Supporting recovery in persons with stress-related disorders: A reflective lifeworld research study of health care professionals in primary health care in Sweden

ABSTRACT

Purpose

The study aimed to describe primary health care professionals lived experiences of supporting recovery in persons with stress-related disorders.

Methods

This study was based on a phenomenological approach known as reflective lifeworld research (RLR). Seventeen health care professionals working in primary health care were included in the study. Lifeworld interviews were conducted to collect data. The data were analysed in accordance with the phenomenological RLR principles of openness, flexibility and bridling.

Results

Health care professionals experienced supporting recovery as a complex process with a need for a tailored approach, regardless of profession. In an alliance, the health care professionals encounter the persons where they are based on their own narratives about their life situation. In an interpersonal platform, the health care professionals use a lingering and flexible approach. Support is provided by encouraging existential reflection and learning as well as guiding the person to consider their own needs. This supports the person’s quest for a sustainable recovery process in his/her life situation.

Conclusions

We conclude that supporting recovery requires a genuinely person-centred care in which elements of existential care are crucial. Primary health care for persons with stress-related disorders could benefit from the development of additional research and models for such an approach.

KEYWORDS:

• Stress
• burnout
• primary health care
• staff
• phenomenology

Introduction

Stress-related disorders constitute a major public health problem globally, and they are the most common reason for sick leave in Sweden (Försäkringskassan, 2020). Stress-related disorders have a major impact on health and lives, and require resources for beneficial care to support recovery. Primary health care has an important role in this respect, and in this study we focus on the lived experiences of primary health care professionals supporting recovery in persons with stress-related disorders.

The concept of stress can be operationalized in various ways, and several diagnoses are used. Selye (1958) defines stress as a general reaction to a stimulus that may pose a challenge and/or threat. Lazarus and Folkman (1984) describe stress in the “transactional model” as an imbalance between perceived demands and the availability of the resources required to handle a situation. Prolonged and persistent stress without sufficient rest can lead to a gradual development of stress-related disorders (Danielsson et al., 2012; Glise, 2013). Such conditions often include exhaustion, cognitive dysfunction, sleep disturbance, reduced tolerance to further stress and somatic symptoms (Bernardsson et al., 2016). A common work-related, non-diagnostic term internationally is “burnout” (Maslach & Leiter, 2008). Several diagnoses are related to stress-related disorders, e.g., adjustment disorder and reaction to severe stress. In Sweden, the diagnosis of exhaustion disorder is commonly used (SE, 2020). Understanding stress-related disorders and care for persons on sick leave is nevertheless complex, and a purely diagnostic perspective limits a holistic view of the person. When a person experiences illness or suffering, such as in a stress-related disorder, this affects the body and therefore one’s whole existence (K. Dahlberg & Segesten, 2010). Jingrot and Rosberg (2008) describe the progress of stress-related disorders as an increasing loss of “homelikeness” in the body and the familiar world. Furthermore, suffering from stress-related disorders has consequences for personal identity, and brings about existential concerns (Alsén et al., 2020) as well as a search for meaning (Engebretsen & Bjorbaekmo, 2019). Persons with stress-related disorders have also been found to feel that their interactions with significant others have been disrupted, threatening their family role and relationships (Engebretsen & Bjorbaekmo, 2020). These existential challenges, and long-term sick leave, affect the person and his/her family. The need for effective care that can support the recovery process is crucial.

The notion of recovery has developed in recent decades as an alternative to the patient/illness focus of psychiatric medicine (Buchanan-Barker & Barker, 2008). Recovery can be understood as a personal process or journey to regain power and live a fulfilling life, in which hope, optimism, meaning and togetherness are important components (Anthony, 1993; Topor et al., 2011; van Weeghel et al., 2019). The initial meaning of recovery integrates persons in their social context but has over the years been diluted and taken a more individualistic form. In recent years explanation of recovery as only a personal journey has re-evolved to include the person´s social context were social aspects as relationships and living conditions are considered as important for recovery (Topor et al., 2011, 2022). In a modern recovery-oriented practice, it is important as a health care professional to have a holistic approach. This means to support the person´s own thoughts, experiences and opinions and simultaneously support the person in a social context. A crucial aspect in this approach is a working relationship built on reciprocity and hope (Le Boutillier et al., 2011; Topor et al., 2011). To support recovery, care for persons with stress-related disorders commonly occurs within primary health care (Wiegner et al., 2019). Sufficient evidence is lacking regarding the effect of rehabilitation and treatment for stress-related disorders, especially with a focus on primary health care (Swedish Agency for Health Technology Assessment and Assessment of Social Services, 2015; Wallensten et al., 2019). Various interventions have been found to have some effect, including workplace interventions, sleep-improvement interventions, and aerobic and cognitive training. Cognitive behavioural therapy, nature-based rehabilitation and multimodal intervention seem to reduce stress symptoms while the intervention is ongoing but lack effect upon earlier return to work (Wallensten et al., 2019). Engebretsen and Bjorbaekmo (2019) suggest a need for humanistic interventions, and Jingrot and Rosberg (2008) suggest interventions that help a person to regain attachment to the body and the world, with a focus on bodily experiences and habitual stress-related patterns. These unconclusive results and recommendations leave health care professionals lacking guidance regarding treatment of stress-related disorders, and a deeper understanding how they actually support recovery is needed.

Previous studies have found that persons suffering from stress-related disorders experience contact with primary health care as a conflict involving mistrust, and which results in feelings of shame that negatively influence the recovery process (Engebretsen & Bjorbaekmo, 2019). Support from staff, peers and family and friends has been described as beneficial for recovery (Salminen et al., 2015). Arman et al. (2011) conveys that seeking to reach beyond the defences of a person with a stress-related disordered, and persistently supporting their exploration of an existential understanding of life, is a way to help.

The humanistic, existential, relational and supportive aspects of care seem important for recovery from stress-related disorders, but little is known regarding the health care professional’s experiences of supporting such persons in a primary health care context. Wiegner et al. (2019) explores how health care professionals practiced and perceived their task as “care managers” in primary health care. This entailed facilitating effective, person-centred treatment for stress-related disorders concordant with evidence-based guidelines. The health care professionals experienced increased continuity, early detection of deterioration, providing self-to-self help, being sensitive to the person’s needs and grounding contact in an alliance to be important (Wiegner et al., 2019). Yet, the care-manager role may be different from the support given by primary health care professionals. To our knowledge, no previous study has studied this phenomenon from the health care professional’s perspective. Health care professionals who have cared for persons with stress-related disorders in primary health care possess valuable experiences that could be used to gain knowledge, improve care and support the recovery process.

Purpose

The study aimed to describe primary health care professionals lived experiences of supporting recovery in persons with stress-related disorders.

Methods

Design

This study is based on a phenomenological approach known as reflective lifeworld research (RLR). This approach is founded Husserl’s philosophical theory of the lifeworld, the theory of intentionality and Mearleu-Ponty’s theory of the lived body (K. Dahlberg et al., 2008). To describe the phenomenon “supporting recovery in persons with stress-related disorders in primary health care”, the RLR methodological principles of openness, flexibility and bridling were used. This can be understood as being open, flexible and to have a reflective attitude towards one’s understanding of the phenomenon. These principles are used throughout the research process in order to avoid to grasp and describe the specific phenomenon to quickly and unreflected (K. Dahlberg et al., 2008).

Participants and settings

Health care in Sweden is managed by decentralized regions or municipalities. Both public and private facilities exist, and basic health and medical care is referred to as primary health care (National Board of Health and Welfare, 2016. In primary health care centres, multidisciplinary teams work together and comprise various occupations including physicians, registered nurses, specialized registered nurses, occupational therapists, psychologists and physiotherapists (National Board of Health and Welfare, 2021).

Participants were recruited partly via email to primary health care centres in the southern part of Sweden and partly by advertising nationally in social media. Invitations to participate and a written information letter were sent to potential participants. The inclusion criteria were being a health care professional in a primary health care context and having experience with caring for persons with stress-related disorders. Interested participants contacted the research group, and a purposive sample was used for sample variation in terms of, e.g., sex, age, occupation and professional experience. Included participants were contacted, and the time, place and interview means (in-person, telephone, Skype, etc.) were decided. Informed consent was provided by the participant in connection with the interview. In total, 32 persons contacted the research group to participate, of whom were 17 included to ensure variation and a manageable data quantity. One request to participate came via regular post to the university which, due to COVID-19 restrictions, was not discovered until data collection was complete, and was therefore not included. The 17 included health care professionals comprised 13 women and 4 men, aged 31–65. The range of primary health care experience was 1–30 years (see Table I for characteristics of the participants).

Table I. Characteristics of the participants (n = 17).

Profession
Assistant mental health nurse	1
Specialised psychiatric nurse	1
District nurse	3
General practitioner	3
Occupational therapist	6
Social worker/reg. psychotherapist	2
Psychologist	1
Sex Women/men Age Min-max Mean Years of primary care experience Min-max Mean	13/4 31–65 48.9 1–30 7.9

Data collection

The lifeworld interviews were conducted in autumn and winter 2020/2021. Five interviews were conducted in person at the primary health care centres, eleven interviews via digital platforms and one via telephone. The interviews began with an introductory question: “Can you tell me about how you support recovery in persons with stress-related disorders?”. The introductory question was seen as an opportunity to invite descriptions of lived experiences. When participants touched on the phenomenon, follow-up questions were asked to help the participant deepen the reasoning about his/her lived experiences of the phenomenon. Follow-up included “Can you describe a situation?”, and “Can you give one or a few examples?” All interviews were conducted by the first author. The interviews were audio-recorded, lasted between 47–104 minutes and were transcribed verbatim.

Data analysis

Interview transcripts were analysed in accordance with phenomenological RLR principles. In RLR, it is crucial to be open minded, flexible and patient in understanding the phenomenon (H. Dahlberg & Dahlberg, 2019; K. Dahlberg et al., 2008). First, transcripts were read repeatedly to get to know the material. This process was characterized by a movement between “the whole—the parts—the whole” in order to reach a new wholeness. Analysis began with the whole being broken down into parts, and searching for section of text that carried the meaning of the phenomenon “health care professionals lived experiences of supporting recovery in persons with stress-related disorder in primary health care”. Meanings were compared based on differences and similarities, and grouped into clusters of meanings. Analysis continued with the search for patterns of meanings. To find these patterns, it is important to search the “in between”, the place between the researcher and the phenomenon, the in-between world connecting us with other subjects and objects in the world (K. Dahlberg, 2006). With an in-between perspective, the analysis continued with “figure and background,” putting contrasting individual meanings and cluster-groups, and comparing meanings to cluster groups and vice versa, while constantly trying to read between the lines and discover underlying patterns between meanings. One must adopt a bridled attitude, which requires the researcher to reflect on his/her own pre-conceptions and slow down the process of understanding, to permit the phenomenon to remain indefinite for as long as possible and the phenomenon’s essential structure to emerge. During the analysis process, the image of an essential structure of meaning gradually became clearer and clearer. The essential structure is the most abstract description of the phenomenon and how meanings relate to each other, and when the essential structure is clarified one can describe its constituents. The constituents describe variations of the phenomenon and are described individually. The essential structure and the constituents form together a new whole (K. Dahlberg et al., 2008). The analysis process was led by the first author and then repeatedly discussed by all authors. The authors had a lengthy reflection process where their own work with the data alternated with joint meetings. New findings were critical discussed and questioned in a bridled attitude throughout the process, always with their preunderstanding in mind. The first author has experience of supporting persons with stress related disorders and works part time as a specialized psychiatric nurse in a primary health care centre. The other authors work as experienced researchers with a background as nurses in different parts of the health care system (see biographical notes for more information).

Ethical considerations

The study was approved by the Swedish Ethical Review Authority (Reg. No. 2020 03163). Decisions have been made pursuant to the Declaration of Helsinki (WMA, 2013) and the Swedish Ethical Review Act (SFS 2003:460). The respondents were informed in writing prior to the interview, and verbally at the time of the interview, regarding the aim of the study, their freedom to withdraw at any time and without explanation and that confidentiality applied throughout the research process. All participants provided informed consent before the interview. Due to a relative high number of willing participants during recruitment, we had to turn some down. For ethical reasons, it was important for us to explain all details to these potential participants and thank them for replying and for their willingness to support research. None expressed any discomfort for not being included.

Results

Supporting recovery in persons with stress-related disorders in primary health care means to meet the person where, in relation to recovery, he or she describes his/her lifeworld and experience of the stress-related disorder. By remaining aware, the health care professional tailors the caring interaction and support to the needs of the person and their narrative. A mutual, interpersonal communication, as well as new ways of understanding lifeworld narratives, is essential for recovery support. Encounters between health care professionals and the person create a unique shared interpersonal platform for care that moves between the person’s life narrative and the health care professional’s understanding of that narrative. This platform creates a shared space for reflection regarding the prevailing imbalance in the person’s unsustainable life situation and the lack of sufficient rest. Recovery support is permeated by an alliance with the person being cared for. This alliance constitutes the “interpersonal glue” of the care relationship, with the care relationship as the external structure of the alliance. Supporting recovery means that the person has space to participate in their care, and this space is created by sensing and accepting the person’s mood, and keeping the alliance in focus. It means looking beyond instrumental parts of caring to encounter the person’s existential situation. A lingering and flexible approach supporting growing insight into a sustainable life balance is needed to support recovery. Given the unpredictability of a recovery journey, care requires continuity and flexibility. Supporting the recovery process can be challenging, but can also result in feeling able to make a difference by supporting a person. Supporting recovery also means having a guiding approach that actively supports the person in learning to rediscover and consider his/her own needs for a mode of life that is sustainable in the long term.

The following constituents further highlight the meaning of the phenomenon “supporting recovery in persons with stress-related disorders in primary health care”: The caring alliance, The interpersonal platform, The lingering and flexible approach and The guiding approach.

The caring alliance

Supporting recovery of persons with stress-related disorders in primary health care means using a caring alliance to instil courage that allows the person to dare to start exploring and changing unhealthy modes of life. The formation of an alliance occurs parallel to the care process. Health care professionals experience this as both difficult and beneficial in relation to the challenges of the recovery process. A continuous, non-judgemental and attentive approach, where the person is taken seriously, lays the foundation for an alliance in which the person can feel trust and security, and can start taking responsibility for his/her recovery journey, first at the primary health care centre and then in their own life.

“First of all, I think it’s important, or it is really the starting point, that the patient feels safe in the care relationship, in the care meeting. And if you feel safe, there is often an greater calm”. (2)

A supporting alliance provides a basis for interaction with a permissive atmosphere where the person cared for has space to express his/her feelings without fear of being judged. The alliance allows the person to feel safe describing in depth how they feel. It is constantly revised and continuously calibrated, an approach aimed at an “alliance-promoting” atmosphere with both verbal and non-verbal communication.

“It’s about creating that sense of security in the consulting room that allows talking about … that I can get a patient to discuss difficult things and ask questions, and that we can work with the resistance which sometimes arises. This creates the opportunity for a confidential conversation”. (11)

The “alliance-promoting” atmosphere can also be maintained with humour and through sharing personal experiences in care. It also entails that the person feels allied with the interprofessional team at the primary health care centre.

The interpersonal platform

When encountering persons with stress-related disorders, an interpersonal interaction is sought, where the person is gradually supported in reflecting on and learning from his/her life narrative. This forms an interpersonal platform, and care takes place and is created within the relationship with the person. The primary health care centre’s interprofessional resources are used as necessary. Different professions can have different theoretical bases and different methods for understanding the person’s narrative. The person’s narrative is inventoried, and unhealthy stress-related patterns are identified and considered. The person’s ability to recover is confirmed and new recovery strategies are formulated. The interpersonal interaction is the framework, while the result of the interaction—the gradually extended narrative—stabilizes the platform as a supporting element. The platform is co-created by health care professionals as they strive to understand the person’s life narrative. In the caring encounter, verbal language, body language and intuition are used to try to understand the person.

“On the one hand, I’m very empathic. I check in. Then it involves asking: what does your everyday life look like? What do you like to do? What’s important to you? What do you need—both in terms of this conversation, but also a question you ask yourself daily, what do I need right now? Do you touch base in that way sometimes?” (1)

Listening and intuitively feeling the person captures different expressions of the stress-related disorder and their ability to recover. The discrepancy between what the person conveys, and what the health care professional understands, creates a space for a caring conversation. This space is gradually filled with content through questions and considerations regarding what the person expresses, while at the same time ensuring correct understanding. The interaction gives rise to further consideration of and questions about the person’s life.

“You need to have the confidence that I’m still here. I am listening to you, I am affirming you, I ensure that I have understood you correctly so as not to pass judgment or imagine I understand something when you didn’t mean it that way at all. Without me touching base, as it were, in the conversation—is this what you mean when you say this, do you mean this, have I understood you correctly now? That touching base makes us a team.” (1)

Switching between the encounter with the person and the narrative occurs simultaneously using a so-called “helicopter perspective” of everything explored and understood earlier during the care process. New information about the person’s life situation is contrasted with the narrative constantly being revised. This involves a shift between proximity to the person’s existential reflections and reviewing the person’s described context. Thus he or she is supported in considering imbalances in his/her life situation related to a stress-related disorder, in understanding how different parts are connected and in a search for balance and recovery. On the interpersonal platform, the person is supported in understanding the different expressions of the stress-related disorder, their effect on the person’s life and the importance of recovery. The interpersonal platform provides opportunities for personal growth and change.

The lingering and flexible approach

The person returns to the primary health care centre in encounters with health care professionals who use a lingering and flexible approach to adapt their attitude to the person and their journey. The person is involved and receives gradually support in assuming greater responsibility for rediscovering his/her ability to initiate a recovery process and recover.

“I think that time helps you to, like—I don’t like the word process, it’s an awful word really but for something like that to start, I mean if you’re talking about a person with exhaustion, an exhaustion disorder or other concerns that are really severe and stress-related, then you need to process this. Yes. You need to work around it in some way, and get closer to the idea that this is how it is, this is how I am, this is how I function, so what should I do to feel well?.” (11)

The lingering and flexible approach is characterized by waiting for the person’s imminent insight and, further, waiting for his/her deeper understanding of how to manage unsustainable stress-related patterns. Beginning by recognizing and considering bodily signals and personal boundaries, as a way start to changing such patterns and developing and maintaining a necessary recovery process, changes life in a way that naturally results in recovery. This takes place in a changing process over time, and the person is encouraged to continue even after the care process has ended.

“You can’t expect to get well in a month. It may not take an eternity, but it might take a while, and that’s something that I prepare patients for. We have to work together so that you get well, so that you get out of this. And it will take time, it will be demanding, but you won’t need to be on sick leave for years if you can tackle stress management and change your attitude towards different stressors over the course of several years until you end up, until you have everything ….in place.” (17)

This process involves various aspects of the person’s life and is both relational and individual, personal and professional. In primary health care, supporting recovery must be a “safe haven” to which the person can return over time, to reflect, learn and rehearse, and then take on daily challenges with new knowledge and insight. The goal is that the recovery process gradually become more dominant in the person’s life.

The guiding approach

Supporting recovery with a guiding approach aims to help the person understand the difference between a state of stress and a state of recovery. The guiding approach means supporting the person in finding “clues” to a sustainable recovery process over time. The person receives guidance in using his/her senses, slowing down the body’s pace, anchoring themselves in their bodies and thus listening to themselves and considering his/her need for recovery. To strengthen these “clues” leading to a sustainable balance, care is based on providing verbally, visually or physically descriptive examples of the body’s need for balance. This may involve verbal metaphors, illustrative images, body awareness or encouraging a focus on sensing one’s surroundings, e.g., in nature.

“Then we try … we try together, of course, with the patient. It’s better if the patient comes up with things that they want to change, but otherwise you have to provide help and maybe indicate some things you see are not sustainable, you can make suggestions.” (7)

This guiding approach receives additional dimensions when provided for several persons with similar experiences who meet in a group. Supporting recovery in these group contexts means to providing an interconnecting link and being responsible for the structure and content of the encounters. Sharing with others reinforces the effects of the guiding approach and provides synergistic effects, such as recognizing oneself in others, feeling that one is not alone in one’s troubles and feeling understood.

“The group is tremendously beneficial for all its members, they contribute a lot that you miss when you meet individually, so group treatment is ….it’s not possible to do it as well individually, I think.” (7)

Another guiding approach is the involvement of significant others. This is done by providing information to increase understanding of the person’s situation and their needs in, e.g., family life. Significant others are involved as a support, either primarily in care through direct contact, or secondarily through supporting the person to communicate with his/her relatives.

Discussion

This study is, to our knowledge, the first that has focused on the phenomenon of supporting recovery in persons with stress-related disorders in primary health care. The results show that the health care professionals experienced supporting recovery as a complex process requiring a tailored approach where relational aspects, such as a caring alliance and collaboration, are foundations of support, regardless of profession. The results also show the importance of meeting the person where they are, starting from their narratives about their life and, from there, shaping an interpersonal platform where reflection and learning are crucial. With this platform, the health care professional provides space for existential reflection regarding the person’s life, and the health care professional can have a guiding approach to supporting the person’s rediscovery and consideration of their own needs. Providing professional support to these persons means being lingering and flexible in following the person’s journey through entering recovery process, achieving sustainable recovery and promoting life balance and health.

The results of this study show that health care professionals express a caring alliance as a- crucial factor for the tailored support described in our result. This alliance was needed to make the person feel safe to express themselves, reflect on and deal with concerns during the primary health care encounter, between health care visits and after completion of care. According to Topor et al. (2011), a reciprocal relationship with a health care professional is important for recovery. Specific treatment methods are of less importance than the all-important working alliance with the professional.

Our results also showed that the interpersonal nature of care is evident, and it was described as an interpersonal platform shifting between the person’s narrative and the health care professional’s attempts to understand that narrative. The efforts of health care professionals to understand correspond with the description by Todres et al. (2014) of important insights when trying to understand the “insiderness” of another person. They point out that the process of “reaching towards” understanding another person is more important than understanding exactly.

The findings in our study describe learning as central for supporting recovery in persons with stress-related disorders. Health care professionals encourage the persons’ insights about personal identity and life situation through reflection and encourage them to expand their narratives about their lifeworld. The importance of learning and insight have been found in previous research. Andersson et al. (2015) found, e.g., how a health care professional’s changed approach—from informing about disease, illness and treatment to supporting a person to a learning about their entire health situation—permits change and reprioritisation. Another example is the group intervention ReDO-10, adapted to primary health care, where learning about life was found important, based on learning through an activity perspective (Fox et al., 2022; Olsson et al., 2020).

Further, the findings of our study describe an overarching interprofessional tailored caring approach that unites beyond theories and methods and may be crucial in supporting recovery on the interpersonal platform. The health care professionals described the importance of communication, attentive listening, taking the person and their feelings seriously, a non-judgemental attitude, offering continuity and safety, being open to humour and sharing personal examples. Topor et al. (2018) describe such approaches in a professional relationship in a recovery-orientated practice as “small things” which are often overlooked but which play an important role for the person to improve their sense of self. These small things can be expressed in words, gestures or actions by the professional but require a reciprocity with the person.

The findings of this study further stress the importance of “a lingering and flexible approach” by primary health care professionals towards persons with stress-related disorders. This approach creates space for reflection and awaiting the person’s imminent insight regarding their ability to recover and, further, supports a gradually increasing insight into how life should be handled and embraced to achieve sustainable balance and recovery. Different studies (Alsén et al., 2020; Arman et al., 2011; Jingrot & Rosberg, 2008) describe such crucial turning points or perspective shifts in persons with stress-related disorders as a “crossroad”, where they can choose to engage in a recovery process and find a way forward. Onken et al. (2007) gives credence to this means of supporting recovery, as described in our results, by explaining the notion of change that is incorporated in different important elements of recovery, both individual and interactional/societal.

Our findings show that recovery can be supported by adapting “the guiding approach” with various instructive or creative tools and existential reflections including metaphors, experiences in nature and reflections in group settings. Creative and nature-based initiatives have also been found beneficial in other studies vis-à-vis stress-related disorders. Gunnarsson et al. (2022) found, e.g., that taking photographs of situations, places or settings linked to well-being, was a good starting point for a conversation about life and health with persons with stress-related disorders. Krantz et al. (2021) found in their autobiographical study that spending time in nature thinking and reflecting undisturbed, was an important part of the recovery process. Hörberg et al. (2020) describe “unconditional beingness” as a crucial existential space for well-being and recovery when living with stress-related disorder. This space can be achieved, e.g., in nature, painting or in undemanding situations together with others where you can be yourself. It seems important that health care professionals, when suitable, provide for such “unconditional beingness” in life. In the findings of our study, the professionals describe guiding persons with stress-related disorder with clues to existential reflections about life as a way to support changing unhealthy patterns. Arman et al. (2011) finds that the caring act can benefit from health care professionals supporting existential reflection to awaken longing and creativity. This indicate that persons with stress-related disorders may benefit from existential elements of care to recover. Care leaders are encouraged to initiate and support existential aspects of care together with health care professionals in primary health care. Further research is needed to understand the importance and effects of existential efforts in primary health care.

The results of our study show that, to support recovery, it is important that health care professionals find the persons wherever they may be in their journey with stress related disorders, and start from their own narrative about their life situation to support recovery. This result is contrary to study of persons with burnout who felt mistrust, misunderstood and rejected in health care encounters, by Engebretsen and Bjorbaekmo (2019). The differences with these results may result from person-centred care being overshadowed by overly result-oriented, time-limited and depersonalized care, as indicated in a study with general practitioners (Derksen et al., 2016). Furthermore, previous research based on the person’s own perspectives highlights the importance of humanistic needs where the persons whole lifeworld is considered (Alsén et al., 2020, 2022; Arman et al., 2011; Engebretsen & Bjorbaekmo, 2019; Jingrot & Rosberg, 2008). This speaks to the importance of a more person-centred approach, where the person and his/her narrative are in focus, which also seems important in our findings from a health care professional perspective.

The results of our study show that supporting recovery involves an overall attitude similar to the recovery-focused approach described in the literature (Onken et al., 2007; Topor et al., 2011; van Weeghel et al., 2019). Buchanan-Barker and Barker (2008) describe such a recovery-focused approach as different from the more accepted medical and diagnostic approach presently dominant in health care. Recovery is not the same as a cure or a return to a state prior to illness with focus on the person’s symptoms. It is a complex and ongoing healing process, or “journey,” with a holistic view of the person (Jacob, 2015; Onken et al., 2007; Tew et al., 2011). It’s reasonable to assume that the recovery-focused approach found in our study might be unconscious or assumed. Raising awareness of the tacit knowledge they possess, and consciously using this knowledge in their work with persons with stress-related disorders, might beneficially support recovery.

Methodological considerations

Due to the COVID-19 pandemic, the strategies for recruitment and data collection in this study had to be adjusted. Major re-prioritizations made recruitment directly from the primary health care centres difficult. Increased restrictions in society made it impossible to conduct interviews in person, as planned. We therefore conducted some of the meetings digitally. A study by Archibald et al. (2019) found that researchers and participants describe digital meetings as a convenient platform for collecting qualitative interview data, due to its ease of use, security and interactivity. Interviewing on a digital platform is a good complement to in-person meetings and gives more qualitative dimensions than telephone meetings. However, the in-person meetings of this study provided interpersonal dimensions that may be missed in digital interviews, especially when conducting lifeworld interviews. K. Dahlberg et al. (2008) conveys that an atmosphere of presence in an interview situation increases the possibility of a necessary openness that is important to grasp in-depth data. As a researcher, this means simultaneously being present in a “bridled” way with the phenomenon and the participant. It is likely easier, in an in-person meeting, to notice different verbal and nonverbal expressions when participants describe lived experiences related to the phenomenon. The necessary adoption of digital meetings by this study is therefore a limitation. On the other hand, digital meetings permitted a greater variation geographically, likely to be important depending on the division of Swedish primary health care into heterogeneous regions of varying structure (National Board of Health and Welfare, 2016). Furthermore, the number of the interviews, their length and the variation in the sample resulted in rich data, which we value as important for the validity and reliability of the results.

This study followed the RLR methodological principles of openness, flexibility and bridling throughout the research process (K. Dahlberg et al., 2008). An open, flexible and bridled attitude permeated both the interview and analysis process by being delaying and a little slow, zooming in and zooming out the focus on understanding the phenomenon and in a flexibly and reflectively way grasping different nuances of the data. This attitude was intended to avoid taking any unknowns for granted. To maintain objectivity throughout interviews and analysis, van Wijngaarden et al. (2017) suggest using such a phenomenological attitude.

Validity in phenomenological research is connected with meaning. The underlaying meaning of the participants’ lifeworld descriptions differs from the participants’ statements, i.e., the content (van Wijngaarden et al., 2017). The first author has searched the transcribed lifeworld interviews for meanings related to the studied phenomenon. We have, within an expanded research group, reflected over and discussed the meaning of these units and the patterns of meaning that emerged. We have also discussed, whenever possible, how our individual preunderstanding affects our understanding of the phenomenon and the analysis of the text, in order to enhance objectivity in the study (van Wijngaarden et al., 2017).

The transferability of the results from this study, the structure of meaning in the essence and the constituents, could probably be generalized to other care contexts with similar interprofessional teams, such as psychiatric outpatient care.

Conclusion

We conclude that care to support recovery may benefit from being genuinely adapted to the specific person and his/her lifeworld. Space should exist for existential questions and learning based on the person’s own narrative, and the alliance and the interpersonal relational aspect are considered as crucial. Regarding the tailored approach of health care professionals described in this study, one important finding is the necessity to anticipate and capture the person’s imminent insight into their own capacity for recovery. The healthcare professionals must provide space and support in finding strategies and meaning in life and recovery. Implementing more recovery-focused models in primary health care could help to raise awareness regarding effective person-centred strategies already applied by health care professionals. In order to support recovery, specific interventions and rehabilitation strategies may be adapted to the person’s individual journey to recovery from a stress-related disorder, and not the other way around. We recommend that elements of existential care be highlighted and given greater space in research and care.

Acknowledgments

We would like to thank all participants in the study and the Swedish Association of Psychiatric and Mental Health Nurses for financial contribution via scholarship for travel during data collection.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This work was supported by the grant-awarding body, the Scientific council in Blekinge County, Sweden (number: LTB-979745).

Notes on contributors

Markus Sjösten

Markus Sjösten (RN, RPN, PhD candidate) is a part-time doctoral student and registered specialist nurse in psychiatric and mental health nursing. He works clinically at Wämö primary health care centre. His field of research is Caring Sciences with a focus on lived experiences of stress-related disorders in primary health care.

Ulrica Hörberg

Ulrica Hörberg (RN, RPN, PhD) is a professor in Caring Science at Linnaeus University, Sweden, where she leads the research group Lifeworld-led Health, Caring and Learning (HCL) and is director of studies for the Caring Sciences PhD programme. Her research explores psychiatric and forensic psychiatric caring, in addition to caring and learning in educational and health care contexts.

Cecilia Fagerström

Cecilia Fagerström (RN, PhD) is director of science of Region Kalmar County and clinical professor in Caring Science at Linnaeus University, Sweden, as well as being co-leader of the ReAction research group. Fagerström has a degree in social care focused on elderly care and management. She has experience with qualitative and quantitative research designs, service and participatory designs to increase decision-support evidence, as well as eHealth solutions for wound management in home health care.

Hanna Tuvesson

Hanna Tuvesson (RN, RPN, PhD) is a registered specialist nurse in psychiatric and mental health nursing and associate professor in caring science. She is a researcher and senior lecturer at the Department of Health and Caring Sciences at Linnaeus University, Sweden. Her research areas include qualitative and quantitative studies of work environment and stress and care related to mental health problems. The research includes participatory designs and close collaboration with stakeholders.