Monitoring Persons’ Rights to Equal Care: Registered Nurses’ Experiences of Caring for People with Mental Ill-Health and Somatic Comorbidity in Psychiatric Outpatient Care

Abstract Persons with severe mental ill-health die early from preventable physical ill-health. Registered nurses in psychiatric outpatient care play a key role in improving persons’ physical health, and it is important to examine how they view their responsibility, their experiences of care, and the obstacles they meet in providing person-centred care. The purpose of this study was to explore registered nurses’ experiences of caring for persons with mental ill-health and somatic comorbidity in psychiatric outpatient care, using qualitative content analysis to analyze data from semi-structured interviews. The results show that these nurses monitored the person’s right to equal care, embraced the whole of the persons suffering, and dealt with unclear boundaries in care. This highlights the unique role that registered nurses play in psychiatric outpatient care via their ability to interpret symptoms and find ways to adapt care based on persons’ needs. Registered nurses consider physical health in all care and provide a link between psychiatric and somatic care. Together with mental health nurses at primary health care centers, they are key in reducing persons’ suffering. There is a need for structural and functional changes in line with person-centred care including collaboration both within and outside healthcare organizations.


Introduction
People with mental ill-health and somatic comorbidity have a shortened lifespan of up to twenty years and those with severe mental ill-health are known to die prematurely from preventable physical ill-health.Further, they may experience violations of human rights, stigmatization, and discrimination (World Health Organization, 2022).According to the World Health Organization (2022), measures are required on several fronts, including increased understanding to reduce stigma, increased availability of care, and more effective treatments.

Background
Physical ill-health is well documented in research focusing on persons with mental ill-health.Contributors to their poor physical health are cardiovascular diseases (Kugathasan et al. 2019;Ringen et al. 2014), gastro-intestinal, haematological and neurological syndromes (Fiorillo & Norman, 2021;Nielsen et al. 2021;Nordentoft et al. 2013;Udey & Niranjan, 2020).Further, persons with mental ill-health are prone to developing metabolic syndrome related to for example anti-depressive and anti-psychotic drug treatment (De Carlo et al. 2023;Findikli et al. 2017).Risk factors such as physical inactivity, poor diet, obesity, smoking and alcohol consumption are also described to contribute to poorer lifestyles among persons with severe mental ill-health (World Health Organization, 2019).
Preventing ill-health and suffering, is the goal of health care (Wynaden et al. 2016).To achieve these goals the efforts need to be person-centered, as person-centred care (PCC) focuses on strengthening a person's resources and involve the person in both decisions and healthcare processes.This can lead to improved self-care and cooperation with healthcare staff (Ekman et al. 2011).PCC is ideal in today's healthcare and is considered to lead to improvements in perceived health and less time spent in care.Wynaden et al. (2016) and Heslop et al. (2016) argue that mental health nurses (MHNs) in psychiatric care have an ethical and public health obligation to lead the work of reducing the difference in life expectancy among persons with mental ill-health and somatic comorbidity.Research show that nurse-led health behavior interventions in psychiatric outpatient care for persons with mental ill-health can improve physical health (Blomqvist et al. 2019;Fernández Guijarro et al. 2019;Fraser et al. 2018;Happell et al. 2012).Thus, MHNs in psychiatric care need to counteract the development of physical ill-health and provide PCC (Blomqvist, Ivarsson et al. 2018;Blomqvist et al. 2019;Fernández Guijarro et al. 2019;Fraser et al. 2018;Gabrielsson et al. 2020;Happell et al. 2012;Heslop et al. 2016;Ward et al. 2018).One significant component in this work is integrating examination of physical health when assessing persons with mental ill-health in psychiatric outpatient care (Blomqvist, Sandgren et al. 2018;Heslop et al. 2016).Such evaluations need to be performed systematically, and must include objective health measurements (Blomqvist, Ivarsson et al. 2018;Ward et al. 2018).
However, there seems to be uncertainty among mental health care professionals about who is responsible for assessing physical health among persons with mental ill-health (Lerbaek et al. 2019;Wynaden et al. 2016).Mental healthcare professionals sometimes choose not to act on physical ill-health due to the severity and persistence of the mental ill-health among their patients (Lerbaek et al. 2019).Research among MHNs suggests that their adherence to physical health guidelines can be considered deficient, and that they do not see physical health care as a priority (Gray & Brown, 2017).Physical health care in psychiatric care is seen by MHNs to be outside their role and the responsibility of other disciplines (Gray & Brown, 2017;Heslop et al. 2016).In addition, MHNs appear to ignore the importance of physical health care for mental health outcomes, even though it has been shown that persons expect the responsibility for their physical health to lie with psychiatric care (Wynaden et al. 2016).
Previous research shows that MHNs can play a central role in improving physical health and providing successful health interventions for persons in psychiatric care (Firth et al. 2019).However, research shows that this view is not always shared by the MHNs (Wynaden et al. 2016).In the light of the above, it is essential to investigate how MHNs in psychiatric outpatient care describe their experiences in terms of caring for persons with mental ill-health and somatic comorbidity.

Aim
The aim of this study was to describe registered nurses' experiences of caring for persons with mental ill-health and somatic comorbidity in psychiatric outpatient care.

Design
The study had an inductive qualitative design, with individual interviews analyzed using qualitative content analysis (Graneheim et al. 2017;Graneheim & Lundman, 2004;Lindgren et al. 2020).The present report was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ).

Study context
The study was carried out among registered nurses (RNs) working in psychiatric outpatient care at two general hospitals with multiple practices in northern Sweden.The psychiatric outpatient settings at these hospitals care for persons with affective and anxiety disorders, neuropsychiatric disorders, psychotic disorders and substance use disorders.The RNs worked in teams together with consultants, physicians, social workers, and psychologists, and with access to physiotherapists and occupational therapists.Roles and duties of the RNs (including those with master-level education in mental health nursing) covers for example nursing assessments, counseling, administration and follow-ups of medical treatment, health behavior interventions and supportive conversations.Further RNs with master-level education in mental-health nursing have a responsibility to initiate and coordinate development of mental health nursing based on science and proven experience while also disseminating their expert knowledge among colleagues.

Participants
The heads of the included hospitals approved the study.At one hospital, a unit manager mediated contact with three RNs, and at the other hospital, RNs were recruited via their workplaces.Inclusion criteria were being an RN working in psychiatric outpatient care and having experience of caring for persons with mental ill-health and somatic comorbidity.Nine RNs participated in the study.All participants received verbal and written information about the study, and all provided their signed consent for participation.Their age ranged from 27-59 (median: 44), and seven of them were women.Participants had worked for 2.5-18 years (median: 5 years) at their current workplace.Eight of them reported previous employment within somatic occupations.Four participants had master's-level education in mental health nursing and had worked in psychiatric care for 14-26 years (median: 16.5 years).The other participants' experience of working in psychiatric care ranged from 2.5-23 years (median: 10 years).

Data collection
Data were collected via semi-structured interviews based on an interview guide.Some participants were interviewed on-site, while others were interviewed via a video platform.The interviews were audio recorded and transcribed verbatim.The interviews began with a main question: Can you please tell me about your experiences of caring for persons with mental ill-health and somatic comorbidity?What are your insights on the care of patients with mental ill-health and somatic comorbidity?How do you address physical ill-health in your clinic?Follow-up questions were asked to deepen the participants' answers.Examples of follow-up questions are: What do you think about that?How might this affect the patient?How do you propose we can assist the patient in this matter?Can you please tell me more?All participants engaged in the questions and were keen to share their experiences of the topic.Each interview lasted between 17-38 min (median: 24 min).CS and ER conducted three interviews together for consensus, and then ER conducted another two interviews and CS another four.

Analysis
Qualitative content analysis was used to analyze the data (Graneheim et al. 2017;Graneheim & Lundman, 2004;Lindgren et al. 2020).CS and ER identified meaning units, condensed them, and labeled the condensations with codes.In discussion with JM, they then sorted the codes into groups on the basis of similarities, and abstracted and interpreted the groups into subthemes.Subthemes were sorted into groups, abstracted, and interpreted into themes.In the next step, all authors discussed the subthemes and themes.A main theme was identified, and after a joint discussion and some elaborations, all authors agreed on the result.All authors are RNs.Two holds a master's degree in mental health nursing and three have a PhD.Four authors had experiences of working as RNs in psychiatric out-and inpatient care.

Ethical considerations
The study followed Swedish law on ethical approval and was conducted in accordance with the Declaration of Helsinki (World Medical Association, 2004).

Results
The findings are presented in five subthemes, two themes, and one main theme (Table 1).The findings are exemplified with quotations, using letters and numbers to distinguish the different participants (e.g.S2).

Monitoring the person's right to equal care
The main theme, monitoring the person's right to equal care, was developed on the basis of two themes that highlighted the RNs' experiences of working to embrace the whole of the persons suffering and to deal with unclear boundaries in care.

Embracing the whole of the persons suffering
The participants described how they strived to understand and interpret the persons' health conditions, and engaged in motivating and providing information for the persons.They also upheld the persons' rights.
Striving to understand and interpret health conditions.The participants described that in their role as nurses they had the important task of observing the persons mood and acting on the basis of the person's needs.They believed that in working close to the individual they had the opportunity to gain a more complete view of the persons state of health than the physicians had access to, and that the persons health could be poor even if the test results seemed good at the physician's annual follow-ups.As the persons did not always seek help for their physical illhealth, the participants considered themselves to be the ones who discovered and identified these problems.The participants drew attention to the fact that medical treatments used in psychiatric care often negatively affected physical health, and so they were careful to ensure that treatment would not worsen the persons health.
The participants expressed that they considered whether the persons health condition stemmed from psychiatric or physical causes.Together with the team, they also considered whether a person's physical ill-health could affect their mental health.They constantly kept in mind the fact that there could be physical causes for the persons health conditions.It was considered important to control what the primary health care center (PHCC) did around the persons, in order to avoid the possibility of only seeing psychiatric causes.The participants felt that it was a challenge to make the right assessments of information given by persons, and that it was sometimes difficult to assess a person digitally or over the phone.Participants stated that they could become better at gathering information from the persons network in order to make better assessments.One thing that made it challenging to provide good care and make good assessments was the fact that many persons did not attend visits.Because they had good knowledge about the person that they cared for, the participants knew that if some persons did not show up, it meant that they were deteriorating.
I would probably say that my role is to make sure that the entire person's needs are met, and that applies regardless of whether it is physical or mental.(S2) Engaging in motivating and providing information.The participants expressed that they were the ones who should give the persons information, and that they should always consider physical aspects as a possible explanation for the persons symptoms.They accomplished this by teaching them about the body and physiology, as well as what consequences the persons choices could lead to and what the risks were.This tuition could also address the relationship between physical health and mental health.They coached the persons on how to accept physical symptoms that could not be treated medically, and helped the persons accept physical injuries or illnesses.They stated that sometimes the persons themselves were sure that there was a physical ailment even when investigations could not confirm this, and in these cases they tried to find other causes for the problems together with the person.The participants reported using psychotherapeutic tools to improve their persons' health, such as emotion regulation, coping skills, and exposure.Health conversations were conducted to prevent the persons from suffering from physical ailments, and motivational conversations were used for behavior change and to motivate persons to seek the right care.The persons' networks could also be used to motivate the persons to seek care for physical complaints.According to the participants, persons who expressed worries about physical ill-health needed to talk about sadness and fear of death if they were diagnosed with severe physical ill-health.It was considered important to have the courage to talk about this with persons.In the participants' experience, when persons had great concerns about their physical ill-health, this needed to be dealt with first before it was possible to treat the persons' mental ill-health.
Adhering to persons' rights.The participants had found that their patients' physical conditions tended to be interpreted as psychiatric problems within somatic care.This could have serious consequences for the persons.The participants described experiences of persons with mental ill-health and somatic comorbidity not receiving adequate care, and stated that it was well-known that persons with mental ill-health were mistreated and received worse somatic care than others.
The participants expressed that some persons did not seek care at the PHCC, and in these cases, the participants took responsibility for monitoring the persons' health at their workplace or via home visits.This could involve taking blood samples requested by other caregivers, visiting persons to encourage them to take their insulin, or dispensing doses for persons where other caregivers were responsible for the follow-up.
The participants stated that they took responsibility for the persons' physical health, even if it was not officially their responsibility, and supported the persons in their contact with other caregivers.They described calling, prioritizing, and advancing assessments that caused persons anxiety.When they had concerns about the persons continuing their other contacts, they asked the persons about how they experienced that help.If a person told them they were not being listened to, they contacted the PHCC and explained the importance of persons receiving adequate help.Further, they were attentive to the persons' need for support in daily life, and they considered the need for psychosocial interventions that affected the persons' mental health.They desired more time to be able to go with persons on visits to other caregivers, and they wanted all persons to have an annual visit to a nurse for a health conversation.
The participants considered the demarcation of the PHCC to be vague.They had found that physicians did not always know to what clinic/discipline the health issue belonged, and they desired more clarity on this point.Further, they felt that it was important not to exceed their level of competence, and to seek help from other agencies with better knowledge of the problem.They believed that the amount of somatic care carried out in psychiatric outpatient care should not increase, as this would limit the help patients receive for their mental ill-health.They pointed out that as RNs in psychiatric outpatient care, they needed to guard the persons right to be cared for by someone who could provide the appropriate care.
It's important for the persons that you don't go beyond your level of competence, and that you stay within what you are confident and capable of.We also need to seek help from other agencies that know this problem better and can interpret it better too.(U2)

Dealing with unclear boundaries in care
It emerged that the participants were dealing with unclear boundaries in care.They wanted to share responsibility, and they also wanted enhanced collaboration with other caregivers such as the physicians and MHNs at the PHCC.
Asking for shared responsibility.Although the participants expressed that there were adequate guidelines for care and treatment, they asked for clearer priorities at the hospital level in order for them to know what was their responsibility.They had found that that when they lacked time, the persons often increased their acute hospital visits, as the long waiting made the persons more desperate for help.The participants expressed that, in health care, little attention was given to persons as unique persons or the possibility to adapt treatment and care for each person.
When caring for persons with mental ill-health and somatic comorbidity, the participants felt they had a great deal of responsibility, especially when physicians lacked experience in psychiatric care and when there was a lack of continuity.As an example, they stated that they often had to remind physicians about the persons' physical ill-health.
We have physicians jumping in and out, who don't have an overall perspective.So we've been given quite a big responsibility, I think, to remind them about physical ill-health.(U3) The participants wanted the PHCC to work on motivating the persons, and to continue to call the person or to contact the psychiatric hospital to get help to reach the person.They considered it important for the persons to have relevant contacts both within the psychiatric hospital and at the PHCC.They wanted MHNs at the PHCC to have a clarified role, and they felt that this role should include responsibility for the persons' physical ill-health and cooperation with the psychiatric hospitals.To reduce the risk of incorrect priorities, they believed that the persons physical health should primarily be the responsibility of the MHN at the PHCC who had relevant knowledge about both mental and physical ill-health.The participants had experienced that a lack of MHN at the PHCC meant that persons' situations often needed to be discussed at the management level, due to a lack of understanding of the persons ill-health as a whole.
Asking for enhanced collaboration.The participants described varying degrees of collaboration with other caregivers.Some had experienced a lack of collaboration with the PHCC, with the only interaction being referral procedures between physicians.They saw a need for enhanced collaboration, and wanted there to be a clear structure that would make things easier for both persons and themselves.Some of them had found that certain PHCCs sent referrals and collaborated more often than others.Moreover, some had had joint meetings with PHCCs that produced good results, including exchange of information and finding joint solutions for certain somatic conditions such as pain and substance abuse.The MHNs working at the PHCC were seen as an extended arm of the health center, and the collaboration with primary health care nurses and MHNs at the PHCC was described as rewarding.In the participants' experience, the MHNs understood the persons' problems and facilitated care contacts.
When the person did not have access to an MHN, collaboration with primary care was perceived as more challenging.The participants themselves saw the potential for improvement in terms of enhanced communication with the MHNs, and felt that collaboration would be better if they met occasionally.More knowledge about each other's organization of care was suggested as something that would be beneficial for persons.The participants expressed that there was a need for consultations about certain persons, and that it was important to have some overlap between psychiatric and somatic care.
Within and between the psychiatric clinics, collaboration around persons mostly worked well, and the participants expressed that it was easier to get in touch within this context than to get in touch with the PHCC.However, they suggested hospital-wide meetings for increased knowledge and sharing information, and asked for meetings to exchange experiences within the hospital, between different units, and with other colleagues.They also felt that communication and collaboration could be improved if it was easier for persons and other healthcare providers to contact them, as availability was described as key.
So that we don't end up sitting in two corners and talking about the same person, and then having different plans and different medications which risk colliding.(U4)

Discussion
The aim of this study was to describe RNs' experiences of caring for persons with mental ill-health and somatic comorbidity in psychiatric outpatient care.The results show that the participants' experiences were focused on monitoring the persons' right to equal care, that the participants embraced the whole of the persons suffering and dealt with unclear boundaries within care.
In order to develop a clear picture of what is valued by the person, RNs should focus on facilitating participation and joint decision-making.Providing information would facilitate this process, as the basis for decision-making is that the person feels properly informed (McCormack & McCance, 2010).Participants in the present study expressed that they taught the persons about physical symptoms and health consequences, and also informed other caregivers about the persons' conditions and the need for adaptation.By strengthening the person and working with shared decision-making, the nurse has an advisory function which involves informing and giving advice to persons without giving them a passive role (Lundström et al. 2020).According to McCormack and McCance (2010), person-centred processes involve working with persons' beliefs and values.Qualities such as commitment, sympathetic presence, shared decision-making, and willingness and ability to meet physical needs are significant factors.
Results showed that RNs desired to assist other caregivers with their knowledge of persons and their mental health.Other research has shown that RNs in psychiatric care wish to be supported by RNs with somatic competence who can focus on the persons physical health (Lundström et al. 2020).Based on this, there seems to be both a need and a desire for the exchange of knowledge and collaboration between RNs in caring for persons with mental ill-health and somatic comorbidity.Current research also highlights the importance of RNs in psychiatric care having a clinical view of physical needs and believes that physical health is their responsibility (Lundström et al. 2020).The RNs in our study did not explicit state that physical health was their responsibility, but they considered the persons' physical health and addressed physical needs when caring for them.This is inconsistent to findings of prior studies stating that mental healthcare professionals sometimes choose not to act on physical ill-health (Gray & Brown, 2017;Heslop et al. 2016;Lerbaek et al. 2019).The cause of this disparity lies outside the scope of this study but explanations for the variance from prior studies could be the philosophy of care, workplace norms as well as differences in education and training of nurses.
Our results indicate that there are differences in care and treatment of persons with mental ill-health.Stigmatizing attitudes and actions toward persons with mental ill-health within somatic health care settings is a worldwide challenge (Sølvhøj et al. 2021).For example, studies have shown that persons with severe mental ill-health run a greater risk than others of dying or needing hospitalization for infectious diseases (Nilsson et al. 2021), including COVID-19 (Maripuu et al. 2020;Nilsson et al. 2021).Our results also show that it could be challenging to assess persons' symptoms, and that persons are often referred several times to other clinics in health care.Further, psychiatric care tends to see only psychiatric symptoms, while within somatic care, persons' physical ill-health seems to be explained as psychiatric issues.Research shows that health care is still divided into body and mind, and that a more person-centred view of the persons health is needed (Lundström et al. 2020).PCC requires that the persons needs are met in several ways: psychologically, physically, socially, and spiritually (McCormack & McCance, 2010).The RNs in our study described experiences of persons receiving the wrong treatment in somatic care, and stated that there was still stigma and ignorance in the care of persons with mental ill-health.This is in line with the results of Fiorillo and Norman (2021), who found that physicians often had a negative attitude toward persons with mental ill-health and underestimated the severness of persons experiences and signs of physical ill-health.Ihalainen-Tamlander et al. (2016) report that MHNs show a greater extent of willingness to help persons with mental ill health and having more sympathy and concern for these persons.Further, Tranter and Robertson (2023) report that MHN's have opportunities to promote positive physical health outcomes for patients.Both the willingness and the opportunities to help is mirrored in our results.
According to Happell et al. (2016), physical symptoms are often interpreted as reflecting mental rather than physical health, despite awareness of the high prevalence of physical health problems in persons with mental ill-health.Known as "diagnostic overshadowing", this practice increases the risks of delays in treatment and can lead to the development of complications.Diagnostic overshadowing is considered to be due to negative attitudes, lack of knowledge by healthcare professionals, and stigmatization (Nash, 2013).Persons with mental ill-health often experience powerlessness arising from negative experiences of seeking help and having their physical health problems dismissed (Ewart et al. 2016).MNHs in psychiatric care play a key role in preventing diagnostic overshadowing, by balancing the biomedical perspective in care with other approaches (Happell et al. 2016).They are a central resource for other care professionals, providing them with the knowledge to better support persons with mental ill-health in their recovery and to help these persons achieve equity in physical health.Working to promote health has been described as a challenge as it questions the dominance of the biomedical perspective's focus on diagnosis and treatment (Jormfeldt et al. 2018).This is also visible in our results, and supports the need for MNHs to lead the work of implementing PCC in psychiatric care.Our results show that it can be seen as difficult to know who should be responsible for the various parts of the person's care.The RNs in the present study described that they needed to guard the person's right to be cared for by other care providers.Being responsible for the coordination of overall health can be a burden, and this burden needs to be shared between care providers.Cooperation is important, and there is a need to clearly state who is responsible for what (Lundström et al. 2020).
The present results show that RNs want to have more time for the persons, in order to succeed in meeting each person with respect and building the relationship on which care rests.According to Haddad et al. (2016), lack of time and high workload do not prevent RNs from incorporating health promotion activities, but Happell et al. (2013) identified lack of time as a barrier to taking on the role of physical health care.In accordance with the ethics of PCC, being consistent in all situations is considered difficult, as it requires awareness in every action, all working methods, and all routines.The overall organization needs to be adapted for this, and there needs to be a learning and conscious investment that extends beyond basic value documents (Swedish Institute for Standards, 2020).Although the RNs in our study asked for more MHNs at the clinic, they also explained that there were few applicants for such positions.Research shows that RNs' role in psychiatric outpatient care is considered invisible and unclear, but also misunderstood by the employer, leading to difficulties in recruitment (Terry, 2019).Thus, in line with previous research, we argue that the role of RNs in psychiatric outpatient care needs to be clarified (Harris & Panozzo, 2019;Lundström et al. 2020).
Our results reveal the great responsibility that RNs take on when it comes to the care of persons with mental ill-health and somatic comorbidity.The participants described how they needed to remind physicians about somatic diseases.Fiorillo and Norman (2021) found that psychiatrists focus on the psychiatric symptoms, have poor communication and cooperation with the PHCC, and rarely carry out physical examinations.We argue that this could be due to psychiatry being separated from other parts of medicine, and the fact that mental ill-health and somatic comorbidity is not sufficiently recognized during psychiatrists' basic and postgraduate training.Our results show a varying degree of cooperation with the PHCC, and it also appeared that the management did not attach importance to collaboration meetings and scheduled consultation with the PHCC.Other studies have found that cooperation between care providers is required in order to enable a healthy life and improved physical health for persons with mental ill-health (Blomqvist, Ivarsson, et al. 2018).As proposed by Happell et al. (2019), MHNs could adopt the role of physical health nurse consultants.In a Swedish context, this could involve facilitating the process of gathering relevant information, including sampling when necessary and monitoring medication side effects, collaboratively planning health checkups with the person, and, with their consent, providing essential support and facilitating communication with other levels of care.However, it is crucial that decisions regarding collaboration are made at a broader organizational level (Lundström et al. 2020).

Methodological considerations
One challenge with qualitative analysis is the freedom to abstract data, as there is a risk that the level of abstraction will become too high and too far from the original text (Graneheim et al. 2017).We deliberately stayed close to the text during condensation and coding, and conducted discussion together to avoid losing the overall picture.The degree of abstraction became higher when forming subthemes and themes, as we were able to see patterns.Our different experiences and knowledge in somatic and psychiatric care contributed to the results being interpreted from different perspectives, which can be seen as a strength.
We employed purposive sampling to target participants with experience of the phenomenon.Purposive sampling can be criticized for limiting data to a few perspectives.Nevertheless, our data mirrors a variance of experiences conveyed by participants who varied in age, sex and had different work-life experience from psychiatric as well as somatic care.Further, the researchers had no preexisting relationships with participants and were not involved in the care.The study did not investigate whether the nurses with a master degree in mental health nursing held identical or varying roles and levels of autonomy in delivering care, or their use of treatment philosophies.This could be perceived as a limitation.However, this aspect was not within the scope of our current study but could be explored in future research.
Data-collection was performed on-site, and via a video platform.Keen et al. (2022) argues video-performed interviews could be seen as a complementary method that can enable data collection when meeting in person is not possible.Using such methods for interviews has both advantages and disadvantages.Krouwel et al. (2019) argue that video interviews are considered to be similar to face-to-face interviews, with the latter being only marginally superior.
The median duration of the interviews in this study might be considered as short, however, Sandelowski (1995) concludes that what determines data quality is a matter of judgment and experience in evaluating the quality of the data related to the aim and the choice of method.We believe that the richness of data and the sample was sufficient and covered significant variations (cf.Johnson et al. 2021).

Conclusion
This study highlights the unique role that RNs play in psychiatric outpatient care, via their ability to interpret and understand both physical and mental symptoms and to find ways to adapt the care on the basis of the person's needs.Ignorance and stigmatization of persons with mental ill-health can lead to mistreatment in the face of somatic care.RNs consider physical health in all care, and are therefore a link between psychiatric and somatic care.In collaboration with the MHNs at the PHCC, RNs in psychiatric out-patient care should have a key role in reducing persons' suffering and monitoring the person's right to equal care.Decisions on such collaborations need to be made at an organizational level.

Relevance for clinical practice
Organizationally, there is a need for structural as well as functional collaboration both within and outside organizations.This seems consistent with the tenets of person-centred care, emphasizing both partnership and collaboration.More research from the perspective of persons in care is needed to increase the understanding of supportive methods promoting physical health in psychiatric outpatient care.
It's not the whole answer, when they sit in the chair in the room and say, 'I have such a pain in my stomach.' You get to know them first, and then you can start talking about their stomach.(U5)

Table 1 .
Overview of the results.