Introduction
The prevalence of neuropsychiatric symptoms (NPSs) associated with dementia is high. Over 80% of people with dementia in nursing homes (NHs) exhibit NPS (Selbæk et al., Reference Selbæk, Engedal and Bergh2013). The treatment of NPS often consists of the prescription of psychotropic drugs (Cornegé-Blokland et al., Reference Cornegé-Blokland2012; Nijk et al., Reference Nijk, Zuidema and Koopmans2009; Selbaek et al., Reference Selbaek, Kirkevold and Engedal2007; Wetzels et al., Reference Wetzels2011), despite concerns about their limited efficacy (Seitz et al., Reference Seitz2013; Sink et al, Reference Sink, Holden and Yaffe2005; Zuidema et al., Reference Zuidema2007) and side effects (Zuidema et al., Reference Zuidema2006). Hence, nonpharmacological interventions are recommended as a first-line treatment for managing NPS.
NPSs are the result of interactions of biological, psychological, social, and physical environmental factors (Cohen-Mansfield, Reference Cohen-Mansfield2000; Steinberg et al., Reference Steinberg2006; Zuidema et al., Reference Zuidema2010). Complex, multicomponent interventions seem to be the most appropriate approach to address these, given the multifactorial origin of NPS. Complex interventions comprise multiple interacting components and are characterized by the number and difficulty of behaviors required by those delivering or receiving the intervention, the number of groups or organizational levels targeted by the intervention, the number and variability of outcomes, and the degree of flexibility or tailoring of the intervention permitted (Craig et al., Reference Craig2013).
Although complex interventions have the potential to reduce inappropriate prescribing of antipsychotic drugs in NHs (Livingston et al., Reference Livingston2017; Thompson Coon et al., Reference Thompson Coon2014), these interventions commonly show small to modest effects (O’Connor et al., Reference O’Connor2009; Quasdorf et al., Reference Quasdorf2016; Zwijsen et al., Reference Zwijsen2014a), which often reflects suboptimal implementation rather than shortcomings of the implemented intervention (Anderson et al., Reference Anderson2013; Craig et al., Reference Craig2013).
To examine barriers and facilitators influencing the implementation of complex interventions for people with dementia in long-term care, we reviewed literature on process evaluations, qualitative studies, and (cluster) randomized controlled trials targeting NPS and/or psychotropic drug use (PDU). By assembling knowledge about factors influencing implementation of complex interventions, effectiveness of interventions can be maximized, and translating results into practice is enabled which in turn enhances widespread implementation (Craig et al., Reference Craig2013; Lawrence et al., Reference Lawrence2012; Thompson Coon et al., Reference Thompson Coon2014; Quasdorf et al., Reference Quasdorf2016; Zwijsen et al., Reference Zwijsen2014b).
Methods
Eligibility criteria
A predefined protocol was developed and registered on PROSPERO (CRD42018112731), on November 9, 2018, and is available in full on the National Institute for Health Research website: https://www.crd.york.ac.uk/prospero/ (Groot Kormelinck et al., Reference Groot Kormelinck2018).
Types of studies
We included process evaluations, qualitative studies (that may include quantitative process data), and (cluster) randomized controlled trial studies that reported barriers and facilitators affecting the implementation of complex interventions targeting NPS/PDU for residents with dementia in long-term care. Systematic reviews or studies not being published in peer-reviewed journals were excluded.
Types of interventions
This review was limited to studies targeting implementation barriers and facilitators of complex interventions aimed at PDU (antipsychotics, anxiolytics, hypnotics, antidepressants, anticonvulsants, anti-dementia drugs) and/or NPS (umbrella term, or at least one symptom). We defined a complex intervention as introduced by Craig et al. (Reference Craig2013, p.588): “multiple interacting components, a certain number and difficulty of behavior of those delivering or receiving the intervention, the number of groups or organizational levels the intervention targets, the number and variability of outcomes and the degree of flexibility or tailoring of the intervention permitted.”
Search
Electronic databases were searched to identify relevant studies. The search was applied to PubMed, Web of Science, PsycINFO, Cochrane, and CINAHL. Searches were run between 28 May and 4 June 2018. No publication date restrictions were imposed. Studies published in English, German, and French were eligible for inclusion. Key search terms related to institution, outcome (barriers, facilitators), and psychotropic drugs or NPS. For full search strategy, see Appendix A1, published as supplementary material online.
Study selection method
Two reviewers (CMGK and SIMJ) independently screened titles and abstracts and selected potentially relevant articles for full-text review. Duplicates were removed using reference manager software (Refworks), after which two reviewers independently reviewed the full text for in- or exclusion. Reviewer findings were compared during the screening process, with disagreements being resolved by involvement of a third reviewer.
Data extraction
We used a predesigned data extraction sheet, which was piloted on several articles before actual use and refined it accordingly. One reviewer extracted data (CMGK), which was checked by a second (SIMJ). Additional reviewers were involved to reach consensus in the case of disagreement. Data that were extracted included setting, study aim, type, content, and results of intervention, implementation method, data collection method, method of analysis, data collection moment, and implementation barriers and facilitators.
Study quality
The methodological quality of each study was assessed using the Critical Appraisal Skills Programme qualitative checklist (Critical Appraisal Skills Programme, 2017). The quality of the studies was appraised by one reviewer (CMGK) and scores were checked by a second (SIMJ). Disagreements were resolved by discussion. Papers were not excluded based on quality. Instead, quality of studies is addressed in the discussion section.
Data synthesis
Each barrier or facilitator was given a code, using Atlas.ti 8.3. The Consolidated Framework for Implementation Research (CFIR) was used to guide data synthesis, following a deductive approach. The CFIR is a comprehensive, “meta-theoretical” framework. The standardized list of constructs allows researchers to identify variables that are most relevant to a particular intervention (Damschroder et al., Reference Damschroder2009). The codes were subdivided into the five domains of the CFIR framework: intervention characteristics, outer setting, inner setting, characteristics of individuals, and process. We kept in mind the possibility that codes might not fit the CFIR.
The importance of the barrier/facilitator was addressed by gaining insight into their frequency. Deductive thematic analysis was used to assess a factor’s positive or negative influence (Elo and Kyngäs, Reference Elo and Kyngäs2008; Hsieh and Shannon, Reference Hsieh and Shannon2005).
Two reviewers (SIMJ and CMGK) independently coded four studies, and findings were compared and discussed. After this, one reviewer (CMGK) continued with coding the other studies. The coding of each study was discussed by both reviewers to reach agreement. The other reviewers were involved to obtain consensus in case of disagreements.
Results
Study selection
The search of all the databases yielded 4734 records of which 15 studies were included. See Preferred Reporting Items for Systematic Reviews and Meta-analysis flow for application of eligibility criteria (Figure 1).
Figure 1. Flowchart of study selection process.
Study characteristics
Table 1 presents the study characteristics. With the exception of one German study, all studies were published in English. Studies were carried out in Australia (n = 2), Canada (n = 2), the U.S.A. (n = 1), the U.K. (n = 3), Norway (n = 1), Germany (n = 2), and the Netherlands (n = 4). The majority of the studies were qualitative (process) evaluations, sometimes combined with quantitative data. Most studies pertained to residents with dementia in NHs, residential aged care facilities, or long-term care homes. We identified four types of interventions, often combined: (1) managing NPS by methodical and multidisciplinary collaboration (n = 10); (2) psychosocial interventions tailored to the resident or person-centered care (PCC) approaches (n = 9); (3) training and education (n = 2); and (4) an activity or exercise program (n = 2). Several implementation strategies were used, such as coaching on the job, follow-up meetings, sharing experiences, and telephone support. Multiple methods of data collection were used, among others questionnaires, focus groups, and individual interviews. Most studies applied triangulation to enhance credibility of findings. A range of stakeholders provided the data on implementation factors, mostly being staff, managers, and/or project coordinators.
Table 1. Characteristics of included studies
Overview of the aim and setting, type and results of intervention, implementation method, data collection method, analysis, and moment of data collection.
* Intervention type: 1 = methodical/multidisciplinary collaboration; 2 = tailored psychosocial interventions/PCC; 3 = training and education; 4 = activity or exercise program.
Abbreviations: BPSD, behavioral psychological symptoms dementia; CADRES, Caring for Aged Dementia Care Resident Study; CMAI, Cohen-Mansfield Agitation Inventory; cRCT, cluster randomized controlled trial; DCM, Dementia Care Mapping; NP, nurse practitioner; PC(C), person-centered (care); PD, psychotropic drug; QoL, quality of life.
Study quality
Table 2 provides a detailed overview of the quality assessments of the studies. On a scale from 0 to 10 (the higher the more quality), five studies scored 5 to 7 points (Borbasi et al., Reference Borbasi2011; Kovach et al., Reference Kovach2008; McAiney et al., Reference McAiney2007; Stein-Parbury et al., Reference Stein-Parbury2012; Wingenfeld et al., Reference Wingenfeld, Seidl and Ammann2011), and ten studies scored 8 to 10 points (Appelhof et al., Reference Appelhof2018; Boersma et al., Reference Boersma2016; Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Ellard et al., Reference Ellard2014; Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; Latham and Brooker, Reference Latham and Brooker2017; Lawrence et al., Reference Lawrence2016; Mekki et al., Reference Mekki2017; Quasdorf et al., Reference Quasdorf2016; Zwijsen et al., Reference Zwijsen2014b).
Table 2. Indicators of study quality
Including study aim, qualitative methodology, design, recruitment strategy, data collection, relationship researcher/participants, ethical issues, data analysis, findings, and value.
* McAiney, Reference McAiney2007. This study is quantitative. Therefore, the two fields are scored as N.A. These fields are considered not relevant in this type of study.
Barriers and facilitators
The barriers and facilitators reported in the studies were grouped according to the five domains and 36 constructs of the CFIR. All codes fitted within the CFIR. Table 3 shows the frequency with which the CFIR constructs were addressed and provides an overview of the CFIR constructs pertaining to the individual studies. A short description of each construct can be found in Table S1, published as supplementary material online.
Table 3. Count of CFIR constructs and overview of individual studies
Abbreviation: CFIR, Consolidated Framework for Implementation Research.
Domain 1. Intervention characteristics
Relative advantage was addressed in six articles (Appelhof et al., Reference Appelhof2018; Boersma et al., Reference Boersma2016; Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Ellard et al., Reference Ellard2014; Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; Lawrence et al., Reference Lawrence2016). The added value of the intervention was having a shared method for multidisciplinary consultations (Boersma et al., Reference Boersma2016), and expected gains in care time led to increased implementation willingness and efforts of staff (Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015). Also, experiencing visible effects and positive reactions of residents were facilitators (Ellard et al., Reference Ellard2014; Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; Boersma et al., Reference Boersma2016). Concerns about consequences of the intervention, such as how to deal with aggression when PDU is reduced, impeded implementation (Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Lawrence et al., Reference Lawrence2016).
Adaptability was addressed by three articles as a facilitating factor (Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; Mekki et al., Reference Mekki2017). For example, the transfer of information and knowledge was tailored to the local NH culture, which stimulated implementation (Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018).
Complexity was addressed in ten articles (Boersma et al., Reference Boersma2016; Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; Kovach et al., Reference Kovach2008; Latham and Brooker, Reference Latham and Brooker2017; McAiney et al., Reference McAiney2007; Quasdorf et al., Reference Quasdorf2016; Stein-Parbury et al., Reference Stein-Parbury2012; Wingenfeld et al., Reference Wingenfeld, Seidl and Ammann2011; Zwijsen et al., Reference Zwijsen2014b). Six articles reported that perceived easiness to apply the intervention in everyday working life was a facilitator (Boersma et al., Reference Boersma2016; Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; McAiney et al., Reference McAiney2007; Stein-Parbury et al., Reference Stein-Parbury2012; Wingenfeld et al., Reference Wingenfeld, Seidl and Ammann2011). This was especially true for interventions that encouraged on-the-job reinforcement of the learning, role modeling, and assisting in integrating knowledge into practice (McAiney et al., Reference McAiney2007). Barriers were experienced difficulty in applying the learned actions and knowledge into practice (Latham and Brooker, Reference Latham and Brooker2017; Quasdorf et al., Reference Quasdorf2016), and the required use of multiple forms and tools (Zwijsen et al., Reference Zwijsen2014b).
Cost was addressed in four articles (Appelhof et al., Reference Appelhof2018; Boersma et al., Reference Boersma2016; Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; McAiney et al., Reference McAiney2007). Facilitators were sufficient funding for the proposed intervention (Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015), wards receiving extra budget from the NH (Appelhof et al., Reference Appelhof2018), and inexpensive training, especially if a regular training budget exists that can be used to provide the intervention (Boersma et al., Reference Boersma2016). Pressures on financial resources such as budget cuts negatively affected the implementation process (Boersma et al., Reference Boersma2016; Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; McAiney et al., Reference McAiney2007).
Four constructs within the domain intervention characteristics yielded no relevant factors affecting implementation in the included articles (see Table 3).
Domain 2. Outer setting
Only few studies reported about factors affecting implementation within this domain. The domain contains four constructs, of which cosmopolitanism and peer pressure were not represented in the reviewed articles (see Table S1 CFIR constructs with short definitions).
Patient needs and resources were addressed by one article. A lack of background information about the residents was a barrier for implementation (Boersma et al., Reference Boersma2016).
External policy was addressed by one article, which stated that changing laws and regulations can negatively affect the implementation (Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015).
Domain 3. Inner setting
Structural characteristics were addressed by eight articles (Appelhof et al., Reference Appelhof2018; Boersma et al., Reference Boersma2016; Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Ellard et al., Reference Ellard2014; Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; Latham and Brooker, Reference Latham and Brooker2017; Quasdorf et al., Reference Quasdorf2016; Zwijsen et al., Reference Zwijsen2014b). Facilitating factors were a well-functioning and stable team, a less hierarchical structure and flexible organizational structures, being specialized in dementia care (Quasdorf et al., Reference Quasdorf2016), and having a small-scale care setting and rural environment (Boersma et al., Reference Boersma2016). Barriers regarding high patient-to-caregiver ratios (Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018), and multiple levels of management made access to resources challenging (Latham and Brooker, Reference Latham and Brooker2017). Half of the articles found staff turnover/absenteeism/fluctuations, shortages, and changing positions to be an impeding factor (Appelhof et al., Reference Appelhof2018; Boersma et al., Reference Boersma2016; Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Ellard et al., Reference Ellard2014; Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; Quasdorf et al., Reference Quasdorf2016; Zwijsen et al., Reference Zwijsen2014b). It might lead to hindering factors such as new staff not being informed about, or familiar with, the program (Appelhof et al., Reference Appelhof2018; Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Zwijsen et al., Reference Zwijsen2014b), and new staff needing time to get acquainted with the intervention (Appelhof et al., 2018; Zwijsen et al., Reference Zwijsen2014b).
Networks and communications was mentioned by all but three articles (Borbasi et al., Reference Borbasi2011; McAiney et al., Reference McAiney2007; Wingenfeld et al., Reference Wingenfeld, Seidl and Ammann2011). Facilitators were communication and contact between staff members and across disciplines (Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; Kovach et al., Reference Kovach2008; Stein-Parbury et al., Reference Stein-Parbury2012), an open communication climate (Quasdorf et al., Reference Quasdorf2016), and support within the team (Boersma et al., Reference Boersma2016; Latham and Brooker, Reference Latham and Brooker2017; Mekki et al., Reference Mekki2017). Implementation benefitted from regular multidisciplinary meetings (Appelhof et al., Reference Appelhof2018), whereas lack of (formal) meetings between staff hindered implementation (Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Ellard et al., Reference Ellard2014; Zwijsen et al., Reference Zwijsen2014b). Conflicts and misunderstandings within the team (Quasdorf et al., Reference Quasdorf2016), lack of contact between disciplines (Zwijsen et al., Reference Zwijsen2014b), difficulty in transferring information between shifts (Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018), and poor information dissemination were barriers (Ellard et al., Reference Ellard2014). Consequences of communication difficulties were insufficient role awareness regarding responsibilities (Boersma et al., Reference Boersma2016; Latham and Brooker, Reference Latham and Brooker2017), being unfamiliar with mutual expectations such as required time and commitment (Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; Latham and Brooker, Reference Latham and Brooker2017) and problems with receiving appropriate support (Latham and Brooker, Reference Latham and Brooker2017). Collaborative relationships with family facilitated implementation, and relationships strained by relatives being critical of staff impeded implementation (Lawrence et al., Reference Lawrence2016).
Culture was addressed in five articles (Boersma et al., Reference Boersma2016; Lawrence et al., Reference Lawrence2016; Mekki et al., Reference Mekki2017; Quasdorf et al., Reference Quasdorf2016; Stein-Parbury et al., Reference Stein-Parbury2012). A more dementia friendly culture as expressed in staff attitudes and the physical environment was helpful (Quasdorf et al., Reference Quasdorf2016), as were mutual respect and reciprocity in relationships with residents (Lawrence et al., Reference Lawrence2016), a positive team culture where people acknowledge each other (Mekki et al., Reference Mekki2017), and staff feeling able to voice opinions (Stein-Parbury et al., Reference Stein-Parbury2012). Staff with different cultural backgrounds and difficulties with the Dutch language were barriers (Boersma et al., Reference Boersma2016).
Implementation climate consists of six subconstructs, of which five were addressed (see Table 3)
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(1) Tension for change was reported in one article. Pressure from peers to resist change negatively affected implementation (McAiney et al., Reference McAiney2007).
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(2) Compatibility was addressed by five articles (Appelhof et al., Reference Appelhof2018; Boersma et al., Reference Boersma2016; Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; Latham and Brooker, Reference Latham and Brooker2017; Zwijsen et al., Reference Zwijsen2014b). Interventions being consistent with care goals facilitated implementation (Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015), while a barrier was that the intervention – as perceived by the care professionals – may not necessarily be in line with the corporate image – as set by the management (Latham and Brooker, Reference Latham and Brooker2017). Overlap with current working was reported as a barrier in two studies. For example, an overlap with tools already available in the electronic health record led to staff being more inclined to keep working according to their old working routine (Appelhof et al., Reference Appelhof2018).
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(3) Relative priority was addressed by six articles (Appelhof et al., Reference Appelhof2018; Boersma et al., Reference Boersma2016; Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; Latham and Brooker, Reference Latham and Brooker2017; Zwijsen et al., Reference Zwijsen2014b). Limited involvement in research projects promoted implementation (Appelhof et al., Reference Appelhof2018), while other innovations implemented at the same time were a barrier (Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015). Implementation of the care program was easier on wards that rarely initiated new projects, which helped staff to remain motivated. Being involved in several new projects seemed to interfere with implementation, since time was scarce (Zwijsen et al., Reference Zwijsen2014b). Ward issues such as renovations to the facility (Appelhof et al., Reference Appelhof2018), transition toward self-directed teams (Appelhof et al., Reference Appelhof2018; Boersma et al., Reference Boersma2016), staff turnover (Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Latham and Brooker, Reference Latham and Brooker2017), and changes in staff members’ positions and management structure were barriers (Zwijsen et al., Reference Zwijsen2014b).
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(4) Goals and feedback were reported by one article. Little or no feedback and collaboration with internal facilitators, and a low level of feedback and engagement within the team and on the individual level hindered implementation (Mekki et al., Reference Mekki2017).
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(5) Learning climate was addressed by eight articles (Appelhof et al., Reference Appelhof2018; Boersma et al., 2016; Borbasi et al., Reference Borbasi2011; Ellard et al., Reference Ellard2014; Latham and Brooker, Reference Latham and Brooker2017; Lawrence et al., Reference Lawrence2016; Mekki et al., Reference Mekki2017; Zwijsen et al., Reference Zwijsen2014b). Openness to changing working routines facilitated implementation (Appelhof et al., Reference Appelhof2018; Mekki et al., Reference Mekki2017), while an insufficient learning climate limited implementation (Boersma et al., Reference Boersma2016; Ellard et al., Reference Ellard2014). The degree of learning climate can depend on the ward. In one study, several wards were reluctant to alter routines, whereas wards that were enthusiastic to work with the care program seemed to have a more open attitude toward change and welcomed external input (Zwijsen et al., Reference Zwijsen2014b). Other facilitators were that the intervention team worked on the floor together with the staff and provided compliments and encouragement (Borbasi et al., Reference Borbasi2011). Also, sufficient support and meetings to discuss events during the day and their negative and positive sides led to positive experiences (Latham and Brooker, Reference Latham and Brooker2017), as did reporting details of success stories and sharing strategies that worked (Borbasi et al., Reference Borbasi2011; Mekki et al., Reference Mekki2017). Staff fearing criticism of the training team hindered implementation (Lawrence et al., Reference Lawrence2016).
Readiness for implementation contains three subconstructs, of which two were addressed (see Table 3).
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(1) Leadership engagement was addressed by six articles (Mekki et al., Reference Mekki2017; McAiney et al., Reference McAiney2007; Stein-Parbury et al., Reference Stein-Parbury2012; Wingenfeld, et al., Reference Wingenfeld, Seidl and Ammann2011; Quasdorf et al., Reference Quasdorf2016; Zwijsen et al., Reference Zwijsen2014b). Key stakeholders taking the lead and an engaged leader acting as internal facilitator were mentioned (Mekki et al., Reference Mekki2017; Quasdorf et al., 2016; Stein-Parbury et al., Reference Stein-Parbury2012; Zwijsen et al., Reference Zwijsen2014b), as well as insufficient authority or guidance, absent or disengaged leaders limiting implementation (Mekki et al., Reference Mekki2017; McAiney et al., Reference McAiney2007; Wingenfeld et al., Reference Wingenfeld, Seidl and Ammann2011).
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(2) Available resources were reported in all but three articles (Borbasi et al., Reference Borbasi2011; Mekki et al., Reference Mekki2017; Wingenfeld et al., Reference Wingenfeld, Seidl and Ammann2011). Work and time pressures were common barriers and existed in eight studies (Boersma et al., Reference Boersma2016; Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Ellard et al., Reference Ellard2014; Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; Latham and Brooker, Reference Latham and Brooker2017; Lawrence et al., Reference Lawrence2016; McAiney et al., Reference McAiney2007; Zwijsen et al., Reference Zwijsen2014b). Management support facilitated implementation (Appelhof et al., Reference Appelhof2018; McAiney et al., Reference McAiney2007; Quasdorf et al., Reference Quasdorf2016; Stein-Parbury et al., Reference Stein-Parbury2012; Zwijsen et al., Reference Zwijsen2014b), while other studies reported lack of management support (Ellard et al., Reference Ellard2014; Latham and Brooker, Reference Latham and Brooker2017). Lack of sufficient resources for implementation was described as a barrier in four studies (Ellard et al., Reference Ellard2014; Latham and Brooker, Reference Latham and Brooker2017; Lawrence et al., Reference Lawrence2016; McAiney et al., Reference McAiney2007). For example, the absence of a quiet space for staff to attend training impeded implementation (Ellard et al., Reference Ellard2014). Enabling staff members to participate in the training by offering it at two moments facilitated implementation (Boersma et al., Reference Boersma2016), while staff members failing to attend training due to inconvenient shift arrangements impeded implementation (Ellard et al., Reference Ellard2014).
Domain 4. Characteristics of individuals
Knowledge and beliefs about the intervention were addressed in all but five articles (Borbasi et al., Reference Borbasi2011; McAiney et al., Reference McAiney2007; Mekki et al., Reference Mekki2017; Latham and Brooker, 2017; Stein-Parbury et al., Reference Stein-Parbury2012). In one study, management had limited awareness of the added value of the intervention and some staff had critical attitudes. However, the expected gains in terms of care time and experienced positive effects on residents made staff enthusiastic to implement the intervention (Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015). Implementation of the program (Appelhof et al., Reference Appelhof2018) or managing disruptive behaviors (Kovach et al., Reference Kovach2008) was time-consuming and increased stress and frustration. Repeatedly starting a functional analysis of behavior was perceived as discouraging (Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018), and interventions being perceived as childish or disrespectful to people with dementia hindered implementation (Boersma et al., Reference Boersma2016; Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015).
Three articles addressed self-efficacy (Borbasi et al., Reference Borbasi2011; Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; Stein-Parbury et al., Reference Stein-Parbury2012). Staff working together with the intervention team improved self-confidence and capacity among staff to manage behaviors (Borbasi et al., Reference Borbasi2011). Yet, one study reported that staff became reserved and insecure during training, because they thought they could not acquire the necessary level of performance (Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015).
Individual stage of change was addressed in seven articles (Boersma et al., Reference Boersma2016; Borbasi et al., Reference Borbasi2011; Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Ellard et al., Reference Ellard2014; Kovach et al., Reference Kovach2008; Lawrence et al., Reference Lawrence2016; Mekki et al., Reference Mekki2017). Staff reluctance with respect to the intervention – or to alter routines – was an implementation barrier (Boersma et al., Reference Boersma2016; Borbasi et al., Reference Borbasi2011; Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Ellard et al., Reference Ellard2014; Kovach et al., Reference Kovach2008; Lawrence et al., Reference Lawrence2016).
Individual identification with the organization was addressed in two articles (Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; Lawrence et al., Reference Lawrence2016). Staff feeling that their qualities were validated was helpful (Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015). A lack of recognition from managers and relatives (and society) limited implementation (Lawrence et al., Reference Lawrence2016).
Other personal attributes were mentioned in eight articles (Appelhof et al., Reference Appelhof2018; Boersma et al., Reference Boersma2016; Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; Kovach et al., Reference Kovach2008; Lawrence et al., Reference Lawrence2016; Mekki et al., Reference Mekki2017; Quasdorf et al., Reference Quasdorf2016). Educated staff (Kovach et al., Reference Kovach2008), and having had earlier experience with PCC methods facilitated implementation (Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015). Low-educated staff impeded implementation (Boersma et al., Reference Boersma2016; Appelhof et al., Reference Appelhof2018), and staff having limited knowledge about their residents’ personal and medical aspects restricted the creativity to find restraint-free solutions (Mekki et al., Reference Mekki2017). For staff, several skill-related barriers were mentioned; limited communication skills (Boersma et al., Reference Boersma2016), having difficulties initiating partnerships with family (Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018), low willingness and ability to analyze and express reflections (Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Mekki et al., Reference Mekki2017), and a too strong reliance on other persons (Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Lawrence et al., Reference Lawrence2016). The staff’s functional understanding of care/“to-do” task-oriented focus was found to be impeding (Boersma et al., Reference Boersma2016; Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; Quasdorf et al., Reference Quasdorf2016), as was poor mastery of the Dutch language by staff (Boersma et al., Reference Boersma2016).
Domain 5. Process
Planning was addressed in four articles (Boersma et al., Reference Boersma2016; Ellard et al., Reference Ellard2014; Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; Quasdorf et al., Reference Quasdorf2016). A strict procedure for implementation was a facilitating factor, although a plan for sustaining the intervention was lacking (Boersma et al., Reference Boersma2016). Considerable performance differences were found between wards with a detailed study protocol with defined implementation components and wards lacking this (Quasdorf et al., Reference Quasdorf2016).
Engaging consists of four subconstructs. Engaging formally appointed internal implementation leaders was addressed in three articles (Boersma et al., Reference Boersma2016; Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Mekki et al., Reference Mekki2017). An engaged, participative leader facilitated implementation (Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Mekki et al., Reference Mekki2017). The support of the study coordinators who worked actively with staff and key persons of the NH was essential. This contributed to overcoming organizational challenges such as staff turnover and transfer of information between shifts (Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018). However, identifying such a leader might not be easy. Insufficient directive guidance to identify a project leader was a barrier (Boersma et al., Reference Boersma2016).
Engaging champions was addressed in all but four articles (Borbasi et al., Reference Borbasi2011; Bourbonnais et al., Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018; Kovach et al., Reference Kovach2008; McAiney et al., Reference McAiney2007). Indeed, the support of champions is acknowledged as a facilitating factor (Appelhof et al., Reference Appelhof2018; Ellard et al., Reference Ellard2014; Quasdorf et al., Reference Quasdorf2016; Wingenfeld et al., Reference Wingenfeld, Seidl and Ammann2011; Zwijsen et al., Reference Zwijsen2014b). However, sometimes no champions were identified at all, or problems with shifts, time, or enthusiasm limited their effectiveness (Ellard et al., Reference Ellard2014). Change of champions was also a hindering factor (Boersma et al., Reference Boersma2016; Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015; Quasdorf et al., Reference Quasdorf2016; Zwijsen et al., Reference Zwijsen2014b). Changes of the ward leader, psychologist, and physician were detrimental due to their crucial role in implementation (Zwijsen et al., Reference Zwijsen2014b). Also, champions need to able to effectively influence their colleagues (Latham and Brooker, Reference Latham and Brooker2017; Stein-Parbury et al., Reference Stein-Parbury2012). Their success depends on drive and enthusiasm (Stein-Parbury et al., Reference Stein-Parbury2012), as well as having listening skills, confidence, to be able to team work, and having good relationships with colleagues (Latham and Brooker, Reference Latham and Brooker2017). Hence, the ways in which the individual was able to fulfill the role seemed more important than power and experience (Latham and Brooker, Reference Latham and Brooker2017).
Reflecting and evaluating are addressed by one article. Timely solving of bottlenecks and continuous evaluation were seen as facilitating factors (Van Haeften-Van Dijk et al., Reference Van Haeften-Van Dijk, Van Weert and Droës2015).
Discussion
Key factors to successful implementation identified in this review included perceived easiness to apply the intervention in practice, strong leadership, support of champions, communication and coordination between disciplines, management support, sufficient resources, educated staff, and culture. Barriers related mostly to unstable organizations, such as renovations, changes toward self-directed teams, high staff turnover, perceived work and time pressures, and being involved in several projects.
Similar to our findings, other reviews demonstrated that lack of time, high staff turnover (Vlaeyen et al., Reference Vlaeyen2017), and lack of organizational support (Beeber et al., Reference Beeber2010) can be barriers to implementation. In a review on implementation of evidence-based practice in community nursing, organizational changes such as decentralization were a barrier, while facilitators were the use of local champions, training being embedded in practice, actual or perceived skills, perceptions about usefulness and evidence that the intervention will positively impact the resident or caregiver (Mathieson et al, Reference Mathieson, Grande and Luker2018). Despite the fact that these reviews took place in a different setting, the barriers and facilitating factors found are comparable to our findings, implying that some barriers and facilitators are generic in nature. However, several “setting specific” factors seem to affect implementation as well. For example, in a systematic review on fall prevention in residential care facilities, poor information transfer among care providers, staff, and family, and across shifts and lack of care plan communication were barriers (Vlaeyen et al., Reference Vlaeyen2017). Similar barriers emerged in our review, implying that these “setting specific” factors should be taken into account in care innovations. As is suggested by Vlaeyen et al. (Reference Vlaeyen2017), we also underline that a focus on modifiable barriers and facilitators such as communication is needed in implementation projects in daily practice.
Other recently published papers in International Psychogeriatrics on implementation in long-term care had similar findings. A review on strategies for successful implementation of psychosocial (including multicomponent) interventions in daily residential dementia care, for instance, found that time required to learn and apply the intervention, having a learning culture, and putting knowledge into practice (such as on-the-job reinforcement of learning) were facilitators, whereas multiple projects running simultaneously impeded implementation (Boersma et al., Reference Boersma, van Weert, Lakerveld and Dröes2015). The commitment of higher management and professionals were important factors in two studies (Boersma et al., Reference Boersma, van Weert, Lakerveld and Dröes2015; Gerritsen et al., Reference Gerritsen2019), which is in line with our results. Our systematic review specifically focuses on the implementation of complex interventions targeting NPS/PDU, while other studies focused on the implementation of guidelines for PCC in NHs (Vikström et al., Reference Vikström2015), implementation of the Meeting Centers Support Program (Van Mierlo et al., Reference Van Mierlo2018), or implementing best practice dementia care in hospitals (Tropea et al., Reference Tropea2017), for example. Several barriers and facilitators identified in those studies are in line with our results, such as inadequate staffing levels (Tropea et al., Reference Tropea2017; Vikström et al., Reference Vikström2015), workload, insufficient time, communication difficulties within team and with family, and limited staff knowledge and skills of dementia (Tropea et al., Reference Tropea2017). In addition, the need for qualified and motivated staff, the presence of a project manager to guide the implementation, and the possibility to target the program to the needs of the target population were identified as facilitators (Van Mierlo et al., Reference Van Mierlo2018). Although those studies had a different focus compared to our review, several barriers and facilitators were in line with our findings. Perhaps this implies that the barriers and facilitators identified in our review may account for different types of interventions and settings, beyond merely complex interventions targeting NPS/PDU.
To summarize, although some implementation factors are generic in nature, setting and organizational factors seem to play an important role in implementation. Our systematic review adds to this that the factors or issues that are perceived as impeding implementation in one care organization can be perceived as no barrier in another care organization. For instance, some organizations seemed to have more difficulties as a result of staff turnover than other organizations. In the study of Bourbonnais et al., (Reference Bourbonnais, Ducharme, Landreville, Michaud, Gauthier and Lavallée2018), for example, staff turnover did not negatively affect implementation, since other persons such as study coordinators continued to work actively with staff. Differences may even exist between wards of a care organization. In the study of Zwijsen et al. (Reference Zwijsen2014b), for instance, the degree of learning climate depended on the ward. Several wards were reluctant to alter routines, while other wards had an open, enthusiastic attitude toward the care program. Hence, perhaps the most important recommendation is that we stress to take into account the local conditions and specific barriers and facilitators of a care organization by means of a tailored implementation plan.
Strengths and limitations
A strength is the use of a well-known, meta-theoretical framework and the applied deductive thematic analysis to synthesize the results. Using the predefined codes of the CFIR provided the complex data with a clear direction (King, Reference King, Cassell and Symon2004). The coded data fitted the predefined constructs of the CFIR. Its standardized nature enhances comparison across studies. A limitation that warrants further consideration is that we did not exclude studies based on our qualitative appraisal. This requires some caution in the interpretation of findings. Ten studies did not consider the relationship between researcher and participant, which potentially led to researcher bias (Critical Appraisal Skills Programme, 2017). Selection and recruitment of participants was also not thoroughly described, potentially leading to bias in the included studies, and consequently in our review. However, for the other categories, the quality of the included studies was generally considered sufficient. Also, the factors found in the included studies might not be the most important ones, but the ones focused on the most. Our results show that constructs within the domains “intervention characteristics,” “outer setting,” and “process” were less frequently addressed than the other domains. Apparently, several parts of the CFIR framework receive little research attention. This is contrary to a recent systematic review, which assessed the application of the CFIR in implementation research in a wide range of study aims and settings. In this review, all constructs were identified to a greater or lesser extent (Kirk et al., Reference Kirk2016). This difference might be explained by the fact that Kirk et al. (Reference Kirk2016) only included studies that used the CFIR, while in our review, the included studies used different theories or frameworks to evaluate implementation. CFIR constructs were not used as a “checklist” of variables for consideration. Possible consequences are that relevant factors were not assessed.
Although it might be relevant to distinguish between barriers and facilitators related to the intervention and those related to the implementation strategy, the reviewed articles rarely present their results in this manner. Furthermore, several interventions incorporate elements, such as training (Smeets et al., Reference Smeets2013), that are considered implementation strategies by others (Gerritsen et al., Reference Gerritsen2011). Further research could explore the added value of this distinction.
Conclusions and implications
Our study showed that the engagement of champions can be an important facilitator, but their effectiveness relies on personal skills and relationships with colleagues. Consequently, we stress that champions should be carefully chosen. Translating learned actions and knowledge into practice by means of on-the-job reinforcement of learning or role modeling should be part of the implementation strategy for complex interventions by default. Caution should be employed while participating in several projects/studies. The capacity of the involved key stakeholders should be leading. The current systematic review demonstrated that the implementation of complex interventions requires a lot of effort of the organizations and their staff members, and the degree of implementation is subject to many factors, which makes it complex. Our results indicate that some factors are generic in nature, but the setting and factors related to the organization such as staff turnover and reorganizations seem to influence implementation as well. The presence of factors and degree to which these are perceived as a barrier might differ between organizations and even between wards, depending on potential facilitating factors that can reduce the influence of the barrier and on the coping strategies of staff. Organization problems on the ward as such may be not necessarily barriers to successful implementation, but the coping mechanisms of the team could be of greater importance. Therefore, barriers and facilitators might be best examined at the organizational level, being for instance an NH, or even on the level of an NH ward. We underline that implementation needs to be adapted to the specific needs and characteristics of the organization in question and needs to focus on modifiable barriers and facilitators. To implement a complex intervention with several interacting components, in a complex and dynamic organization, with its own local characteristics and specific barriers and facilitators, is challenging and advocates for a tailored intervention and implementation plan. Assessing and addressing possible barriers and facilitators before and during implementation by means of tailored implementation can increase effectiveness (Baker et al., Reference Baker2015).
Frameworks such as the CFIR can help identify which constructs have predictive ability, which can be manipulated to enhance implementation outcomes, and the situations in which specific constructs are salient.
Future studies could explore whether a focus on the “forgotten” constructs would be beneficial for implementation.
Conflict of interest
None.
Description of authors’ roles
Study concept and design: Claudia M. Groot Kormelinck, Sarah I.M. Janus, Martin Smalbrugge, Debby L. Gerritsen, Sytse U. Zuidema.
Acquisition of data: Claudia M. Groot Kormelinck, Sarah I.M. Janus.
Analysis and interpretation of data: Claudia M. Groot Kormelinck, Sarah I.M. Janus, Martin Smalbrugge, Debby L. Gerritsen, Sytse U. Zuidema.
Drafting of the manuscript: Claudia M. Groot Kormelinck, Sarah I.M. Janus.
Critical revision of the manuscript: Claudia M. Groot Kormelinck, Sarah I.M. Janus, Martin Smalbrugge, Debby L. Gerritsen, Sytse U. Zuidema.
Acknowledgements
We thank Dr. Sjoukje van der Werf (medical information specialist, University Medical Center Groningen) for her help with the search strategy.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/S1041610220000034
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