Healthcare professionals’ perspectives on contextual factors related to (re)referral and (re)admission to geriatric psychiatry of people with dementia and behaviour that challenges living in nursing homes in Germany: a qualitative study

Escalation or crisis and the related referral and admission of people with dementia from nursing homes to geriatric psychiatry often results from a complex interplay of disease-related, structural and interprofessional factors. In particular, few contextual links have been identified at the interface between nursing homes and geriatric psychiatry. The study followed an exploratory qualitative design. Between May and July 2024, 17 semi-structured interviews were conducted with six nursing home directors/nursing service managers, six nurses, and five general practitioners/specialists. Data were analysed using qualitative content analysis according to Kuckartz and Rädiker. Reporting was based on the COREQ checklist for qualitative studies. Building on six deductive main categories, we developed 14 subcategories. (1) Multifactoriality and multidimensionality of dementia and behaviour that challenges: 1.1 Characterisation and complexity; 1.2 Impacts. (2) Interventions in behaviour that challenges: 2.1 Trigger identification; 2.2 Non-pharmacological measures; 2.3 Use of psychotropic drugs. (3) Structure-based ability to act: 3.1 Treatment barriers; 3.2 Care conditions. (4) Interprofessional cooperation: 4.1 Information exchange and decision-making; 4.2 Roles and collaboration; 4.3 Transitions. (5) Resources of the setting: 5.1 Professional factors; 5.2 Environmental factors. (6) Coping with the crisis situation: 6.1 Procedures in the crisis development process; 6.2 Individual and psychosocial factors. Our findings reveal contextual factors in the care of people with dementia and behaviour that challenges that are linked to the escalation of care situations, the development of dementia crises, and to the referral and admission of people with dementia to geriatric psychiatry. These results indicate that structural, personnel and interprofessional changes are necessary at both the personal and professional levels throughout the entire care pathway in order to enable person-centred care for people with dementia. To this end, we recommend the expansion of outpatient geriatric psychiatric care services to improve accessibility and support for nursing staff in crisis situations, clearly defined responsibilities in interprofessional collaboration, dementia-specific training for nursing staff in nursing homes and resilience-building team programmes to improve crisis management are also necessary. Following positive ethical approval, we prospectively registered the study in the German Clinical Trials Register on 2 May 2024, prior to the inclusion of the first participant (DRKS-ID DRKS00034176).