From the answers on open questions in Q2, several categories of barriers and facilitators emerged which were confirmed in the analysis of the transcripts of the interviews. The categories can be divided into three themes: organizational aspects, culture of the DSCU and the layout of the care program.
Organizational aspects
Staff turnover It became apparent from the interviews that staff turnover rates could influence the implementation process. Staff turnover sometimes resulted in situations in which only a part of the team was truly well informed about the care program. Although attempts were made to train new staff members, the situation remained suboptimal. While the turnover of nursing staff had adverse consequences, the change of DSCU leader, psychologist or physician was even more detrimental, for they had a leading role in implementing the care program. When these key stakeholders were absent for a period, there was often a drop in attention for implementing the care program. When key stakeholders were then replaced, the new person would often need time to get acquainted with the use of the care program as well as all other methods used on the DSCU, which greatly slowed down the implementation. Overall, there were no DSCUs without change in key stakeholders; there was a mean turnover of 2.64 key persons (range 1 to 6) per DSCU. Absence or change of these key persons was a real barrier in implementing the care program, as this psychologist points out in one of the interviews:
Psychologist:
Well, for example, I drew up a plan for this lady. And in my absence, a physician, a new physician, just crossed right through it.
High workload High workload and time being scarce were often mentioned as one of the barriers to implementing the care program. Although opinions differed on the amount of time the care program would really cost once implemented, it was obvious that having to learn to work according to the care program would cost some time, which was, in the eyes of care personnel, not always available.
Nurse:
But we work under a constant lack of time and staff shortage. And these kinds of things are the first to slip through then.
Psychologist:
Yes, well, really the time pressure, yeah that’s it. And then also my own involvement… I realize I’m not at the unit very often and I kind of feel like, please don’t use it [the care program], because I can’t handle anything extra at the moment. And well, I think that is alarming, because that is a very ambiguous signal that you are sending
Concurrent and former projects It appeared that implementation of the care program was easier on DSCUs that rarely initiated new projects. Key persons in these DSCUs stated that being cautious not to adopt too many new projects helped in keeping care staff motivated when a new project was proposed. In contrast, some DSCUs were involved in several new projects, such as implementing electronic health records for all residents or using new forms for quality improvement on the DSCU. This seemed to interfere with implementing the care program, as time was already scarce. Also, some of the staff members of those DSCUs expressed skepticism about new projects. They had seen many new projects come and go during the last years, many of which did not cause relevant improvement to daily care.
Psychologist:
Yeah, well, it makes a difference that we are not, well, this is a fairly new location, where they have not started up all kind of new projects, which does make a difference you know.
Multidisciplinary meetings For the care program to work properly there has to be a structure in which physician, psychologist and care staff meet each other regularly. Although this happens during the (obligatory) multidisciplinary care meetings, it was a precondition for implementing the care program that there would be extra time in which the forms of the care program would be discussed. In reality, this precondition was not always met. The working hours of the physician or psychologist did not always correspond with each other or with the care staff that completed the form. Because of the lack of contact between disciplines, a resident was sometimes treated by more than one discipline without interdisciplinary consultation and with one of the disciplines not using the care program. Also when care staff completed an analysis form it sometimes took many weeks before a psychologist or physician was able to respond to it; this did not encourage care staff to complete more forms in the future.
Organizational changes During the implementation of the care program, some of the DSCUs encountered minor or major organizational changes. For example, in one of the DSCUs there were plans at hand that would change the position of several staff members. Another organization changed their management structure, which caused changes in responsibilities and duties of DSCU leaders. Such changes cause turmoil on DSCUs which interferes with the implementation of the care program.
Culture of the organization/DSCU
Support of key persons For a rapid and solid implementation process it was important that key persons such as physicians, psychologists and DSCU leaders functioned as ‘team champions’ in supporting the use of the care program [
25]. These team champions could support the implementation by embracing the care program and emphasizing to care staff that they complete the forms when they report challenging behavior, and by reporting back on the forms or helping complete them when care staff found it difficult. Without one or more key persons taking the lead on implementation and on stimulating the care staff to use the forms, it was very difficult to keep everyone focused on using the care program. Also, support of higher management of the organization (for example, by calculating in extra time) facilitated the implementation, because more time and understanding were available during implementation.
Attitude towards change In the individual interviews, some respondents stated that their team was very open to a new method in managing behavioral problems. These teams often seemed to be motivated to start working with the Grip on Challenging Behavior care program. In other DSCUs, respondents observed there was more reluctance in changing current routines and procedures. This was also noticed by DSCU managers and sometimes by psychologists and physicians.
Certified nurse assistant:
People are often stuck in the old system. They do not always want to try out new things. But if you save time later on, that affects the resident I think.
Aspects of the care program
The care program was not digitally available Some of the organizations of which the DSCUs were part had recently transferred to using electronic health records. Part of this transfer was to eliminate all paper files and forms, so as to create one method of working. Because the digital systems are different for almost every nursing home, it was not possible to provide one general digital version of the care program and it was therefore only provided as a paper version. For those DSCUs that only had a digital administration systems, the paper forms of the care program became easily forgotten. Also, the work method of using forms did not fit in with the normal working methods, which was a barrier for the implementation.
Many forms The care program consists of eight different forms (detection tool, three analysis forms (nursing staff, psychologist, physician), an extra analysis tool for the psychologist, a treatment form, an evaluation form and one agenda form to overview the process). Although the use of the forms was separated by different disciplines and time periods, many respondents complained that, at first sight, the number of forms was overwhelming and that this made it tempting to discuss behavior informally or via email instead of starting to fill in an analysis form. When asked, however, respondents often stated that almost all forms were useful and completing the forms did not take much extra time after all. Even so, merely the first impression and the prospect of having to complete the forms did hinder the implementation.
Team leader:
The only thing that does not really work as an advantage, although you do really need all, is the number of forms. And I think that when you just put it out there, like ‘these are the forms’… that that can scare people off.