Process evaluation of a tailored intervention to Reduce Inappropriate psychotropic Drug use in nursing home residents with dementia.

BACKGROUND: Research suggests that collaborative and tailored approaches with external expertise are important to process implementations. We therefore performed a process evaluation of an intervention using participatory action research, tailored information provision, and external coaching to reduce inappropriate psychotropic drug use among nursing home residents with dementia. The process evaluation was conducted alongside a randomized controlled trial assessing the utility of this approach. METHODS: We used Leontjevas' model of process evaluation to guide data collection and analysis, focusing on the relevance and feasibility, extent of performance, and barriers and facilitators to implementation. Data on the relevance and feasibility and on the extent of performance were collected using a questionnaire targeting internal project leaders at nursing homes and our external coaches. Implementation barriers and facilitators were identified by individual semi-structured interviews. The Consolidated Framework for Implementation Research was used to structure and describe the identified barriers and facilitators. RESULTS: The intervention was viewed positively, but it was also considered time consuming due to the involvement of many people and designing a tailored action and implementation plan was viewed as complex. The extent of performance differed between nursing homes. Delays in implementation and suboptimal execution of actions may have reduced effectiveness of the RID intervention in some nursing homes. Barriers to implementation were reorganizations, staff turnover, communication issues, unclear expectations, and perceived time pressures. Implementation also depended on the involvement and skills of key stakeholders, and organizations' readiness to change. Although external coaches stimulated implementation, their additional value was rated variably across organizations. CONCLUSIONS: Barriers to implementation occurred on several levels and some barriers appear to be inherent to the nursing home environment and could be points of leverage of future implementation trajectories. This underlines the importance of assessing and supporting organizations in their readiness to change. Sensitivity analyses, taking into account the week in which nursing homes started with implementation and the degree to which actions were implemented as intended, will be appropriate in the effect analyses of the trial.

The construction of a conceptual framework explaining the relation between barriers to change of management of neuropsychiatric symptoms in nursing homes: a qualitative study using focus groups.

BACKGROUND: Several efforts have been made to change management of neuropsychiatric symptoms (NPS) in nursing homes, however only few were successful. Numerous barriers to change in healthcare were identified, yet only one conceptual model is known to study their interrelationships. Unfortunately, this model does not discuss specific barriers encountered in nursing home practice. The aim of this study is to explore perceived barriers to change in the management of NPS in nursing homes and to construct a conceptual framework providing insight into the relative importance and interrelationships of these barriers when improving quality of care. METHODS: Four focus groups were conducted in different dementia special care units of one Dutch nursing home. Participants were either nursing staff, treatment staff or relatives of residents. Qualitative thematic analysis was conducted according to the five phases defined by Braun & Clarke. Finally, a conceptual framework showing the interrelations of barrier-themes was constructed using text fragments of the focus groups. RESULTS: We constructed a conceptual framework consisting of eight themes of barriers explaining the extent to which change in NPS-management can be achieved: 'organizational barriers', 'personal barriers', 'deficiency of staff knowledge', 'suboptimal communication', 'inadequate (multidisciplinary) collaboration', 'disorganization of processes', 'reactive coping' and 'differences in perception'. Addressing 'organizational barriers' and 'deficiency of staff knowledge' is a precondition for change. 'Suboptimal communication' and 'inadequate (multidisciplinary) collaboration' play a key role in the extent of change achieved via the themes 'differences in perception' and 'disorganization of processes'. Furthermore, 'personal barriers' influence all themes - except 'organizational barriers' - and may cause 'reactive coping', which in turn may lead to 'difficulties to structure processes'. CONCLUSIONS: A conceptual framework was created explaining the relationships between barriers towards achieving change focused on improving management of NPS in nursing homes. After this framework has been confirmed and refined in additional research, it can be used to study the interrelatedness of barriers to change, and to determine the importance of addressing them for achieving change in the provided care.

Reducing inappropriate psychotropic drug use in nursing home residents with dementia: protocol for participatory action research in a stepped-wedge cluster randomized trial.

BACKGROUND: Psychotropic drugs are often prescribed to treat neuropsychiatric symptoms in nursing home residents with dementia, despite having limited efficacy and considerable side effects. To reduce the inappropriate prescribing of these psychotropic drugs, various non-pharmacological, psychosocial, person-centered, or multidisciplinary interventions are advocated. However, existing multidisciplinary interventions have shown variable effects, with limited effectiveness often resulting from suboptimal implementation. We hypothesize that an effective intervention needs to fit the local situation of a nursing home and that support should be offered during implementation. METHODS: We will embed participatory action research within a stepped-wedge cluster randomized controlled trial to study the effects of a tailored intervention and implementation plan to reduce inappropriate psychotropic drug prescribing. Nursing homes will be provided with tailored information about the perceived problems of managing neuropsychiatric symptoms and we will offer coaching support throughout. Alongside the participatory action research, we will perform a process evaluation to examine the quality of the study, the intervention, and the implementation. Our aim is to recruit 600 residents from 16 nursing homes throughout the Netherlands, with measurements taken at baseline, 8 months, and 16 months. Nursing homes will be randomly allocated to an intervention or a deferred intervention group. During each intervention stage, we will provide information about inappropriate psychotropic drug prescribing, neuropsychiatric symptoms, and difficulties in managing neuropsychiatric symptoms through collaboration with each nursing home. After this, a tailored intervention and implementation plan will be written and implemented, guided by a coach. The primary outcome will be the reduction of inappropriate prescribing, as measured by the Appropriate Psychotropic drug use In Dementia index. Secondary outcomes will be the frequency of psychotropic drug use and neuropsychiatric symptoms, plus quality of life. A mixed methods design will be used for the process evaluation. Effects will be assessed using multilevel analyses. The project leader of the nursing home and the coach will complete questionnaires and in-depth interviews. DISCUSSION: We anticipate that the proposed tailored intervention with coaching will reduce inappropriate psychotropic drug prescribing for nursing home residents with neuropsychiatric symptoms. This study should also provide insights into the barriers to, and facilitators of, implementation. TRIAL REGISTRATION: NTR5872 , registered on July 2, 2016.