Nurses' experiences of an outreach interprofessional mental health service for nursing homes: a qualitative descriptive study

Accessible Summary What is known on the subject? Treatment and mental health care in familiar environments are beneficial for older people experiencing mental health issues. But there are not enough qualified and specialized nurses who can meet the complex needs of nursing home residents experiencing mental health issues. The University Hospital of Psychiatry Zurich, Switzerland, established an outreach interprofessional mental health service to foster the care for residents experiencing mental health issues in nursing homes. Based on existing studies, little can be said about whether nurses in nursing homes find these types of services helpful. What does this paper add to existing knowledge? Nurses in nursing homes caring for residents experiencing mental health issues felt relieved by having inclusive support from the interprofessional mental health service. Nurses appreciated the mental health team and felt accompanied and more confident in their daily work. Results showed that nurses wanted to be included in the care and treatment processes and to work as partners on an equal footing with the mental health team. What are the implications for practice? Outreach interprofessional mental health services for nursing homes should take into account nurses' views and professional experience, and value and respect their role as nurses. Outreach interprofessional mental health services for nursing homes should offer further training in psychiatric nursing, include an accessible contact person in the team, and develop clear processes and responsibilities. Abstract Introduction Outreach interprofessional mental health services for nursing homes can increase the quality of care for residents experiencing mental health issues but research on how nurses in nursing homes experience such a service is lacking worldwide. Aim To describe how nurses experience the involvement of an outreach interprofessional mental health team in the care for older people experiencing mental health issues in nursing homes and to identify barriers to and facilitators of interprofessional collaboration. Method Qualitative descriptive analysis based on 13 semi‐structured interviews. Framework analysis and complex adaptive systems theory were applied. Results One core theme with two main categories: Nurses experienced relief from burden through inclusive support provided by the mental health team. Main categories were feeling accompanied and confident as a nurse and partnership‐based collaboration. Discussion Results showed for the first time that nurses felt supported by the mental health team and were encouraged to find new ways of coping with challenging situations. Implications for Practice To empower nurses, mental health teams should take into account nurses' perceptions in the treatment process, value and respect their role as nurses, transfer knowledge in both formal and informal settings, establish a steady and reliable contact person, and define processes and responsibilities.


| INTRODUC TI ON
Mental health care for nursing home residents faces several challenges. Three of these challenges are particularly relevant for the present study: First, residents experiencing mental health issues often have behavioural issues, such as agitation or aggressiveness, which can lead to an increased workload for nursing staff (Collet et al., 2018;van den Brink et al., 2017;Vogel et al., 2017). Evidence suggests that work stress is positively associated with intention to leave (Gaudenz et al., 2017;Kuo et al., 2014;Stewart et al., 2011).
Second, nursing staff in Swiss nursing homes are usually less qualified compared to hospital and home care staff, making it difficult to provide specialized nursing care for residents experiencing mental health issues. The skill mix in Swiss nursing homes consists of 25% nurses, 35% healthcare assistants and 40% nursing aides (Andreani, 2020). Third, many nurses leave their profession early in their life course (Marquis & Andreani, 2020;Merçay et al., 2016). As a result, nursing homes face difficulties in recruiting qualified and experienced nursing staff.
Nursing staff shortages together with complex healthcare needs of residents experiencing mental health issues likely put the quality of care at risk (McGarry et al., 2019). Previous evidence suggests that integrating mental health professionals and working in interprofessional teams can increase the quality of care for residents experiencing mental health issues and improve outcomes of care (Kilpatrick et al., 2020;Klug et al., 2019;van der Wolf et al., 2019).
Also, research suggests that specialized interprofessional mental health services reaching out to nursing homes fill a gap in care for older people experiencing mental health issues (Fischer et al., 2011;Koekkoek et al., 2016;Stocker et al., 2018).
In 2013, the Clinic for Old Age Psychiatry of the University Hospital of Psychiatry Zurich, Switzerland, established an outreach interprofessional mental health service (we use the acronym AGIL that refers to the German name of the service). The target population was people aged 65 and older experiencing mental health issues and their relatives living in their own home or in nursing homes in the metropolitan area of Zurich. Old age psychiatrists, psychiatric nurse specialists and a clinical social worker were part of the AGIL team. Services included medical treatment, case discussions, specialized nursing care and social work counselling, as well as team supervision, training and counselling of staff in nursing homes. Figure 1 shows a logic model of the key components and intended outcomes of AGIL (MacDonald, 2018). Services such as AGIL are not implemented widely in the Canton of Zurich or in other parts of Switzerland.
Research evaluating outreach interprofessional mental health services is scarce. Two previous studies showed that interprofessional mental health services for nursing homes may foster the treatment of residents experiencing mental health issues and support nursing staff (Fischer et al., 2011;Koekkoek et al., 2016). To our knowledge, there is no research, national or international, on how nurses in nursing homes experience the involvement of such services in the care for older people experiencing mental health issues.
Also, little is known about the barriers and facilitators that are present in the collaboration between nursing staff and interprofessional teams of outreach mental health services. Such findings are needed Aim: To describe how nurses experience the involvement of an outreach interprofessional mental health team in the care for older people experiencing mental health issues in nursing homes and to identify barriers to and facilitators of interprofessional collaboration.
Method: Qualitative descriptive analysis based on 13 semi-structured interviews.
Framework analysis and complex adaptive systems theory were applied.

Results:
One core theme with two main categories: Nurses experienced relief from burden through inclusive support provided by the mental health team. Main categories were feeling accompanied and confident as a nurse and partnership-based collaboration.
Discussion: Results showed for the first time that nurses felt supported by the mental health team and were encouraged to find new ways of coping with challenging situations.
Implications for Practice: To empower nurses, mental health teams should take into account nurses' perceptions in the treatment process, value and respect their role as nurses, transfer knowledge in both formal and informal settings, establish a steady and reliable contact person, and define processes and responsibilities.

K E Y W O R D S
geriatric psychiatry, health services research, interprofessional relations, mental disorders, mental health services, nursing homes, psychiatric nursing to further develop AGIL and other comparable outreach interprofessional mental health services that aim to improve the care for residents in nursing homes experiencing mental health issues.
We aimed to describe how nurses experience the involvement of the AGIL team in the care for older people experiencing mental health issues in nursing homes and to identify barriers and facilitators in the collaboration between nursing staff and the AGIL team.

| Study design
We applied a qualitative descriptive design based on framework analysis (Ritchie & Spencer, 1994;Goldsmith, 2021) to explore nurses' experiences with the involvement of the AGIL team. Framework analysis is a pragmatic approach that originated in applied political science and has been increasingly used in health research in recent years (Goldsmith, 2021). We chose complex adaptive systems (CAS) theory as the theoretical framework. CAS are characterized by relationships between different actors that change continuously through non-linear interactions (McDaniel et al., 2009). Using CAS theory helped the first author to focus on interactions and context during data collection and analysis, and to reflect on tensions arising during the research process (McDaniel et al., 2009).
We based our research on four quality criteria: utility, feasibility, accuracy and propriety (German Society for Evaluation [DeGEval], 2019;Kidder & Chapel, 2018). The first author collected, analysed and interpreted the data as part of her master's thesis in nursing science. Regular supervision from the last author and exchanges with members of her research group supported the quality and credibility of the research process.

| Context and setting
In Switzerland, long-term care for elderly people is regulated on the cantonal level. Zurich is in the German-speaking part of Switzerland, where nursing homes are decentralized and run by municipal and private institutions (Rodrigues & Nies, 2013). Nursing homes are diverse in size, location and focus of care. Basic medical care is provided by general practitioners (GPs) in private practice who give consultations in nursing homes, including psychiatric medical treatment.
The costs of medical consultations and nursing care are covered by federally mandated universal health insurance (Schneeberger & Schwartz, 2018). The costs of social care are paid by the residents and, if residents do not have sufficient means to cover these costs, by the municipality (Rodrigues & Nies, 2013).

| Recruitment and participants
At the time of recruitment, AGIL collaborated with 43 nursing homes. The size of the nursing homes ranged from residential groups with around 10 places to larger facilities with around 110 places. The nursing homes delivered generalized or specialized long-term care.
We included managers in the sample due to their significant influence on the design and quality of care (Asante et al., 2021;Backman et al., 2018). To include perspectives from various settings, we applied a purposive sampling strategy and recruited 13 participants F I G U R E 1 Key components and intended outcomes of AGIL

| Ethics
This study does not fall under the remit of the Swiss Human Research Act because no health-related personal data were obtained or processed. The responsible ethics committee issued a declaration of non-competence. Participants received verbal and written information about the study and gave written informed consent. Withdrawal was possible at any time. The study presented no additional risks to the participants or the residents of the nursing homes.

| Data collection
Data were collected with semi-structured individual interviews, field notes and a questionnaire to obtain sociodemographic data. We developed the interview guide based on the literature and used the principles of collecting, checking, sorting and subsuming to generate the interview questions (Helfferich, 2011). Table 2 lists the interview prompts. Interviews were conducted between September and December 2020 and lasted between 28 and 66 minutes. The average duration was 40 minutes. Eleven interviews were conducted faceto-face in the nursing homes. Due to rising COVID-19 cases during the period of data collection (Riou et al., 2021), two interviews were conducted by phone.

| Data analysis
The interviews were recorded and transcribed verbatim (Dresing & Pehl, 2011). To protect personal data, the names of the participants and the nursing homes where they were employed were coded in the transcripts (DeGEval, 2019). Transcripts were checked against the audio recordings. Data analysis involved five steps: familiarization, identifying a thematic framework, indexing, charting and mapping and interpretation (Ritchie & Spencer, 1994). Charting included writing a summary of each subtheme for each participant and adding quotations to the summaries. Mapping and interpretation included combining all charts to identify concepts across themes (Ritchie & Spencer, 1994). Memos were written to record thoughts and connections in the research process. We consulted memos and field notes to ensure that the main message of the interviews was reflected in the final categories (Ritchie & Spencer, 1994), and we additionally considered sociodemographic data to ensure the accuracy of the results (DeGEval, 2019). We used MAXQDA 2020 to analyse the data (VERBI Software, 2019).

| FINDING S
The analysis revealed one core theme that contains two main categories. The core theme shows that nurses experienced relief from burden through inclusive support when the AGIL team was involved in the care for older people experiencing mental health issues. The two main categories relating to the core theme were feeling accompanied and confident as a nurse and partnership-based collaboration.
We found that the categories were interdependent of each other and that each category included two subthemes. Figure 2 shows the main findings.
Overall, the participants experienced relief from burden when they were involved in the treatment process. They wanted to share

| Feeling accompanied and confident as a nurse
The first main category included two subthemes: expanding one's scope of action in challenging situations and mutually sharing responsibility with the AGIL team.

| Expanding one's scope of action in challenging situations
This subtheme shows that participants were committed to expanding their scope of action in challenging situations. They did so by extending their knowledge and integrating the perspective of the AGIL team.

Challenging situations
All participants encountered challenging situations when caring for residents experiencing mental health issues. Most frequently mentioned were situations in which residents did not behave as the participants expected, and situations in which the participants felt that residents were unwilling or unable to engage in nursing interven-

Accessibility
All participants mentioned that they felt accompanied by the AGIL team, mainly when team members were easily accessible. When the AGIL team was not readily accessible, the participants were concerned that this would impede them in providing appropriate care. About half of the participants mentioned that they generally had trouble during psychiatric emergencies in getting support from an emergency psychiatrist within a reasonable time and had to handle emergency situations on their own. Some participants tried to reach out to the AGIL team in such cases. This suggests that they were probably not aware that responding to emergencies is not part of AGIL's remit. However, when participants were able to reach the AGIL team in critical situations, they were guided in providing the necessary care and treatment, which helped to prevent emergencies: Because in the past, the biggest stress factor was that we had situations that were extremely difficult and stressful for us, for the resident himself who was affected as well as for the rest of the residents. And what is extremely difficult is that you try to reach a doctor, and no one is available anywhere. You just have the feeling that you are alone in the situation, you cannot get any further, and the situation is no longer bearable. And that is quite bad. And that has never really been the case with me in this project.

Continuity of staff
The participants reported that having access to a reliable AGIL con- One participant described experiencing the support as follows: We experienced it as very liberating during this time.
It was good for the team that we could just let go and say: Look, she will get another visit tomorrow; someone will take care of her again tomorrow. We could, how shall I say, not let go, but we could put it in other hands. And I think that did the team some good as well.

(Participant 12)
Half of the participants wished that the AGIL team would visit more often. More frequent visits might strengthen continuity and promote positive aspects of the involvement of AGIL, such as a reduced workload and emotional relief.

| Partnership-based collaboration
The second main category shows that participants wanted to work as partners with the AGIL team. It included two subthemes: valuing the experience and competence of nurses and discussing and deciding collectively as an interprofessional team.

| Valuing the experience and competence of nurses
This subtheme shows that it was important to the participants to be valued as nurses. This finding was reflected in statements of the participants as they related their own strategies and work experience in caring for residents experiencing mental health issues. This subtheme includes receiving positive feedback about their work and coping skills.

Participants' own strategies and work experience
Participants emphasized their own strategies and work experience in caring for residents experiencing mental health issues.
Strategies included conducting self-organized case discussions or trainings, supporting each other professionally and emotionally within a team, implementing nursing interventions, and intensifying care. It seemed important to the participants that their effort was acknowledged by the AGIL team. Two participants expressed this as follows: We do not always need someone from outside.

(Participant 3)
We also know a little bit about how to handle things.

Receiving positive feedback
The participants appreciated receiving positive feedback about their work and coping skills from the AGIL team. The positive feedback contributed to a feeling of being relieved in challenging situations.
Also, feeling valued and respected as nurses seemed to be fundamental for the participants to accept the support of the AGIL team and to be able to expand their scope of action (see above, subtheme expanding one's scope of action).

| Discussing and deciding collectively
This subtheme shows that participants wanted to discuss and decide issues collectively, as members of an interprofessional team.
In the participants' view, this improves the treatment and care for the residents. This subtheme involves including the participants' perceptions in the treatment process and constructive collaboration with GPs.

Including the participants' perceptions
All participants were committed to contributing to the residents' treatment. The participants wanted to share how they perceived residents' current state of health and emphasized that the AGIL team should consider these perceptions to facilitate a shared decisionmaking process: I find it meaningful to take on board the team which is around 24/7 and to show the resident: we are a part of the attending team.

Constructive collaboration with GPs
All participants described interprofessional collaboration with GPs.
One third of the participants experienced that GPs accept the AGIL team and that they engage in constructive discussions. However, two thirds of the participants experienced friction in interprofessional collaboration with GPs. They reported that GPs had limited time and did not involve them in their clinical assessment or treatment decisions. Also, the participants felt that GPs did not actively include the AGIL team. Finally, some participants said that the old age psychiatrists of the AGIL team had no direct contact with the GPs. These participants found themselves in an intermediary role between GPs and the old age psychiatrists of the AGIL team. They were not comfortable in this position and would have preferred that GPs and the old age psychiatrists of the AGIL team interact directly with each other. Maintaining contact with each other could help with assigning tasks to different players. One participant experienced this clearly when the responsibilities of the AGIL team and the GPs were defined explicitly. This led to more structured and professional collaboration.

| DISCUSS ION
This study aimed to describe how nurses experience the involvement of AGIL in the care for older people experiencing mental health issues in nursing homes and to identify barriers and facilitators in the collaboration between nursing staff and the AGIL team. The present study shows for the first time that nurses in nursing homes felt relieved by having inclusive support. The results suggest that nursing staff appreciate services such as AGIL and feel accompanied and confident in their daily work. The interviews showed that nurses were able to expand their scope of action in challenging situations and to share responsibility together with the AGIL team.
There are few studies addressing the effects of outreach interprofessional mental health services in nursing homes. Fischer et al. (2011) showed that psychiatric consultation teams support the care of nursing home residents experiencing mental health issues. Koekkoek et al. (2016) showed that nurses experienced less work stress and that residents had significantly fewer psychiatric symptoms after consultation with a multidisciplinary psychiatric team (Koekkoek et al., 2016).
Those studies did not, however, address nurses' experience. We found that the participants felt relieved from burden and believe that this reduces work stress, which likely translates into a lower intention to leave (Gaudenz et al., 2017;Kuo et al., 2014;Stewart et al., 2011).
Some participants of our study expressed a lack of psychiatric knowledge and psychiatric nursing experience and expressed a need for further training. Muralidharan et al. (2019) showed that nurses in nursing homes are not adequately trained to care for residents diagnosed with severe mental disorders. Nurses who participated in this study appreciated that members of the AGIL team shared their knowledge, and they wanted to find new ways to cope with challenging situations.
The literature shows that an increase in nurses' competencies is linked with higher job satisfaction and lower turnover intention (Aloisio et al., 2021;Tomietto et al., 2019). Thus, it may be beneficial to invest in further education and training for nurses.
Nurses in this study wanted to share responsibility for the care of the residents with the AGIL team and emphasized that a reliable contact person was important to them. This is consistent with the results of a study by Schärli et al. (2017), who suggest that high rotation and a lack of continuity hinder interprofessional collaboration.
In line with these findings, nurses in this study expected that their experience and competence are valued by AGIL team members.
Some nurses in the present study experienced friction in cooperating with GPs. Responsibilities were sometimes unclear. Fleischmann et al. (2016Fleischmann et al. ( , 2017 investigated GPs' and nurses' views during nursing home visits. Their results show that nurses wanted to be involved in the treatment process, which is in line with the findings of our study. To improve the collaboration with GPs, Fleischmann et al. (2016) propose a structured course of action according to the requirements of nursing homes. Further studies showed that context-based and defined workflows improve interprofessional collaboration (Gurtner & Wettstein, 2019;Schmitz et al., 2017). Considering the diversity of settings that the AGIL team and other outreach mental health services work in, it may be demanding to define these workflows on a case-bycase basis. Given that constructive interprofessional collaboration is linked with improved outcomes in patient care, this finding shows that there is potential for further development (Zwarenstein et al., 2009).
Implementing defined workflows and responsibilities might improve interprofessional collaboration among the stakeholders.
Our results show that the AGIL team and the participants work in heterogeneous and unpredictable situations and settings, which are key characteristics of CAS (Pype et al., 2018). Based on CAS theory, a linear approach to practice is not reasonable. Rather, several attempts and joint development of individual strategies are needed (Pype et al., 2018). Our results relate to various aspects of CAS.
The finding that nurses feel more confident when they are accompanied is consistent with the concept of 'workplace learning' (Pype et al., 2018, p.6

| LI M ITATI O N S
The sample in this study included solely nursing staff. A larger sample involving all stakeholders, such as AGIL team members and GPs, would have helped to paint a broader picture. Also, we could not include team members of other outreach interprofessional mental health services because these are not established widely in Switzerland. This could limit the generalisability of our results. Ward service managers, who acted as gatekeepers, had high workloads that were more intense during the period of data collection due to the COVID-19 pandemic (Riou et al., 2021). Due to high workloads, two participants seemed under pressure during the interviews and may have described their experiences in less detail than the other participants. Attaining an adequate sample size was demanding given those circumstances. Contrary to our initial intention to include only nurses with a tertiary education in the sample, we also interviewed two healthcare assistants. Healthcare assistants have an upper secondary education and bear a high level of responsibility in Swiss nursing homes.

| CON CLUS ION
Our results suggest that an outreach interprofessional mental health service such as AGIL contributes to relieving the burden on nursing staff caring for older people experiencing mental health issues in nursing homes. Our findings point out opportunities for further developing AGIL and similar outreach interprofessional mental health services.

| RELE VAN CE S TATEMENT
To support nursing staff in the care for nursing home residents, the University Hospital of Psychiatry Zurich, Switzerland, established an outreach interprofessional mental health service. This study explored how nurses in nursing homes experienced the involvement of the service, and it identified barriers to and facilitators of interprofessional collaboration. Results show that nurses felt supported by the service and point out opportunities to further develop the service. The findings will help to improve interprofessional collaboration and to further develop this and other outreach interprofessional mental health services that aim to improve the care for residents experiencing mental health issues.

ACK N OWLED G EM ENTS
We thank the nursing homes that helped us realize this study. Special acknowledgements are directed to the nurses for participating in the interviews.

CO N FLI C T O F I NTE R E S T
Samuel Vögeli was part of the AGIL team when the study was conducted. He has established significant parts of AGIL and has been involved in its operations.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.

E TH I C S S TATEM ENTS
The Ethics Committee of the Canton of Zurich issued a declaration of non-competence (req 2020-00854). The manuscript is based on interviews with nurses. No health-related personal data were obtained. The risks for the informants were minimal.