Table 1 Overview of all themes reflecting the mentioned barriers by participants, barrier-subthemes supporting these themes and relevant secondary quotes grounding the barrier-subthemes

Use of temporary staff

A1, pa7: “Well I expect, if I allow to notify the behavior coach when there is agitation that they [LPN] will do so. But again, today I noticed that the behavioral coach wasn’t contacted. So, I think that’s very frustrating. Part of the reason was probably that there were temporary staff present.” NP

A2, pa8:” Especially the regular staff, they show more commitment. {…} Especially the people from the employment agency, we have seen that before. (…) One time one of the temporary staff on the unit, a resident was showing agitation, but she ignored it completely and just walked past the resident.” N

A3, pa20: “There are some things that remain undone when temporary staff is present. You just have to, as part of the team, you have to be aware of that.” LPN

Insufficient staff on the unit

A4, pa8: “One evening, there were two (LPN’s) from the employment agency and there was one nurse aid present and the capacity was minimal. {…}.” N

A5, pa2: “You know, of course you want to please every resident and everyone … but that’s not always possible. Or that you’re with too little staff …” LPN

A6, pa2: “at the end of the week, oooh, there was too few staff, so you’re alone, from seven in the morning on.” LPN

Discontinuity by frequent staff turnover

A7, pa18: “Relatives sometimes have complaints about us, that there is a lot of staff turnover, that happens on a regular basis. NA

Pa17: Yes, that is the only complaint they have. UM

Pa18: Fortunately!” NA

A8, pa8: “With constantly changing staff, especially the physicians, you get a very ad hoc approach. And that is how it goes, because if one is present very little or … not present fulltime, there is someone different every time, you have to keep making new agreements.” P

A9, pa2: “But of course you also have the turnover of the physicians. LPN

Pa3 & pa4: Yes. LPN & RLPN

Pa2: We have had many changes and every physician wants something else with it [psychotropic drugs] and sometimes I really think that is a disadvantage. LPN

Pa4: Yes that is true. RLPN

Pa2: We have had … how many physicians did we have in the past several years? LPN

Pa4: I think I have worked with six.” RLPN

A10, pa11: “The physicians also change often here.. FM

Pa13: Yes the physician that was here now, that one has been here for a few months, but she already left again. FM

Pa11: Yes … gone again. FM

Pa13: I do not want to imply that this one isn’t good, that is not what I am trying to say. FM

I: But it [the physicians] changes a lot? We just mentioned the regular team, but that also applies for the others?

Pa15: My husband has been here for two years now, this is his sixth physician.” FM

A11, pa22: “We have actually had many different physicians here the past year, now another new one. And every physician also has their own method. And own mindset. And has their own vision on this [psychotropic drug prescription]. And we have to change.” RLPN

A12, I: You all actually indicate that staff varies strongly. With one you have a good connection and with the other you don’t.

All: Yes … Yes … FM

Pa13: I think that is the biggest mistake, the residents get very restless of all those unfamiliar faces. FM

Pa 12 &15: Yes.. FM

I: Exactly, so you notice a lot of staff turnover?

Pa11: Yes, a lot.” FM

A13, pa5: “To evaluate your actions is important. P

Pa7: Also, with each other I think, how are we doing now? NP

Pa5: To do that in a more structured way, that is our intention. P

Pa5: And that actually works better with a regular team than if you have a changing team, because then … well … That needs no explanation.” P

A14, pa15: “What we see now … Today that person is here, tomorrow it’s someone else, but that person doesn’t see that he [the resident] is behaving totally different from the day before or from usual. FM

A15, pa17: “The thing is that … discontinuity of staff, that is … really a trigger for … eh … for behavior. Behavioral problems. That is … People just react to that. It is a trigger for mistakes also. But it is also {…} very important.” UM

Lack of time

A16, pa17: “I heard in the work meetings for example was that the staff has little time to consult each other. There is no time to convey the information from shift to shift.” UM

A17, pa5: “To extract the life history in clinical practice is found hard to execute. {…} There is a need … That is expressed by everyone. But the execution and time, that is a major problem.” P

Lack of continuous education

A18, pa6: “But there should actually be cycles of training with pointers to deal with difficult behavior [of residents], there are new insights, we can inspire each other with cases from the past half year. Ehm … Then you’ll keep the spirits up together, you share, but that just does not get established. {…} There is not a kind of cycle like every few months there is a training for every team. That has to be stated [to management] every time again, that that is important.” P

Reduced staff motivation and effort

B1, pa4: “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 is a big difference between colleagues. RLPN

Pa2: I think so too. LPN

Pa4: One will deepen their knowledge more than others.” RLPN

B2, pa7: “Well, I have to be honest, well … I have the idea that we are already heading the right direction if I’m very honest. Yeah … It can always be better, but that … you have to keep striving for that, but I think that the people who are here, that everybody is consciously working on that [improving prescription of psychotropic drugs]. And … yeah, so in that way we are already heading in the right direction. NP

I: You emphasize the process that takes place in your team, you are very enthusiastic about the collaboration and the team, in a very broad sense?

Pa7: Well the people that are here right now, I just notice, yeah, I also speak for myself, but I notice that everyone is benevolent to do and also to … to commit themselves to it. And is motivated for it. Yes … I really noticed that.” NP

Negative staff emotions

B3, pa6: “I thought they [staff] were much more resistant. {…} They themselves became agitated. And to the person, or the behavior, they judged that, they judged the person and not the disease or the behavior that stemmed from that disease.” P

B4, I: “How are NPS perceived?

Pa6: Yes … well with irritation and also the feeling that there’s not much to do about it. There’s no point anyway. Or it will not get better.” P

B5, I: “How do you experience NPS?

Pa3: Sometimes like helplessness. Like there is nothing you can do about it. Sometimes this is what I think … then you’re really at a loss what to do.” LPN

B6, I: “What do you expect of the physician in general?

Pa22: I do not agree with it [psychotropic drugs] being stopped. Really, I do not agree with it. RLPN

Pa19: Me neither. LPN

Pa22: We are here all days, if you read [the report] you can see it. You [other LPN] are in the nightshift, you also know it. I really don’t agree with it, but whether I like it or not, it will happen. If the physician decides it … RLPN

Pa19: Yes, then we don’t have a leg to stand on. LPN

Pa22: I cannot influence it. RLPN

Pa19: No … I find that disappointing.” LPN

Dissatisfaction of relatives

B7, pa13: “There is not enough attention; people here already said it before. You cannot always expect everything from the people [staff], but … but then you come to the point [the problem of the available staff] again of the staff and I am so disappointed in that, that it’s so bad.” FM

Deficiency of staff knowledge

C1, I: “Do you think there are enough knowledge and skills available along the whole line and well along the line of your colleagues or other disciplines? (interviewer)

Pa3: Yes, well … They don’t. We ourselves also don’t. No, maybe that sounds a bit weird, but that’s just the way it is. Yes, I mean it’s also very important for yourself.” LPN

C2, I: “But are you saying that knowledge in all areas is not always present?

Pa4: No … In all areas it’s not. RLPN

I: That is also what others also …

All: Yes …

Pa3: Yes, I think so. I think we all lack enough knowledge. LPN

Pa3: We sometimes know more about the computer than we know about that [neuropsychiatric symptoms]. Sometimes yes. You need to have more knowledge about that.” LPN

C3, pa3: “And if someone totally panics because he sees big spiders walking on the wall, then you know …. Oh … that fits the picture of the disease. So, he sees things that are not there. You can panic about that and so yes … as long … if you don’t have that knowledge … then you would think … that man is not well at all. I have to call the physician quickly as he has to go to the hospital.” LPN

Lack of evaluation

D1, pa10: “In the past several years, if someone has a restriction of freedom, that that will usually remain 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

D2, I: Evaluation of psychotropic drugs, how does that work?

Pa7: Oftentimes, that doesn’t happen. NP

Pa9: Very little. Well longer than the three months that were allowed, after which it should be evaluated. That was … yeah often too long. N

Pa7: Yes, I think that this needs more attention. What the psychologist also said, we need to address decisions that have been made and evaluate those again, that is missing.” NP

Lack of (multidisciplinary) consultation of key disciplines

D3, pa8: “We are actually never present at such meetings [multidisciplinary consultation]. {…} It would be 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.” N

D4, pa4: “The physician has really been busy with all medication … to look into it per resident and consult with the family and to stop many medications. {…} I had one resident … they, yes I think that, experimented with him a lot. And then I can feel something about it, I can say something, but they don’t listen to you and then I think [curse] … He went from one medication to the other because it wasn’t working and then I think … Well just stop with it for once. Because maybe it is all counterproductive and eh … I think we should have more of a say in these matters.” RLPN

Lack of multidisciplinary consultations / meetings

D5, pa10: “It is also weird that we have never had a meeting. That is what I am thinking now. Because actually you do … What you do in the evening and at night, is what I do during the day. BC (pa10)

Pa 8 & 9: Yes. N

Pa10: We have never had a meeting about that.” BC

Flawed internal reporting and communication

E1, pa 11: “Well I find the communication very bad among the workers. FM

Pa13: Yes. FM

I: But that is very general, what do you mean?

Pa111: One does not know what the other does. FM

I: Within the group?

Pa11: Within the group. Nursing staff … Yes …” FM

E2, Pa13: “I say it often, everything goes well up until the door of the unit. And then the problems start. FM

I: {…}

Pa13: No, I mean the planning and communication, those I find very bad from that side [of the management], the higher you get in management.” FM

E3, Pa6: I think that the coordination therein is also important. Because hearing this question, I also think how many conversations do I have with relatives? Not that much, but also because I’m assuming that the physician does that or the registered nurse or care staff.” P

Lack of sharing experiences

E4, pa6: “The sad part again is that results are not really shared and it could be so inspiring if you know: ‘Wow, we did that very well together. And someone went from very unhappy and displaced to … enjoying a pleasant gettogether, while that is the thing that provides a good vibe, next time we can do this together too’.” P

E5, pa10: “Especially the old school, 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

E6, pa7: “That we would give more feedback to each other. That we knock our heads together. How is that man or woman doing? And that the behavioral coach is present and maybe the RLPN. I think that could be improved … Well that can be improved.” NP

Unclear communication of changes with family

E7, pa18: “Yes, then the family is not informed … {…}, then it was not clear why it was stopped. Everything was just stopped. Everything can go. But it does not work that way. Because family wants to be informed with every change in medication, why is it stopped, with explanation.” NA

E8, pa7: “Recently a resident or a partner of a resident told me … She said: “I want to be more involved in the decision-making regarding the treatment of my husband. That has never happened in the past years, I was totally ignored in this area.” She was very unsatisfied with this. {…} In principle we do that! The care staff link it back to the family. And if there are decisions with a big impact in terms of medication, then I contact them myself, but it would appear that it has not always happened. In that way I think we leave some loose ends sometimes. I don’t want to say that I always inform everyone, but at least I try to. NP

Communication with relatives is considered time consuming

E9, Pa4: Officially it [resident background information] should be according to the domains [of life]. But there is so little time to … I myself am an RLPN, to fill it in. To start the dialogue with a relative because you have to do it by means of a form. I think that’s … difficult to start that conversation, to plan it or … plan the conversation is not a problem, but … to fill it in you know … You have to talk about all the different domains … It takes an incredible amount of time. So usually we discuss the workplan, we make that and then over time we shortly add the things we have a need for, but it will never be as detailed as it would be according to the domains.” RLPN

Unstructured processes

F1, I: “But then you have to evaluate some things.

Pa7: Yes, and that, that could be improved. I think so, yes. So we actually have to structure that too, shouldn’t we?” NP

F2, pa8: “Also the past period there have been many changes [turnover of physicians] here, which caused the systematics to get a little lost. And eh … What we also said before, you need continuous people to consult with each other and to … to apply policies. {…} with constantly changing staff especially in the ranks of the physicians, you get a very ad hoc approach. And that is how things are, because if someone is present very little or … not present fulltime, either there is someone else all the time, you have to make new agreements every time...” P

F3, pa9: “Yes except we have no clear timespan, how long will you keep trying? {…} People can be willing to keep investigating things, because maybe if we do this, that will have the effect we’re hoping for. We don’t have much clarity about the timespan and sometimes that could be very important. If that doesn’t work than we have to take action quickly, to try to break through the pattern with medication. P

Pa7: Yes, I think that can be more structured too.” NP

F4, pa10: “Yes, there are many good ideas, that is not the problem, but in one way or another it doesn’t come together. That is my feeling.” BC

Ambiguity of division of responsibilities and tasks

F6, pa6: “I think it is important, that they [physician and psychologist] are in a position … in which they 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

F7, pa6: “I sometimes find it hard in the collaboration with the unit manager, the role of the unit manager and the collaboration. It’s not just the teams, but also what is each other’s role in that way?” P

F8, pa5: “In clinical practice it is found that it is hard to execute [to extract the life history]. Very concrete over time, who executes it? Does the care staff execute it, or does the psychologist do it, the social worker that we have had here for some time, now not anymore? So who will do it?” P

F9, pa7: “The feedback to the RLPN on do you this or shall I do it, sometimes I leave loose ends. NP

F10, pa10: “I don’t know what kind of role you [registered nurses] have exactly. I thought that it was purely medical … the medical area so to say, so an extension of the physician.” BC

F11, pa6: “Well, for example if there is resistance of care staff to … to do certain things or an intervention or people say they will do it and they won’t. Who is going to guide that? Who is responsible then? Of course I can address, but if it’s a motivational problem, well … then it is not up to me to find it out where the problem is located.” P

F12, Pa6: Coaching of the team, really guide them, to pep them up and give them energy, inspire them, yes, I think that’s something for the unit manager to do. P

Pa9: But for that purpose, you see them too little on the unit, the unit managers. I think that is also one of the problems. N

Pa6: The unit managers are too busy with the planning in my opinion. That kind of stuff.{…} While to me, that’s not their primary task. So that part is something they can develop themselves in, together with the multidisciplinary team. And then also the support of the management for the unit manager.” P

Decision-making culturesus

F13, pa1: “Before you have managed to make a change. Everybody thinks something about it and eh …” UM

Difficulty breaking patterns

G1, pa1: “{…} things that are like this for years, that is very hard to break through, to change. That I encounter with everything on this care unit.” UM

G2, pa1: “We have a recreational therapist that is really on the unit. But she is still so busy with actually … well … coordinating volunteers, that is actually what she’s doing at the moment. Yes … she has to change her work routines. But that is very difficult for her. I’m talking about it with her now. But we all have a clear picture of what we want from the care perspective. And that doesn’t change overnight.” UM

G3, pa2: “But also things that have been this way for years like those residents go to drink coffee every morning and then the others stay behind and then I had a big discussion about that with her [occupational therapist]. {…} Those things are so rigid, those residents do this all days, so …” LPN

Concerns relatives on changing practice

G4, pa15: “The nursing staff determines what my husband’s day looks like. FM

Pa11: And you have no say in the matter. FM

Pa15: No … FM

Pa11: You can … you may, but nothing will happen … It will not be addressed.” FM

G5, Pa16: I myself am part of the board [of client representatives] … It doesn’t help much. I actually miss that a bit {…} We are in the middle of the residents, between clients and between the management. It has to have more of a voice in matters. Because they present a plan of care {…}. We only have to read it. Well … Look then it’s already too late. That is too late … {…} Because they already took the decision and the board of resident representatives only has to say if they agree with it, that’s what we’re good for.” FM

G6, pa25: “My husband came here on the unit. He was here at the daycare. Well then it came to pass that he actually had to stay here [on the unit]. So we had a look at one of the units. What they presented us then … It is going to be like this and there will be a fence, the doors will open, people will be able to walk around outside and all those things and more.FM

I: That hasn’t happened yet …

Pa16: No nothing … FM

Pa11: Up until today not yet. …” FM

G7, pa10: “We do notice in the nursing home, there are a lot of good ideas and a lot of nice developments and eh … Those are actively pursued but it also always kind of slips away.” BC

Responding late to behavior

G8, pa8: “We are actually only called when there is something wrong with the resident. If we just have more information [to help them] … not. N

Pa5: That also happens very often with us. We are being called, I don’t want that anymore actually, only if there are difficult situations, but you should have to chance to get to know the people a bit. And that is actually our main goal, I think the perspective of the person, the goal is also not to reduce people, but to get a complete picture of them.” P

G9, pa5: “There is too much thinking going on or waiting for too long … You’ll get some kind of escalation, an accumulation of behavior. I view all behavior as normal behavior, it’s all … It fits our residents; it is an expression of something. You have to look for the meaning of it. And if you wait too long with that. Only if there is … A last … disruption of the balance in that person of in their environment, then they blow the whistle and that way of thinking and observing, I would like to see that changed.” P

G10, pa3: “Yes well he [psychologist] cannot give the solution immediately, however we can think together, well … how can we prevent this from happening and he can provide us with the tools. And then we are searching for a solution together. Instead of bringing the salt afterwards when the egg is already finished. Then it has already happened.” LPN

Not signaling changes in behavior

G11, pa15: “There should be a regular team on every unit. To ensure that the people who are there know okay … This resident behaves different from yesterday. FM

Pa 14 &16: Yes. FM

Pa15: What we see now … Today it’s that person, tomorrow someone else, but that person doesn’t see that he [the resident] might be different from the day before or from normal. FM

I: If it is not noticed in time …

Pa15: If it is not noticed in time … or whatever then it is necessary for us to stay on top of things all the time. Because it has to come from us like guys there is something wrong, he’s behaving differently, he is not usually like this.” FM

MENTIONED

Expressed differences in perception between colleagues

H1, pa4: “But what I think is disturbing, doesn’t have to be disturbing for her [other LPN] or doesn’t have to be a problem for her [other LPN]. It has something to do with you, as an individual. That is why we have to consult each other. We are all different.” RLPN

H2, pa4: “Every physician has their own working method. Their own way of thinking. And their own vision on that [psychotropic drugs].” RLPN

H3, pa17: “Well some [physicians] prescribe a bit faster than others. And you’ll respond quickly to what somebody says. Because the care staff calls and now I’m saying this without nuance. But “oh that resident is agitated so can’t we give her a pill?” Some will say yes that is possible and will prescribe so to say and others will say but when does she get agitated and what happened before …” UM

H4, pa6: “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

pa7: “If I’m honest, I have never experienced that [evaluation of restrictions of freedom of the resident] before.” NP

H5, pa18: “{…} multiple residents already went to bed with clothing over their pajama. I was thinking, what is this?! First getting them out again … Yeah … Because I couldn’t find them [in the living room]. NA

Pa17: You could also just let them sleep. UM

Pa18: Yeah, but yeah … Then they would have done it on their own. That felt very wrong. For me … NA

Pa20: I hadn’t undressed them again. LPN

Pa18: Yeah then my colleague will come the next day saying what a mess has pa18 left behind. NA

Pa20: Yeah, well … too bad.” LPN

NOTICED

Observed differences in perception between focus group participants

Difference in perspective on participation of different disciplines in multidisciplinary consultation.

H5, pa5: “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 … that is 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

Later on in the same focus group

H6, pa8: “We are actually never present at such meetings [multidisciplinary consultation]. {…} It would be 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.” N

Multidisciplinary consultation (structuring of consultation necessary or not necessary difference in opinion)

H7, pa17: “… Moments to evaluate usually happen in a very small setting. Only those who … A multidisciplinary consultation always sounds so big. But then there are the evaluation moments and those can be planned at any opportunity, whenever it’s necessary. So that’s what we do. That doesn’t need to be structured.” UM

Discussion in another focus group:

H8, pa9: “I think those [restrictions of freedom] are being evaluated by the physician in the ward round. And monthly. That is not something that is being discussed multidisciplinary, but I think that the physician, that is being discussed with the physician. P

Pa10: Maybe that will improve now? BC

Pa7: I have never experienced that to be very honest. I think that too can be improved.” NP

Discrepancy between what nursing staff does and what the NP thinks that happens.

H9, pa7: “Recently a resident or a partner of a resident told me … She said: “I want to be more involved in the decision-making regarding the treatment of my husband. That has never happened in the past years, I was totally ignored in this area.” She was very unsatisfied with this. So in that way I have learned from this case to maybe … In principle we do that! The care staff links it back to the family. And if it are decisions with a big impact in terms of medication, then I contact them myself, but it would appear that it has not always happened. In that way I think we leave some loose ends sometimes. I don’t want to say that I always inform everyone, but at least I try to. NP

Nursing staff in another focus group:

H10, pa18: “Yes, then the family is not informed … {…}, then it was not clear why it was stopped. Everything was just stopped. Everything can go. But it does not work that way. Because family wants to be informed with every change in medication, why is it stopped, with explanation.” NA

Complaints

H11, pa18: “The family sometimes has some complaints to us, that there is a lot of different staff again, that happens quite often actually. NA

Pa17: Yes, well that is the only complaint they have. UM

While in the focus group of relatives:

H12, Pa15: The nursing staff determines what my husband’s day looks like. FM

Pa11: And there is nothing you can do about that. FM

Pa15: No … FM

Pa11: You can … You are allowed, but nothing … Nothing is done about it.” FM