We are at a bit of an impasse in geropsychology: we have psychosocial interventions that we believe will work for treating neuropsychiatric symptoms in dementia patients; however, effective implementation of those interventions remains an elusive goal. This has resulted in the continued reliance on psychotropic drugs for symptom management in dementia patients, despite evidence of limited efficacy (e.g. Seitz et al., Reference Seitz2013). The paper by Groot Kormelinck and colleagues (2020) in this issue examines the available literature for barriers and facilitators of effective implementation of “complex interventions” (Craig et al., Reference Craig2013) for neuropsychiatric symptoms in dementia. The interventions examined by Groot Kormelinck et al. (Reference Groot Kormelinck2020) ranged from exercise programs to multidisciplinary collaborations. Although complex interventions are more likely to be effective than those targeting a single mechanism of change or requiring adherence to a strict protocol, they are also more susceptible to barriers at a myriad of levels within the implementing organization, including those on the “front lines” of daily patient care (e.g. nurses and nursing assistants), those in mostly supervisory roles (e.g. psychiatrists and psychologists), and those in upper administration (e.g. section chiefs and hospital directors).
Several factors led to increased facilitation of intervention implementation in the Groot Kormelinck et al. (Reference Groot Kormelinck2020) analysis. Notably, staff perception of the effect of the intervention and the ease with which the intervention could be enacted were moderators of successful implementation. Staff who work in skilled nursing facilities are often overworked (White et al., Reference White, Aiken, Sloane and McHugh2020) and understandably would be reluctant to implement new processes that they view both as unnecessarily complicated and unlikely to work. Top-down approaches in which the decisions for policy change are made by those far removed from the day-to-day experiences of staff are thus less likely to result in effective implementation of evidence-based approaches to care. Within psychological care, the importance of “buy-in” from the patient is critical to successful treatment. The same is true on a larger scale for implementation of complex interventions in skilled nursing facilities: without the support of the individuals who are actually doing the intervention, there is unlikely to be substantial change. This was reflected in one of the articles reviewed, which found that implementation of complex interventions was positively facilitated by a less hierarchical structure within the organization (Quasdorf et al., Reference Quasdorf2017).
Similarly, having sufficient resources to enact the intervention, both in terms of cost and staff time, was noted as facilitating successful implementation of non-psychotropic treatment of dementia symptoms. A lack of resources may indeed be an insurmountable barrier for many in charge of implementing a change in procedures. Staff who are asked to do a task without being provided the means with which to do that task are simply unlikely to comply. Furthermore, the suggestion that many of the facilities included in the review did not supply sufficient funds or training implies that even those at the “top” of the decision-making process for those sites may not have been fully committed to the implementation of the new procedures.
Finally, communication was highlighted as a key issue in the majority of the articles reviewed (Groot Kormelinck et al., Reference Groot Kormelinck2020). Indeed, communication is the bedrock of the other facilitators/barriers discussed: lack of communication is likely associated with poorer staff buy-in for the change in procedure in the first place, as well as increased levels of turnover. The benefits of a “participative leader” and “champions” may in fact be due to increased communication between leadership and staff (Ruben and Gigliotti, Reference Ruben and Gigliotti2016). This underlines the need to focus on broad institutional functioning overall when implementing substantial policy changes. Facilities that lack clear lines of communication between those making the decisions and those doing the implementing are less likely to be able to successfully transition to new procedures, including those involving increased levels of patient-centered care.
Although Groot Kormelinck et al. (Reference Groot Kormelinck2020) were able to review data from 15 studies conducted across the globe (Australia, Canada, the United States, the United Kingdom, Norway, Germany, and the Netherlands), this no doubt only represents a small minority of the implementation efforts currently underway. The evaluation of implementation efforts in skilled nursing facilities represents its own challenge and has its own set of barriers. Often, the individuals in charge of these efforts are in strictly clinical or administrative roles, such that any formal write-up of the processes implemented would have to occur in off-work hours. Furthermore, such evaluations in many ways represent a case study approach, which may be off-putting to journal editors seeking to publish only rigorous clinical trials.
In sum, the findings from Groot Korelinck and colleagues (2020) are a valuable step toward tackling the gap between intervention development and intervention implementation of neuropsychiatric symptoms in dementia patients. Increased emphasis on communication and respect for staff perspectives will likely result in increased success of complex interventions within long-term care settings.
We are at a bit of an impasse in geropsychology: we have psychosocial interventions that we believe will work for treating neuropsychiatric symptoms in dementia patients; however, effective implementation of those interventions remains an elusive goal. This has resulted in the continued reliance on psychotropic drugs for symptom management in dementia patients, despite evidence of limited efficacy (e.g. Seitz et al., Reference Seitz2013). The paper by Groot Kormelinck and colleagues (2020) in this issue examines the available literature for barriers and facilitators of effective implementation of “complex interventions” (Craig et al., Reference Craig2013) for neuropsychiatric symptoms in dementia. The interventions examined by Groot Kormelinck et al. (Reference Groot Kormelinck2020) ranged from exercise programs to multidisciplinary collaborations. Although complex interventions are more likely to be effective than those targeting a single mechanism of change or requiring adherence to a strict protocol, they are also more susceptible to barriers at a myriad of levels within the implementing organization, including those on the “front lines” of daily patient care (e.g. nurses and nursing assistants), those in mostly supervisory roles (e.g. psychiatrists and psychologists), and those in upper administration (e.g. section chiefs and hospital directors).
Several factors led to increased facilitation of intervention implementation in the Groot Kormelinck et al. (Reference Groot Kormelinck2020) analysis. Notably, staff perception of the effect of the intervention and the ease with which the intervention could be enacted were moderators of successful implementation. Staff who work in skilled nursing facilities are often overworked (White et al., Reference White, Aiken, Sloane and McHugh2020) and understandably would be reluctant to implement new processes that they view both as unnecessarily complicated and unlikely to work. Top-down approaches in which the decisions for policy change are made by those far removed from the day-to-day experiences of staff are thus less likely to result in effective implementation of evidence-based approaches to care. Within psychological care, the importance of “buy-in” from the patient is critical to successful treatment. The same is true on a larger scale for implementation of complex interventions in skilled nursing facilities: without the support of the individuals who are actually doing the intervention, there is unlikely to be substantial change. This was reflected in one of the articles reviewed, which found that implementation of complex interventions was positively facilitated by a less hierarchical structure within the organization (Quasdorf et al., Reference Quasdorf2017).
Similarly, having sufficient resources to enact the intervention, both in terms of cost and staff time, was noted as facilitating successful implementation of non-psychotropic treatment of dementia symptoms. A lack of resources may indeed be an insurmountable barrier for many in charge of implementing a change in procedures. Staff who are asked to do a task without being provided the means with which to do that task are simply unlikely to comply. Furthermore, the suggestion that many of the facilities included in the review did not supply sufficient funds or training implies that even those at the “top” of the decision-making process for those sites may not have been fully committed to the implementation of the new procedures.
Finally, communication was highlighted as a key issue in the majority of the articles reviewed (Groot Kormelinck et al., Reference Groot Kormelinck2020). Indeed, communication is the bedrock of the other facilitators/barriers discussed: lack of communication is likely associated with poorer staff buy-in for the change in procedure in the first place, as well as increased levels of turnover. The benefits of a “participative leader” and “champions” may in fact be due to increased communication between leadership and staff (Ruben and Gigliotti, Reference Ruben and Gigliotti2016). This underlines the need to focus on broad institutional functioning overall when implementing substantial policy changes. Facilities that lack clear lines of communication between those making the decisions and those doing the implementing are less likely to be able to successfully transition to new procedures, including those involving increased levels of patient-centered care.
Although Groot Kormelinck et al. (Reference Groot Kormelinck2020) were able to review data from 15 studies conducted across the globe (Australia, Canada, the United States, the United Kingdom, Norway, Germany, and the Netherlands), this no doubt only represents a small minority of the implementation efforts currently underway. The evaluation of implementation efforts in skilled nursing facilities represents its own challenge and has its own set of barriers. Often, the individuals in charge of these efforts are in strictly clinical or administrative roles, such that any formal write-up of the processes implemented would have to occur in off-work hours. Furthermore, such evaluations in many ways represent a case study approach, which may be off-putting to journal editors seeking to publish only rigorous clinical trials.
In sum, the findings from Groot Korelinck and colleagues (2020) are a valuable step toward tackling the gap between intervention development and intervention implementation of neuropsychiatric symptoms in dementia patients. Increased emphasis on communication and respect for staff perspectives will likely result in increased success of complex interventions within long-term care settings.
Conflict of interest
None.