one researcher and verified independently by a second researcher. Each code was assigned one primary TDF domain to promote the feasibility of actionable results for future implementation. Each domain of the TDF was linked to the corresponding component of the BCW to support the future identification of evidence-based interventions (Michie et al., Reference Michie, Van Stralen and West2011).
The two primary analysts were a graduate student (K.A.) new to the LTC area of study and an academic geriatrician (Z.G.) with expertise in treating dementia and in clinical care for older adults, whereas the third analyst (A.M.T.) was a qualitative researcher with training in gerontology. The present research was approved by the University of Calgary Conjoint Health Research Ethics Board (REB20-1077) and reported according to the COnsolidated criteria for REporting Qualitative research (COREQ) checklist (Tong, Sainsbury, & Craig, Reference Tong, Sainsbury and Craig2007).
Results
Participants
Ten interviews with care providers practicing in the LTC setting were completed. Interviews were completed with physicians or nurse practitioners (Group 1; n = 5) and nurses or allied health professionals (e.g., social workers, occupational therapists) (Group 2; n = 5). Demographic details of participants are presented in Table 1.
Table 1. Characteristics of participants completing interviews
Barriers to and Facilitators of Anxiety Management
The results are presented based on barriers and facilitators at the resident, provider, or system level. Codes at each level were grouped based on common themes identified throughout the data related to anxiety detection, diagnosis, treatment planning, pharmacological or non-pharmacological treatment, or overall anxiety management. The themes identified and related codes are displayed in Table 2. All codes, classified within a TDF domain, have been reported for anxiety detection or diagnosis (Table 3) and treatment (Table 4). A matrix of all codes by case, either physicians and nurse practitioners or nurses and allied health professionals, is reported for each domain of the TDF (Supplementary Table S1).
Table 2. Themes and codes within each theme labelled as a barrier or facilitator, organized by themes at the resident, provider, and system level
Table 3. Codes related to anxiety detection and diagnosis mapped to the domains of the Theoretical Domains Framework and linked to the COM-B model
Table 4. Codes related to anxiety treatment planning, pharmacological and non-pharmacological treatment, and management mapped to the domains of the Theoretical Domains Framework and linked to the COM-B model
Resident-level barriers and facilitators
The presence of cognitive impairment or co-morbidities in residents was identified as a factor that added to the complexity of anxiety detection, diagnosis, treatment planning, and management with either pharmacological or non-pharmacological treatments.
…And the fact that they often have cognitive impairment or dementia, and that does make the diagnosis more difficult. – Participant 1; Group 1
Participants identified resident-level risks or factors such as polypharmacy and variable responses to medications as barriers to pharmacological treatment. The ability of residents to engage in activities and challenges with leaving the facility to access interventions such as psychotherapy were identified as barriers to non-pharmacological treatment. Residents who could communicate changes or symptoms facilitated the detection and diagnosis of anxiety. Anxiety detection, diagnosis, and treatment planning were facilitated by care providers being familiar with the resident, knowing their history, and noticing changes.
Having a motivated staff and team on the unit who know the patients well and can recognize those non-verbal cues and triggers. – Participant 2; Group 1
Utilizing collateral sources to obtain information about the resident helped providers personally know the resident and facilitated anxiety detection and diagnosis, while having a baseline understanding of the resident facilitated the ability to consult specialized services. Diagnosis and treatment planning were facilitated by care providers making individualized diagnoses and individualized treatment plans:
I think it should be an approach that works best for them that matches their needs and matches where they’re at. – Participant 10; Group 2
Provider-level barriers and facilitators
Care provider education was identified as a barrier to anxiety detection, diagnosis, pharmacological treatment, and general management. Education for staff was necessary for them to be able to use screening tools, detect anxiety in residents, and advocate for a diagnosis as needed.
A poor understanding of how pharmacological treatments worked and unrealistic expectations for pharmacological treatments were identified as barriers to using pharmacological treatments. Participants voiced uncertainty about frontline staff’s training in anxiety detection and management and noted that the personal assumptions and beliefs of staff were barriers to providing education to staff.
… I find in general staff want a quick fix so they want a medication that’s going to work quickly and work well, and that generally doesn’t exist. So, I think the challenges are just managing realistic expectations about treatment. – Participant 5; Group 1
Provider-level beliefs that anxiety disorders are not common in LTC and that an anxiety diagnosis was only relevant if resources were available to manage it were barriers to diagnosing anxiety. Providers being unfamiliar with different treatment options was identified as a barrier to anxiety treatment planning, while titration challenges and increased paperwork for staff were noted barriers to pharmacological treatment.
Participants noted that it could be challenging to get staff to implement care plans and non-pharmacological treatments. Issues with implementing care plans were attributed to a lack of uptake of the treatment suggestions made by mental health specialists, a lack of staff capacity and/or time, and non-pharmacological treatments not being prioritized by staff or not being offered if family was present, as this was deemed unnecessary for residents occupied with family.
I do find non-pharmacological stuff does not get implemented as much…we do find it a bit harder just because of people remembering or, you know, losing track of time, getting tied up with a million other things that they’re doing. Those are the types of things that get missed or are less of a priority by day-to-day staff. – Participant 8; Group 2
Participants identified that pharmacological treatments could not adequately address anxiety when used alone, but noted a general reliance on pharmacological treatments given the lack of other supportive, non-pharmacological therapies.
Staff well-being was a noted barrier to anxiety management and included the impact of staff anxiety on residents, how resident anxiety was time and energy consuming for staff, and how burnout in staff led to a lack of interest in delivering new treatments.
… there’s been instances even where the staff might be anxious about working with some of the residents or just anxious about going to work in general with the pandemic and that has been difficult in terms of engaging the staff to try and implement some of the interventions… – Participant 10; Group 2
Professional attributes including active listening, clinical observation, and interview skills facilitated anxiety detection. Completing global assessments or clinical interviews was also identified as facilitating anxiety detection and diagnosis. Providers attempting to understand why treatment plans were not implemented and their willingness to use trial and error facilitated treatment plan development.
I think because the anxiety is so multi-factorial, that there is no one treatment that works for everyone and there’s a lot of trial and error in figuring out the treatment plan. – Participant 2; Group 1
The importance of having a dedicated, engaged staff who cares about residents as well as the importance of support, follow-through, and accountability by front-line staff was noted. Multidisciplinary coordination, family involvement, and trusting relationships between residents and staff were noted as being key to anxiety management. Communication was also identified as a facilitator of non-pharmacological treatment and overall management of anxiety, and included adding non-pharmacological treatments to the care plan, talking with residents’ social networks to identify treatments, staff helping educate family on approaches for anxiety management, and communication within teams.
Participants identified that anxiety was optimally managed by pairing pharmacological and non-pharmacological treatments together, and highlighted that anxiety, whether diagnosed or not, should be managed. It was noted that non-pharmacological treatments were used as the first line of treatment, to address the root cause of anxiety, manage temporary anxiety, and treat anxiety secondary to dementia or related behavioural symptoms. Participants often suggested that anxiety was informally managed through the approach or manner in which staff delivered care.
Providers’ knowledge about medication safety measures, including being transparent about the risks and benefits of treatment, valuing the resident’s quality of life over ease of care, knowledge of medication profiles, and regular medication reviews and monitoring facilitated pharmacological treatment. Pharmacological treatment was identified as being utilized as the first line of treatment based on the clinical training of nurses and physicians and the ease of delivery. Participants identified that pharmacological treatments were important for anxiety management and may be especially appropriate for residents with severe anxiety symptoms. Antidepressants were identified as the first line of pharmacological treatment, but the use of antipsychotics was suggested for use with severe behaviours and benzodiazepines were used for quick effects.
… there’s a need and a purpose for anti-anxiety medications. I’m not a fan of benzos [benzodiazepines]. I won’t use those in seniors because of the side effect profile but … say we’re going to start an SSRI [selective serotonin reuptake inhibitor] of some kind if there’s no contraindications, then we will start a low dose, go slow, monitoring. – Participant 9; Group 1
System-level barriers and facilitators
Environmental factors specific to LTC such as rooms with multiple occupancies and the medicalized environment were barriers to anxiety management. Participants identified that a home-like environment with natural lighting and a safe space to go outside would facilitate anxiety management.
Access to resources was identified as a barrier to anxiety detection, treatment planning, and pharmacological and non-pharmacological treatment. Anxiety was not routinely screened for in residents, with a noted lack of resources such as valid screening tools or the availability of tools required to complete a full assessment.
I actually don’t think I ever have [used anxiety detection tools] as part of my protocol … I don’t know if any of my colleagues use anything official. – Participant 8; Group 2
Access was identified as a barrier to non-pharmacological treatment and anxiety management and included issues related to limited availability of non-pharmacological treatment options, lack of psychotherapy in LTC, and limited facility funding and capacity of staff and facility management. Participants identified the funding model within LTC and a lack of resources available for staff to manage anxiety, including champions to ensure consistent delivery of interventions, in-house expertise in anxiety management, and variable access to resources among LTC sites as barriers to anxiety management.
… the availability of the resources and the ability to implement particularly non-pharmacological treatments would be a challenge [to treatment planning], and probably access to resources and specialty care for more complex cases. – Participant 7; Group 1
Participants did, however, identify that access to specialist resources or community supports facilitated the use of non-pharmacological and pharmacological treatments as well as anxiety management. Mental health specialists were able to support the treatment and management of complex cases as well as provide tailored education for staff, model interventions for staff, and provide site-specific recommendations.
Culture and the stigma around treating anxiety were noted barriers to diagnosing anxiety, the use of pharmacological and non-pharmacological treatments, and anxiety management. Culture, which included how society views anxiety as the responsibility of the individual (making it hard to treat) and how mental health issues are not yet normalized in LTC, was identified as a barrier to anxiety management.
The stigma associated with pharmacological treatments was a recognized barrier and included family’s hesitancy regarding pharmacological treatment, staff worries about certain pharmacological treatment options, and how a formal diagnosis impacted how pharmacological treatment was viewed. Stigma related to staff providing emotional versus medical care was a barrier to non-pharmacological treatment.
… there’s a lot of stigma around the use of benzodiazepines … However, I find that there’s less judgment – you know unconscious generally – but judgment from staff if somebody has a PRN [as-needed prescription] Ativan and they have a formal diagnosis of longstanding anxiety disorder … – Participant 8; Group 2
The culture within facilities was found to facilitate the use of non-pharmacological treatments. Facility leadership was noted to impact the priority of non-pharmacological treatments, with some facilities encouraging the use of non-pharmacological treatments.
The impact of the COVID-19 pandemic was viewed as a barrier to many aspects of anxiety management. During COVID-19, resident anxiety was noted to have increased, staff burnout had led to less interest in trying new interventions, the non-pharmacological interventions offered were limited, and service priorities and routines were altered.
… a lot of the facility staff and individuals, the residents, are extremely burnt out and their capacity to initiate new ideas and to try new things is quite low just because they’ve been so stressed and their bandwidth is so low with regards to the pandemic - that’s been a huge issue in terms of interventions. – Participant 10; Group 2
Discussion
Interviews with care providers were completed to understand the perceived barriers to and facilitators of managing anxiety in residents of LTC. The range of care provider roles represented in the data provided different perspectives on anxiety management and allowed us to obtain a nuanced understanding of this issue. Using the TDF, behavioural domains that address the noted barriers to anxiety detection or diagnosis and treatment, organized also by care provider group, were identified. By linking the TDF to the BCW, findings were situated within behavioural intervention categories to form the basis of future intervention identification, development, and implementation to address the barriers to anxiety management, while also leveraging the facilitators.
The key barriers to anxiety management identified indicate that there is a need for:
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1. Prioritization of measurement-based care for anxiety inclusive of early and accurate identification and management of anxiety in residents;
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2. Accessible provision of non-pharmacological treatments that are tailored to the resident’s needs; and
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3. A care delivery environment that supports anxiety management, inclusive of both resident and staff well-being.
Need to Prioritize Measurement-Based Care for Anxiety in Residents
There is a need to adopt a measurement-based approach to care for anxiety that uses accurate tools to detect and follow up on anxiety symptoms. Specialists, including psychiatrists and mental health clinicians were identified as having limited capacity and saw residents only on a consultive basis. There is a need for staff to be able to detect and manage anxiety before the condition escalates to the point that specialized services are required.
Complexity of anxiety symptoms, disorders, and co-morbidities
Anxiety was viewed as a common experience for residents, often related to dementia or other co-morbidities, and less often as a primary disorder. Anxiety often occurs on a spectrum ranging from temporary anxiety symptoms caused by a situation or event, to anxiety symptoms related to a disease such as dementia, to primary anxiety disorders. Participants from the physician and nurse practitioner group made a clear distinction between anxiety symptoms and disorders and in some cases were hesitant to label anxiety symptoms related to dementia as anxiety. The high prevalence and burden of anxiety symptoms for persons living in LTC, regardless of etiology, calls for regular screening to identify symptoms, and for appropriate processes for diagnosis to be implemented.
Screening with accurate tools required
Anxiety was not regularly screened for by care providers. Participants noted that staff may lack the education necessary to detect anxiety in residents. Previous research supports the finding that there is a need for bedside care staff to be trained in mental health (Ellis, Molinari, Dobbs, Smith, & Hyer, Reference Ellis, Molinari, Dobbs, Smith and Hyer2015). The inability to identify anxiety in residents can lead to it remaining undetected and untreated, eroding resident quality of life and creating challenges for care providers. Staff training in anxiety recognition and management is needed.
Standardized anxiety detection tools were not used in practice although a previous systematic review identified that tools such as the GAI, HADS-A, and Rating Anxiety in Dementia (RAID) Scale have evidence of validity for detecting anxiety in the LTC population (Atchison, Shafiq, et al., Reference Atchison, Shafiq, Ewert, Leung and Goodarzi2022). The prevalence of cognitive impairment was noted to complicate anxiety detection and diagnosis because of symptom overlap and difficulty communicating symptoms. There is a need for anxiety detection tools, such as the RAID Scale (Goyal, Bergh, Engedal, Kirkevold, & Kirkevold, Reference Goyal, Bergh, Engedal, Kirkevold and Kirkevold2017; Shankar, Walker, Frost, & Orrell, Reference Shankar, Walker, Frost and Orrell1999) or global measures of neuropsychiatric symptoms such as the Neuropsychiatric Inventory (NPI) (Cummings et al., Reference Cummings, Mega, Gray, Rosenberg-Thompson, Carusi and Gornbein1994; Wood et al., Reference Wood, Cummings, Hsu, Barclay, Wheatley and Yarema2000), both of which include caregiver/informant reports of symptoms, which have evidence of validity for use in cognitively impaired persons in LTC.
Existing diagnostic criteria are insufficient
To diagnose anxiety symptoms or disorders, specialists often utilized clinical interviews, which may be based on criteria from the DSM (American Psychiatric Association, 2013). Clinical interviews were limited by the degree to which residents were able to communicate symptoms and also by collateral sources’ knowledge of residents’ experiences. Reference standards such as the DSM were created for the general adult population and do not take into consideration the complex conditions within LTC, or the biological underpinnings of anxiety in those with neurocognitive disorders. More work and training for care providers in LTC is required around appropriate processes for diagnosis, because a focus on criteria-based diagnoses alone, especially for those living with dementia in LTC, may contribute to underdiagnosis.
Access to history and teamwork needed to diagnose anxiety and develop treatment plans
Participants underscored the importance of understanding the underlying or contributing factors to residents’ anxiety symptoms. Resident histories, including documented diagnoses, treatments that had previously worked, and information provided by family helped providers understand resident anxiety. Specialists’ cross-sectional view of residents highlighted the importance of a team approach and reliance on collateral sources to access information required to detect and diagnose resident anxiety. Access to residents’ histories and involvement of all team members will help with understanding the cause of anxiety symptoms, diagnosing anxiety disorders, and developing appropriate treatment plans.
Need for Accessible Provision of Non-Pharmacological Treatments Tailored to Resident Needs
Non-pharmacological treatments favoured or used alongside pharmacological treatments
Non-pharmacological treatments were described as the mainstay treatments for anxiety in LTC. Pharmacological treatments were identified as having a role in anxiety management, but were not thought to be a complete solution. Facilities were noted to have limited or variable access to non-pharmacological interventions. A systematic review of treatments for anxiety identified a variety of non-pharmacological interventions including music therapy (Costa, Ockelford, & Hargreaves, Reference Costa, Ockelford and Hargreaves2018; Ergin & Yücel, Reference Ergin and Yücel2019; Guetin et al., Reference Guetin, Portet, Picot, Pommié, Messaoudi and Djabelkir2009; Mohammadi, Reference Mohammadi2011; Raglio et al., Reference Raglio, Bellelli, Traficante, Gianotti, Ubezio and Villani2008; Sung, Chang, & Lee, Reference Sung, Chang and Lee2010), cognitive therapy (An, Wang, Sun, & Zhang, Reference An, Wang, Sun and Zhang2020; Helmes & Ward, Reference Helmes and Ward2017), mindfulness or relaxation (Ikemata & Momose, Reference Ikemata and Momose2017; Peizhen, Shuming, & Huixian, Reference Peizhen, Shuming and Huixian2020; Prakash, Seran, & Thilakan, Reference Prakash, Seran and Thilakan2019), exercise programs (Rezola-Pardo et al., Reference Rezola-Pardo, Arrieta, Gil, Zarrazquin, Yanguas and López2019, Reference Rezola-Pardo, Rodriguez-Larrad, Gomez-Diaz, Lozano-Real, Mugica-Errazquin and Patiño2020), and therapeutic touch (Alp & Yucel, Reference Alp and Yucel2020; Fraser & Kerr, Reference Fraser and Kerr1993; Simington & Laing, Reference Simington and Laing1993; Yücel, Arslan, & Bagci, Reference Yücel, Arslan and Bagci2020) that benefitted anxiety in residents; however, most were not identified in interviews as being used in LTC. Literature suggests that non-pharmacological behavioural management techniques, although found to be effective, are rarely used in practice by staff as a result of a lack of knowledge, skills, or resources (Brodaty, Draper, & Low, Reference Brodaty, Draper and Low2003). There is a need for providers not only to have access but also to take the time to deliver non-pharmacological interventions, regardless of the underlying cause of anxiety symptoms, to reduce resident suffering at that moment.
Non-pharmacological treatments tailored to cognitive status
Residents with cognitive impairment were thought to be limited in their ability to engage with or participate in non-pharmacological interventions. Interventions such as psychotherapy were thought to be ineffective for those with cognitive impairment; however, interventions such as listening to preferred music (Guetin et al., Reference Guetin, Portet, Picot, Pommié, Messaoudi and Djabelkir2009; Sung et al., Reference Sung, Chang and Lee2010) have been found to benefit anxiety. Non-pharmacological treatments should be tailored to the cognitive and functional abilities of residents and should be activities that the resident enjoys engaging in, which underscores the importance of having access to resident histories and involving family in treatment planning.
Non-Pharmacological treatments include approaches to patient care and emotional care
The approach to patient care used by staff was a key non-pharmacological intervention that was universally recognized by participants. Approach to patient care included tone of voice, providing reassurance, and how transfers were completed. Approach to patient care is a simple, actionable non-pharmacological intervention for managing anxiety that can readily be implemented.
Residents were identified as often needing one-to-one or emotional care and non-pharmacological interventions that were tailored to their cognitive abilities and needs. It was often thought that staff did not have the capacity or a sense that they had permission to provide such care. Previous research has found that the emotional care provided to residents by staff relies heavily on staff time and is contingent upon knowing the resident (Fjær & Vabø, Reference Fjær and Vabø2013). Having supportive facility leadership and including time for patient-centred care within care plans helps ensure the delivery of emotional care and may reduce the stigma experienced by staff when providing non-medical care.
Need for a Care Delivery Environment that Supports Anxiety Management
LTC needs to be a home-like environment
The care delivery environment in LTC was identified as a factor that could be modified to become more individualized and home-like and less medicalized. Staff well-being must also be considered when thinking about the care delivery environment for resident anxiety management. Burnout and staff anxiety can lead to staff becoming disengaged in the delivery of care and can negatively impact residents’ anxiety symptoms. Staff burnout is a modifiable factor that may be easier and lower risk to address than resident-level interventions. Previous research has found that environmental factors including staff consistency, approach to care, and environmental design can influence resident behaviour (Garcia et al., Reference Garcia, Hébert, Kozak, Sénécal, Slaughter and Aminzadeh2012). To best manage anxiety, LTC facilities should be home-like for residents and create a community where staff and leadership within facilities also feel connected.
Time and resources are needed to support anxiety management
The ability to provide non-pharmacological treatments was limited by staff time constraints. Staff need more dedicated time to deliver non-pharmacological interventions, to reduce the potential for staff to reach a point of care burnout, prevent the absence of treatment, and reduce the reliance on pharmacological treatments.
Whereas specialized services are available to work with staff and provide individualized education on anxiety management and non-pharmacological treatments, there is a need for more education coupled with skills training (Arlinghaus & Johnston, Reference Arlinghaus and Johnston2018) for nursing staff, to promote independent anxiety management. Staff must understand how to identify anxiety, deliver informal interventions such as a calm and gentle approach or evidence-based interventions including therapeutic touch (Alp & Yucel, Reference Alp and Yucel2020; Fraser & Kerr, Reference Fraser and Kerr1993; Simington & Laing, Reference Simington and Laing1993; Yücel et al., Reference Yücel, Arslan and Bagci2020) and music therapy (Costa et al., Reference Costa, Ockelford and Hargreaves2018; Ergin & Yücel, Reference Ergin and Yücel2019; Guetin et al., Reference Guetin, Portet, Picot, Pommié, Messaoudi and Djabelkir2009; Mohammadi, Reference Mohammadi2011; Raglio et al., Reference Raglio, Bellelli, Traficante, Gianotti, Ubezio and Villani2008; Sung et al., Reference Sung, Chang and Lee2010), and access resources such as specialized mental health services. It is important to ensure that staff have access to the resources they need to manage resident anxiety, are comfortable working in the LTC setting, and have the education required to manage the residents they care for.
Impact of COVID-19
In Canada, LTC was disproportionately impacted by COVID-19, with structural issues, such as staffing levels and infrastructure, being the underlying causes (Canadian Institute for Health Information., 2021). The COVID-19 pandemic response led to many changes within the LTC environment that impacted the anxiety levels of residents and staff as well as the capacity for staff to treat resident anxiety symptoms. Work protocols within LTC (Alberta Health Services, 2020; Government of Alberta, 2022) shifted during the COVID-19 pandemic and were likely more time consuming, which could have contributed to burnout levels in staff. Times of crisis when resident and staff anxiety levels simultaneously increase highlight the need to have adequate resources in place and an environment conducive to anxiety symptom management.
Strengths and Limitations
A strength of this study was that the perspectives of a range of stakeholders such as nurses, physicians, and allied health professionals practicing in LTC were considered; however, the number of participants representing each group, particularly specific allied health disciplines, was small. All care providers worked within the same health care system but the insights generated are likely transferable to similar settings, particularly within Canada. Interviews took place after the second wave of COVID-19 in Alberta and providers may have had an increased awareness of anxiety, which may have impacted the findings. This study is limited by the absence of interviews with bedside nursing staff. Challenges recruiting this population were likely the result of increased demands in care delivery related to the COVID-19 pandemic.
Future Directions
Before interventions can be developed, it is important to garner the perspectives of other key stakeholders including residents, care partners, family, nursing staff, and facility management. Once these perspectives are better understood, then tailored interventions can be designed and implemented to address barriers to the delivery of evidence-based care for anxiety in LTC. In practice, there is an immediate need for staff to be educated on how anxiety presents in the LTC population and how it can be managed. Anxiety management may be best supported by initiating measurement-based care for anxiety inclusive of regular screening protocols and the delivery of non-pharmacological treatments that have evidence of benefit within the LTC setting. At a policy level, there is a need for increased workforce training and increased staffing levels to enable care staff to have the time and ability to provide emotional care to residents, which ultimately points to a need for increased funding for the LTC system.
Conclusions
This study offers the first step toward developing simple interventions that can be disseminated widely to improve how evidence-based care for anxiety is delivered. Although some aspects of anxiety management are progressing, there remain major barriers to providing tailored non-pharmacological therapies, including lack of staff time and resources. Adaptations or interventions focused on care providers or environmental factors pose no immediate risk to residents and should be prioritized. Initiating measurement-based care for anxiety, increasing access to and delivery of non-pharmacological treatments, and creating a care delivery environment that supports anxiety management are key focus areas that may improve the care delivered to LTC residents, ultimately improving the quality of life for those living and working in LTC.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/S0714980823000417.
