Participant characteristics
Four focus groups were conducted, see figure 1. Focus groups 1 and 4 consisted of nursing staff, all female with different levels of education [31]. Focus group 1 encompassed of licensed practical nurses (LPN; N=2; educational level EQF3), LPN responsible for the coordination of care for individual residents (RLPN; N=1, educational level EQF3), and the unit manager (UM; N=1; physiotherapist) of the care unit. Focus group 4 consisted of the following participants: LPN (N=2, educational level EQF3), RLPN (N=2, educational level EQF3), nurse assistants (NA; N=2; educational level EQF2) and UM (N=1; registered nurse; educational level EQF6). The focus group of treatment staff consisted of: registered nurses: responsible for behavioral treatment decisions outside office hours (RN; N=2), psychologists (P; N=2), a nurse practitioner: functioning at the level of a physician (NP; N=1, educational level EQF7) and a behavioral coach: responsible for behavioral treatment decisions within office hours (BC; N=1), one of whom was male. The last focus group consisted of four partners and two adult children of the residents. Half of the relatives was female, half was male. The focus groups took between 84 and 115 minutes. In the results presented below, the word ‘participants’ is used when participants of all four focus groups reported these findings, in any other case the participant’s function is mentioned.
Thematic analysis
The analysis resulted in the identification of eight themes of barriers: ‘Organizational barriers’, ‘Personal barriers’, ‘Deficiency of knowledge’, ‘Inadequate (multidisciplinary) collaboration’, ‘Suboptimal communication’, ‘Disorganization of processes’ ‘Reactive coping & resilience of organization’ and ‘Differences in perception’. These interacting themes of barriers were brought together in a framework explaining the extent to which change is impaired in a nursing home given the existing barriers. Some of these barriers are explicitly linked to prohibiting change, as shown in corresponding quotations, others regard impediments to good care, indirectly impairing change. Firstly, we will describe the barrier-subthemes and themes: the building blocks of which the framework is composed. Thereafter, the framework, which shows the relationships between the themes, will be described.
Additional quotations to the ones mentioned in the results below, are included in Table 1 (appendix). Each quotation is addressed by its corresponding code: the letter corresponds with the theme, the number with the quotation within that theme, i.e. A1, H5.
A. Organizational barriers
The first theme consists of barriers that were related to the organization and organizational decisions. This theme is composed of the following subthemes: ‘Use of temporary staff’, ‘Insufficient staff on the unit’, ‘Staff turnover’, ‘Lack of time’ and ‘Continuous education’. The ‘use of temporary staff’ and a ‘lack of sufficient staff’ on the unit (A4) inhibited the implementation of interventions as well as the continuity of care (A1). In addition, a difficulty in maintaining the continuity of care was caused by a ‘turnover’ within the ranks of the physicians (A13) and a ‘turnover’ within the nursing staff (A7, A12). Furthermore, these barriers impeded the extent of change reached.
“We have actually had many different physicians here the past year, now another new one. And every physician has also their own method. And own mindset. And has their own vision on this [psychotropic drug prescription]. And we have to change, but the resident as well.” RLPN (pa22)
Moreover, a lack of time influenced the transferring and consistency of information between staff (A1). Lastly, participants indicated that continuous (cyclic) training for nursing home staff was important to get inspired, acquire new insights, and to in incorporate these insights into daily practice (A17). The absence of continuous (cyclic) training is a barrier to change.
B. Personal barriers
The second theme consists of barriers that are related to personal factors. This theme is composed of the following subthemes: ‘Motivation and effort’, ‘Initiatives by staff’, ‘Emotions of staff’ and ‘Emotions of relatives’. Participants stressed differences in ‘motivation and effort’ among staff members. Some considered it important to show motivation in relation to the work ethics to colleagues by sometimes staying a little bit longer on the unit when necessary (B1) or by showing effort to gain more knowledge on for example diseases, but mentioned that others did not.
B4: “It’s also up to the person, I think. One is interested more quickly, as you said yourself, to search themselves, what fits with this disease, what should I think of? Is there another approach necessary? Someone else might think: Do I care? I work here and that’s it. {…} I think there are a lot of differences between colleagues. RLPN (pa4)
One will deepen their knowledge more than others.” RLPN (pa4)
Furthermore, the benevolence of the multidisciplinary team to change and to maintain that change in order to improve quality of care, impacts the motivation of individual staff members to change (B2). Moreover, consequences of not taking action by staff when needed and to reflect on their own actions, as was summarized in ‘initiatives by staff’, were deemed important barriers (B5-B7). Another important barrier-subtheme included in the theme personal barriers was ‘emotions of staff’. It primarily entailed emotions of nursing staff about hopelessness around the interaction with residents or treatment staff and the proposed treatment of behavior (B9-B11).
The ‘emotions of relatives’ might influence the amount of change, through a disappointment felt over and over again. In particular, emotions of relatives were apparent when problems arose on the unit with their relative. Relatives sometimes felt disappointed about turnover of staff and temporary workers (B12).
C. Deficiency of knowledge
The third theme consists of barriers that are related to knowledge. This theme is composed of the subtheme: ‘Deficiency of knowledge’. The treatment of NPS and therefore also prescription of psychotropic drugs was strongly related to knowledge of staff, or a deficiency thereof (C1).
“And if someone totally panics because he sees big spiders walking on the wall, then you know…. Oh… that fits into the picture of the disease. So he sees things that are not there. You can panic about that and so yes… as long… as you don’t have that knowledge… then you would think… well that man is not well at all. I have to call the physician quickly as he has to go to the hospital.” LPN (pa3)
D. Inadequate (multidisciplinary) collaboration
The fourth theme consists of barriers that are related to inadequate (multidisciplinary) collaboration. This theme is composed of the following subthemes: ‘Evaluation’, ‘(Multidisciplinary) consultation of key disciplines’ and ‘Multidisciplinary consultations / meetings’. The participants indicated that lack of evaluations of initiated processes of change and of treatments started was a key barrier in inadequate (multidisciplinary) collaboration.
“In past several years, if someone has a restriction of freedom, than that usually remained that way. And before it comes up for discussion again or before it gets discussed like ‘is it actually still necessary that someone is restrained’, that woman is not going to get up anymore. That you… If no one makes a remark about it, that that sometimes persists longer than necessary.” BC (pa10)
Lastly, not consulting other key staff members impaired a healthy (multidisciplinary) collaboration, even though the exclusion of these members was not done consciously (D3). Additionally, having frequent meetings with this staff was considered valuable and a lack thereof might have impaired the establishment of new and effective treatments for residents (D6).
E. Suboptimal communication
The fifth theme consists of barriers that are related to communication. This theme is composed of the following subthemes: ‘Flawed communication’, ‘Sharing experiences’, ‘Unclear communication of changes with family’, ‘Communication with relatives takes time’, and ‘Little participation of relatives’. The theme ‘suboptimal communication’ is a very broad theme, which entails different kinds of communication such as: 1) communication between staff as seen by relatives, 2) communication between staff as seen by the staff and 3) communication between relatives and staff as seen by staff and relatives.
One of the relatives of a resident described the communication between nursing staff members as flawed, which, in turn, impaired the quality of care (E1). Participants stated ‘sharing experiences’, such as asking for help and sharing success stories, was important to inspire each other into improving care, whereas lack thereof was seen as a barrier.
“Especially the old school [LPN], they really have a… really a… a culture of wanting to control, they want to have the right touch. And if they need to ask for help, sometimes that is a… that is too much to ask. Or a… Or… One is not so easily inclined to share a problem. They keep it to themselves. And I find that very unfortunate.” BC (pa10)
In addition, there was confusion about the communication of changes (for example in medication) with family. Physicians expected nursing staff to discuss certain changes in medication with relatives, while the nursing staff experienced difficulties explaining these to the relatives due to flawed reporting by the physician in the patient file (E6). Furthermore, an LPN remarked that because communication about the resident with relatives was time consuming, often only the bare essentials were discussed. This resulted in incomplete information in the patient file (E8).
Moreover, ‘Little participation of relatives’ was an important aspect, since the relatives played a major role in the life of residents on the units. One of the registered nurses explained that participation of relatives on the units was essential, because relatives provide a quiet atmosphere in the living room, which resulted in less NPS (E12).
F. Disorganization of processes
The sixth theme consists of barriers that are related to disorganization of processes. This theme is composed of the following subthemes: ‘Unstructured processes’, ‘Ambiguity of the division of responsibilities and tasks’ and ‘Decision-making culture’. This theme entailed information related to the obstacles, either culture-based or related to a key person, in organizing (care) processes. The necessity of structuring evaluation and consultation about NPS and its treatment was primarily mentioned by the nurse practitioner and psychologists (F1, F3). Furthermore, obstacles in structuring processes were mentioned, such as ideas that do not converge (F4). Moreover, participants expressed confusion concerning the division of responsibilities and tasks. Especially ambiguity about the person who manages the process of care was mentioned (F9, F11).
“I think it is important, that they are in their position… from which you can collaborate. So that it is clear, who does which task? Eh… Who is the coordinator? Is the physician the main point of contact in case of NPS or is it the nurse practitioner? Or is it the psychologist? I sometimes find that difficult, I sometimes think who is the captain on that ship?” P (pa6)
Lastly, within this theme, the ‘unfulfilled expectations of management’ and their support of staff are important barriers. Staff expected the unit manager to coach and inspire the nursing staff, while in practice the unit managers were predominantly busy with planning tasks (D7).
The last item mentioned in this theme was the culture of trying to reach consensus when making a decision. This culture was seen as frustrating by participants, which elongated the time necessary to structure processes (F12).
G. Reactive coping & resilience of organization
The seventh theme consists of barriers that are related to resilience of the organization or reactive coping of the persons within that organization. Reactive coping is a coping style in which one awaits circumstances to unfold before responding, which may complicate initiation or maintenance of change. This theme is composed of the following subthemes: ‘Difficulty breaking patterns’, ‘Concerns relatives on changing practice’, ‘Responding late to behavior’ and ‘Not signaling changes in behavior’. Participants mentioned how difficult it was to change existing practice and that sometimes they encountered resistance (G2, G3). The manager of one of the care units explained that it is difficult to break existing patterns, to change.
“…things that are going like this for years, yes that is very hard to break through, to change. That is in everything on this care unit.” UM (pa1)
Furthermore, the organization did not proactively involve the relatives in the decision process. Relatives voiced their concerns about the way their input about the care of their relative was not used in the nursing home. They said they did not have any influence on the care process (G4) and that although the relatives were sometimes consulted by the nursing staff, this consultation took place after the final decision already had been made (G5).
In addition, an LPN mentioned a tardiness in responding to behavior of residents by involving other disciplines afterwards, when the damage was already done (G10). Although interventions have been used to improve the timing, nursing staff maintained their behavior of delayed responding. ‘Responding late to behavior’ and ‘Not signaling changes in behavior’ by staff impaired the care process (G11).
H. Differences in perception
The eighth theme consists of barriers that are related to differences in perception. This theme is composed of the following subthemes: ‘expressed differences in perception between colleagues’ and ‘observed differences in perception between colleagues’. The first subtheme was mentioned by participants in the focus groups, while the second was observed in the different focus groups by the researchers. These two subthemes are a broad collection of all differences and controversial views expressed and observed in the focus groups.
There were two ways by which ‘the differences in perception between colleagues’ became clear. First, the participants mentioned differences in the experience of norms and values (H1), vision and work approach and attitude between colleagues (H2, H3). Secondly, there was a difference in view on the course of affairs on for example evaluations by physicians/psychologists and care staff, as was illustrated by the psychologist and nurse practitioner.
“I think those [restrictions of freedom of the resident] are being evaluated by the physician in the rounds, monthly. That’s not something that’s discussed multidisciplinary…” P (pa6)
If I’m honest, I have never experienced that [evaluation of restrictions of freedom of the resident] before.” NP (pa7)
These quotes show that the different disciplines were not aware of the activities, work and tasks of the other. In addition, several intercollegiate differences in perception were observed by the researchers, while transcribing and analyzing the data, using memos. The psychologist mentioned he did not see any need in the presence of registered nurses in the multidisciplinary meetings about behavior of residents, while later on in the same focus group, the nurses emphasized it would have been useful for them to be present in such meetings.
“People are broadly discussed in the multidisciplinary meetings. There we address what they need… {…} What would be good interventions, fitting for that person. So, then we have a much broader context than… where we talk about someone. Of course, not everyone is present. For example, you [registered nurses] do not have anything to do with that.” P (pa5)
“We are actually never present at such meetings [multidisciplinary consultation]. No… Well I have to say that the last period I’m not being called so often to… Well where we were just talking about. Regarding restlessness with the residents, even apart from the fact that a few years back we got many phone calls. It would have been relevant if we’d be present there. Because we work in the evenings, we work at night, the weekends. We are here such a big part of the time. We are always the ones that get called.” RN (pa8)
Furthermore, the nurse practitioner thought nursing staff informed relatives about changes in medication. However, nursing staff were under the impression that the nurse practitioner or physician would inform the relatives (H9, H10). Another contradiction was observed about the assumptions on necessity to structure meetings between a unit manager and behavioral coach/nurse practitioner. The unit manager did not want to structure the frequency of evaluation meetings; according to her, this was not necessary in a small setting. The other group, however, emphasized that structuring the frequency and time of these meetings would improve the continuity of care., because the meetings often didn’t take place (H7, H8).
Moreover, the staff remarked that relatives had little complaints, while relatives mentioned many complaints in their focus group, for example on staff turnover (H11, H12).
Relationship and hierarchy between barrier-themes.
Next, based on the accounts of the participants and our observations, we will explain the relations and hierarchy between the different themes by means of a framework (see Figure 2).
Figure 2 starts at the bottom with the themes ‘Organizational barriers’ and ‘Deficiency of knowledge’. Participants mentioned ‘Organizational barriers’ (especially turnover and temporary staff) in relation to all mentioned themes above, making this theme one of the starting points for the possible hindrance of change. On the same level, we identified the theme ‘Deficiency of knowledge’, which was directly influenced by ‘Organizational barriers’; participants mentioned that a ‘lack of time’, ‘staff turnover’ and the ‘use of temporary staff’ in itself created a deficiency of knowledge in the unit. One of the relatives described the phenomenon of ‘temporary staff’ as follows: “They are appointed by the employment agency, well… nine out of ten times, they do not know chalk from cheese.” FM (pa14)
The third layer consists of an interaction between the themes ‘Suboptimal communication’ and ‘Inadequate (multidisciplinary) collaboration’, ‘Differences in perception’ and ‘Disorganization of processes’. ‘Suboptimal communication and ‘Inadequate (multidisciplinary) collaboration’ were so strongly related that they were put in the same box, there was no way to say which of these themes influenced the other. A poor quality of communication impeded good collaboration and sharing of information, which disrupted structuring of processes. The following was said about this relation: “I think it is important, that there is a starting point from which you can collaborate. In order that it is clear, who does which task? Eh… And who is the leader, who is the point of contact in case of NPS, the physician?” P (pa6).
‘Suboptimal communication’ and ‘Inadequate (multidisciplinary) collaboration’ were causes for observed discrepancies in perception and assumptions. These observed discrepancies in perceptions and assumptions led to unstructured processes, according to the participants (F7 & F8, F9 & F10, G3). There was no structured approach and there were many ambiguities about agreements made (G7 – G10). Moreover, the unstructured approach and ambiguous agreements resulted in impediments for a structured collaboration and structured deliberations on NPS.
Next, there were two relations: first, ‘Personal barriers’ separately enhanced the negative influence of ‘Reactive coping & resilience of organization’, which is strongly related to ‘Disorganization of processes’ and, through that theme, to the extent of change. Second, an interaction is present between ‘personal barriers’ and ‘disorganization of processes’, via ‘reactive coping’ ‘Initiative by staff’ is absent, there is usually a reactive coping style, which inhibits the start of structuring processes. In their turn, the subsequent difficulties which can be encountered, cause a reactive coping style and frustration (emotions) in staff.
“But, again, today I encountered that the behavioral coach wasn’t contacted. So, I think that’s very frustrating.” NP (pa7)
It was difficult to break already existing behavioral patterns and try a new approach, which impeded collaboration to structure processes (H5, H7). ‘Personal barriers’ were related to all themes except organizational barriers. They were strongly related to the theme ‘deficiency of knowledge’, since the barrier-subtheme ‘motivation and effort’ was a necessity to increase knowledge of staff (B4). Furthermore, according to the participants, good communication and collaboration were a result of ‘motivation and effort’ of, and ‘initiative taken by staff’.
“I’m always a little bit earlier, you [other LPN] always come a little earlier too, so you’ll sit down or leave later. That facilitates information exchange. RLPN (pa23)
Because I just joined the team, I think it’s very important for me to receive more information. Obviously, you read, but it is more pleasant to consult like this [face-to-face]. So sometimes I stay a little bit longer.” LPN (pa19)
Finally, the result of all previously mentioned themes of barriers, influences the extent to which change of care processes is impaired in the nursing homes.