The construction of a framework explaining the relation between barriers to change in nursing homes: a qualitative study

Background Many studies have tried to achieve change in the treatment of neuropsychiatric symptoms in nursing homes, however only few of them succeeded. Numerous barriers to change were identified, yet only one conceptual model is known to study the relationships between these barriers in healthcare. Unfortunately, this model does not discuss specific barriers encountered in nursing home practice. The aim of this study is to explore perceived barriers to change in nursing home organizations and to construct a framework providing insight into the relative importance of and the relationships between these barriers with regard to improving quality of care. Methods In order to explore the barriers to change in nursing home care, four focus groups were conducted in different dementia special care units of one nursing home in the Netherlands, with a specific focus on NPS and psychotropic drug use. Participants were either nursing staff, treatment staff or relatives of residents. Qualitative thematic analysis was conducted according to the five phases constructed by Braun & Clarke. Finally, a conceptual framework showing the interrelations of themes was defined using text fragments of the focus groups. Results We constructed a framework consisting of eight themes of barriers explaining the extent to which change can be achieved: 'organizational barriers', 'personal barriers', 'deficiency of knowledge', 'suboptimal communication', 'inadequate (multidisciplinary) collaboration', 'disorganization of processes', 'reactive coping' and 'differences in perception'. Addressing 'organizational barriers' and a 'deficiency of knowledge' is a precondition for change. 'Suboptimal communication' and 'inadequate (multidisciplinary) collaboration' play a key role in the extent of change achieved via the themes 'differences in perception' and 'disorganization of processes'. Furthermore, 'personal barriers' influence all themes - except 'organizational barriers' - and influence the extent of change. 'Personal barriers' can cause 'reactive coping', which in turn may lead to 'difficulties t structure processes'. Conclusions A framework was created explaining the relationships between barriers towards achieving change in nursing homes, focused on improving quality of care. This framework can be used to study the interrelatedness of barriers to change, and to determine the importance of addressing it in order to achieve change in the provided care.


Introduction
In the Netherlands 70.000 people with dementia reside in care facilities such as nursing homes [1]. Of these residents, approximately 27% use antipsychotic drugs as a treatment for neuropsychiatric symptoms (NPS) and 40% use antidepressants [2]. Guidelines advise a restricted use of psychotropic drugs in the treatment of NPS and advocate the use of psychosocial interventions [3]. The analysis and treatment of NPS is a multidisciplinary process, wherein among others, the physician, psychologist and nursing staff play an important role [4]. Proper treatment of NPS is important, due to the negative influence of improper treatment of NPS on the quality of life of residents and on nursing staff. For example, nursing staff might experience anxiety and burnout as a result of NPS in residents [5,6]. Therefore, various multidisciplinary interventions have been developed to reduce the frequency of psychotropic drug use and/or NPS, or to improve residents' quality of life [4, 7 -12]. Unfortunately, the (long-term) effectiveness of many of these interventions in terms of reduction of psychotropic drug use was shown to be limited [7,8,12,13].
The small effects of interventions for psychotropic drug use may be a result of difficulties to implement interventions and induce change in nursing homes [14]. In that respect, a number of studies has been conducted to identify specific barriers towards implementation of (complex) interventions in nursing homes, often by means of a process evaluation. A major barrier -which has been reported on multiple occasions -is the complexity of the guideline or intervention to be implemented [15,16]. These interventions are frequently complex due to a multidisciplinary approach, in which each discipline (i.e. nurses, physicians, and psychologists) applies different types of interventions [4]. In addition, a major barrier reported was the high turnover of the nursing home workforce [14][15][16][17][18][19]. Moreover, reorganizations, other innovations running at the time of the intervention, absent feeling of relevance by the staff [8,17,18,20] and the culture of the care unit, including attitude towards change, are barriers towards changing current practice [14].
In the past, research has been conducted to identify barriers and to classify these into categories i.e., themes. For example, Mentes & Tripp-Reimer (2002) provide an overview of barrier themes encountered in nursing home research: residents, staff, administrative and organizational issues, attitudes, research protocols and research assistants.
Furthermore, Corazzini et al. (2015) studied challenges (barriers) encountered while implementing 'culture change in nursing home staff' and 'leadership behaviors' that facilitated this change. They found six key themes, which described these challenges and leadership behaviors: 'relationships', 'standards and expectations', 'motivation and vision', 'workload', 'respect of personhood' and 'physical environment' [21]. Finally, the English National Institute for Health and Clinical Excellence (NHS) carried out a systematic review, which offered five types of barriers to change in healthcare and ideas to overcome these barriers. The five types of barriers identified were: 'awareness and knowledge', 'motivation', 'practicalities', 'acceptance and beliefs' and 'skills' [22]. Identifying themes of barriers is important as these can assist in understanding the causes of barriers and how to address these. Yet, insight into the relationships between themes of barriers is even more helpful in effectively addressing barriers, as it allows for a better determination of the magnitude of the barrier and of strategies to resolve it [23]. There is evidence indicating that assessment of barriers -before attempting implementation of an intervention or attempting to change current practice -will increase the chance of success [24]. improvement of the quality of care. Although many barriers to change and overarching themes have been identified in previous research, there is no framework available that explains the relationship between these perceived barriers in nursing homes. Therefore, the aim of this study is to explore the perceived barriers to change in nursing homes and to construct a framework providing insight into the importance of and relationships between these barriers.

Design and Setting
A pilot study was conducted in preparation of a larger trial 'Reduction of Inappropriate psychotropic Drug use in nursing home patients with dementia (RID) In this pilot study, focus groups were formed to identify barriers to change in nursing homes. The focus group interviews took place in a Dutch nursing home, wherein all involved professionals were employed by this nursing home. Qualitative thematic analysis [25] was used to identify barriers to change and their interrelations. We complied with the COREQ checklist in conducting and reporting this study, see supplement A [26].
Four (monodisciplinary) focus groups were organized in two care units of one nursing home in the Northern part of the Netherlands. To increase diversity of the sample, one traditionally built large scale care unit and a small-scale living facility were included in this research. Two focus groups included nursing staff and their manager (group 1 & 4), one included only treatment staff (group 2) and one relatives (group 3), see figure 1. The nursing staff was recruited via the unit managers. The treatment staff and relatives were recruited by the head researcher (SUZ) and the unit managers. Staff was approached faceto-face for participation, relatives of residents were approached via mail

Data collection
Participants of the focus groups were stimulated to express their views and exchange opinions on difficulties in the care process of their care unit for residents with dementia, with a specific focus on NPS and psychotropic drug use. Furthermore, participants were stimulated to discuss general barriers concerning possible implementation of interventions to address and improve the treatment of NPS and reduce psychotropic drug use. A guide to direct the discussion was developed, based upon literature and consultation of clinical experts, following guidelines for conducting focus groups [27]. The focus groups were moderated by a psychologist from another location of the same care organization. To prompt statements on barriers, questions were asked about one or more of the following practical topics: (1) mutual expectations on collaboration among members of the nursing staff, unit manager, physician, psychologist, other disciplines and relatives to detect, diagnose and treat residents with NPS, (2) the actual use of the Dutch guideline for problem behavior [3], (3) the applied work plan for signaling NPS, (4) knowledge about residents' background, (5) applied treatment solutions for NPS, (6) knowledge and experience of various disciplines, (7) reasons for prescribing psychotropic drugs and (8) limitations experienced in the management of NPS/psychotropic drug use. Interviews were audio-taped. Information on sex and profession of the participants was obtained.

Data analysis
All interviews were transcribed ad verbatim, and transcriptions were cross-checked with the recordings afterwards. Qualitative thematic analysis was used by continued open coding, wherein barrier-themes identified in previous research were used as background information. Furthermore, the framework was refined until no new information could be added from the existing four focus groups, and the stage of conceptual saturation was reached [25]. The ultimate goal was the construction of a model to identify connected topics [28].
Data analysis was an iterative process according to the five phases described by Braun & Clarke (2006) and was conducted by two researchers (C.T. and K.V.). C.T. has a background in medicine, while K.V. has a background in psychology. The researchers started the analysis by reading and familiarizing with the data (phase one: familiarizing yourself with your data). Hereafter, relevant quotations for answering the research question were independently marked as free quotations using Atlas.ti software v 7.5.10, (Atlas.ti Scientific Software development GmbH, Berlin, Germany). Next, the researchers individually labelled these quotations with codes, staying as close to the text as possible.
In addition, memos were given to contradictions and deviating opinions in the focus groups. Then, the researchers discussed all codes until consensus was reached (phase two: generating initial codes). Subsequently, both researchers independently categorized all codes into barrier-subthemes (using 'clustered codes' and 'subthemes' in Atlas.ti) and discussed these until consensus was reached to ensure reliability. Afterwards, the researchers (C.T. and K.V.) had multiple meetings to analyze and discuss the relation between different barrier-subthemes. Barrier-subthemes that were related, were brought together in themes of barriers (themes) by D.G. and C.T. (phase three and four: searching for themes; reviewing themes). In addition, all memos were crosschecked with identified themes to check for new insights and content. Remarkable or contradictory quotations based on memos were reported and memos with the same content were categorized together. After grouping all barrier-subthemes into themes, themes were named according to their content (phase five: defining and naming themes). The interrelations between themes of barriers were defined by using text fragments of the focus groups and hereafter visualized in a conceptual framework. To construct this framework four researchers (C.T., K.V., D.G. and A.P.) had multiple discussions.

Ethical Approval
The study was undertaken in accordance with the declaration of Helsinki [29], the applicable Dutch legislation and in agreement with the code of conduct of Health Research [30]. In the results presented below, the word 'participants' is used when participants of all four focus groups reported these findings, in any other case the participant's function is mentioned.

Thematic analysis
The analysis resulted in the identification of eight themes of barriers: 'Organizational barriers', 'Personal barriers', 'Deficiency of knowledge', 'Inadequate (multidisciplinary) collaboration', 'Suboptimal communication', 'Disorganization of processes' 'Reactive coping & resilience of organization' and 'Differences in perception'. These interacting themes of barriers were brought together in a framework explaining the extent to which change is impaired in a nursing home given the existing barriers. Some of these barriers are explicitly linked to prohibiting change, as shown in corresponding quotations, others regard impediments to good care, indirectly impairing change. Firstly, we will describe the barrier-subthemes and themes: the building blocks of which the framework is composed.
Thereafter, the framework, which shows the relationships between the themes, will be described.
Additional quotations to the ones mentioned in the results below, are included in Table 1 (appendix). Each quotation is addressed by its corresponding code: the letter corresponds with the theme, the number with the quotation within that theme, i.e. A1, H5.

A. Organizational barriers
The first theme consists of barriers that were related to the organization and organizational decisions. This theme is composed of the following subthemes: 'Use of temporary staff', 'Insufficient staff on the unit', 'Staff turnover', 'Lack of time' and 'Continuous education'. The 'use of temporary staff' and a 'lack of sufficient staff' on the unit (A4) inhibited the implementation of interventions as well as the continuity of care (A1). In addition, a difficulty in maintaining the continuity of care was caused by a 'turnover' within the ranks of the physicians (A13) and a 'turnover' within the nursing staff (A7, A12). Furthermore, these barriers impeded the extent of change reached. Moreover, a lack of time influenced the transferring and consistency of information between staff (A1). Lastly, participants indicated that continuous (cyclic) training for nursing home staff was important to get inspired, acquire new insights, and to in incorporate these insights into daily practice (A17). The absence of continuous (cyclic) training is a barrier to change.

B. Personal barriers
The second theme consists of barriers that are related to personal factors. This theme is composed of the following subthemes: 'Motivation and effort', 'Initiatives by staff', 'Emotions of staff' and 'Emotions of relatives'. Participants stressed differences in 'motivation and effort' among staff members. Some considered it important to show motivation in relation to the work ethics to colleagues by sometimes staying a little bit longer on the unit when necessary (B1) or by showing effort to gain more knowledge on for example diseases, but mentioned that others did not. The 'emotions of relatives' might influence the amount of change, through a disappointment felt over and over again. In particular, emotions of relatives were apparent when problems arose on the unit with their relative. Relatives sometimes felt disappointed about turnover of staff and temporary workers (B12).

C. Deficiency of knowledge
The third theme consists of barriers that are related to knowledge. This theme is composed of the subtheme: 'Deficiency of knowledge'. The treatment of NPS and therefore also prescription of psychotropic drugs was strongly related to knowledge of staff, or a deficiency thereof (C1).
"And if someone totally panics because he sees big spiders walking on the wall, then you know…. Oh… that fits into the picture of the disease. So he sees things that are not there.
You can panic about that and so yes… as long… as you don't have that knowledge… then you would think… well that man is not well at all. I have to call the physician quickly as he has to go to the hospital." LPN (pa3)

D. Inadequate (multidisciplinary) collaboration
The fourth theme consists of barriers that are related to inadequate (multidisciplinary) collaboration. This theme is composed of the following subthemes: 'Evaluation', '(Multidisciplinary) consultation of key disciplines' and 'Multidisciplinary consultations / meetings'. The participants indicated that lack of evaluations of initiated processes of change and of treatments started was a key barrier in inadequate (multidisciplinary) collaboration.
"In past several years, if someone has a restriction of freedom, than that usually remained that way. And before it comes up for discussion again or before it gets discussed like 'is it actually still necessary that someone is restrained', that woman is not going to get up anymore. That you… If no one makes a remark about it, that that sometimes persists longer than necessary." BC (pa10) Lastly, not consulting other key staff members impaired a healthy (multidisciplinary) collaboration, even though the exclusion of these members was not done consciously (D3).
Additionally, having frequent meetings with this staff was considered valuable and a lack thereof might have impaired the establishment of new and effective treatments for residents (D6).

E. Suboptimal communication
The One of the relatives of a resident described the communication between nursing staff members as flawed, which, in turn, impaired the quality of care (E1). Participants stated 'sharing experiences', such as asking for help and sharing success stories, was important to inspire each other into improving care, whereas lack thereof was seen as a barrier.
"Especially the old school [LPN], they really have a… really a… a culture of wanting to control, they want to have the right touch. And if they need to ask for help, sometimes that is a… that is too much to ask. Or a… Or… One is not so easily inclined to share a problem. They keep it to themselves. And I find that very unfortunate." BC (pa10) In addition, there was confusion about the communication of changes (for example in medication) with family. Physicians expected nursing staff to discuss certain changes in medication with relatives, while the nursing staff experienced difficulties explaining these to the relatives due to flawed reporting by the physician in the patient file (E6).
Furthermore, an LPN remarked that because communication about the resident with relatives was time consuming, often only the bare essentials were discussed. This resulted in incomplete information in the patient file (E8).
Moreover, 'Little participation of relatives' was an important aspect, since the relatives played a major role in the life of residents on the units. One of the registered nurses explained that participation of relatives on the units was essential, because relatives provide a quiet atmosphere in the living room, which resulted in less NPS (E12).

F. Disorganization of processes
The sixth theme consists of barriers that are related to disorganization of processes. This theme is composed of the following subthemes: 'Unstructured processes', 'Ambiguity of the division of responsibilities and tasks' and 'Decision-making culture'. This theme entailed information related to the obstacles, either culture-based or related to a key person, in organizing (care) processes. The necessity of structuring evaluation and consultation about NPS and its treatment was primarily mentioned by the nurse practitioner and psychologists (F1, F3). Furthermore, obstacles in structuring processes were mentioned, such as ideas that do not converge (F4). Moreover, participants expressed confusion concerning the division of responsibilities and tasks. Especially ambiguity about the person who manages the process of care was mentioned (F9, F11). The last item mentioned in this theme was the culture of trying to reach consensus when making a decision. This culture was seen as frustrating by participants, which elongated the time necessary to structure processes (F12).

G. Reactive coping & resilience of organization
The seventh theme consists of barriers that are related to resilience of the organization or reactive coping of the persons within that organization. Reactive coping is a coping style in which one awaits circumstances to unfold before responding, which may complicate initiation or maintenance of change. This theme is composed of the following subthemes: 'Difficulty breaking patterns', 'Concerns relatives on changing practice', 'Responding late to behavior' and 'Not signaling changes in behavior'. Participants mentioned how difficult it was to change existing practice and that sometimes they encountered resistance (G2, G3). The manager of one of the care units explained that it is difficult to break existing patterns, to change.
"…things that are going like this for years, yes that is very hard to break through, to change. That is in everything on this care unit." UM (pa1) Furthermore, the organization did not proactively involve the relatives in the decision process. Relatives voiced their concerns about the way their input about the care of their relative was not used in the nursing home. They said they did not have any influence on the care process (G4) and that although the relatives were sometimes consulted by the nursing staff, this consultation took place after the final decision already had been made (G5).
In addition, an LPN mentioned a tardiness in responding to behavior of residents by involving other disciplines afterwards, when the damage was already done (G10).
Although interventions have been used to improve the timing, nursing staff maintained their behavior of delayed responding. 'Responding late to behavior' and 'Not signaling changes in behavior' by staff impaired the care process (G11).

H. Differences in perception
The eighth theme consists of barriers that are related to differences in perception. This theme is composed of the following subthemes: 'expressed differences in perception between colleagues' and 'observed differences in perception between colleagues'. The   " RN (pa8) Furthermore, the nurse practitioner thought nursing staff informed relatives about changes in medication. However, nursing staff were under the impression that the nurse practitioner or physician would inform the relatives (H9, H10). Another contradiction was observed about the assumptions on necessity to structure meetings between a unit manager and behavioral coach/nurse practitioner. The unit manager did not want to structure the frequency of evaluation meetings; according to her, this was not necessary in a small setting. The other group, however, emphasized that structuring the frequency and time of these meetings would improve the continuity of care., because the meetings often didn't take place (H7, H8).
Moreover, the staff remarked that relatives had little complaints, while relatives mentioned many complaints in their focus group, for example on staff turnover (H11, H12).
Relationship and hierarchy between barrier-themes.
Next, based on the accounts of the participants and our observations, we will explain the relations and hierarchy between the different themes by means of a framework (see Figure 2). 'Suboptimal communication' and 'Inadequate (multidisciplinary) collaboration' were causes for observed discrepancies in perception and assumptions. These observed discrepancies in perceptions and assumptions led to unstructured processes, according to the participants (F7 & F8, F9 & F10, G3). There was no structured approach and there were many ambiguities about agreements made (G7 -G10). Moreover, the unstructured approach and ambiguous agreements resulted in impediments for a structured collaboration and structured deliberations on NPS.
Next, there were two relations: first, 'Personal barriers' separately enhanced the negative influence of 'Reactive coping & resilience of organization', which is strongly related to 'Disorganization of processes' and, through that theme, to the extent of change. Second, an interaction is present between 'personal barriers' and 'disorganization of processes', via 'reactive coping' 'Initiative by staff' is absent, there is usually a reactive coping style, which inhibits the start of structuring processes. In their turn, the subsequent difficulties which can be encountered, cause a reactive coping style and frustration (emotions) in staff.

"But, again, today I encountered that the behavioral coach wasn't contacted. So, I think that's very frustrating." NP (pa7)
It was difficult to break already existing behavioral patterns and try a new approach, which impeded collaboration to structure processes (H5, H7). 'Personal barriers' were related to all themes except organizational barriers. They were strongly related to the theme 'deficiency of knowledge', since the barrier-subtheme 'motivation and effort' was a necessity to increase knowledge of staff (B4). Furthermore, according to the participants, good communication and collaboration were a result of 'motivation and effort' of, and 'initiative taken by staff'.

So sometimes I stay a little bit longer." LPN (pa19)
Finally, the result of all previously mentioned themes of barriers, influences the extent to which change of care processes is impaired in the nursing homes.

Discussion
In this study we focused on the identification of perceived barriers to change in nursing homes and we aimed to construct a framework explaining the relation between these different barriers. We extracted eight themes of barriers that impede the extent to which change is likely. Some are direct barriers and some are indirect barriers. Some of the major studies included nursing staff and treatment staff in their focus groups [16,21], acknowledging the importance of the influence of relatives and their perception [20]. Our study is one of the first to include family members in the focus groups to allow for a 360 degrees view of the barriers to change experienced in a nursing home. Furthermore, we underlined the importance of including nursing staff in the focus groups, because they form the bridge between treatment staff and patients and their relatives.
Although our study resulted in a novel framework explaining the relationships between barriers to change, it had some possible drawbacks. First, the study was carried out in preparation of selecting and implementing an intervention for reducing inappropriate psychotropic drug use. The focus of the focus group questions was therefore on management and treatment of NPS in combination with the prescription of psychotropic drugs. We asked concrete questions about suboptimal care and did not use the more abstract terminology of barriers to change. Due to this strategy we hope to have facilitated the conversation and to have elicited specific information about everyday practice. However, there is a possibility that we missed some of the barriers encountered.
Secondly, both the presence of the unit manager in the focus groups of the nursing staff and the moderator, sometimes asking provoking questions, could have negatively influenced participants to speak frankly. Next, the attending physician was newly employed in this nursing home at the time of the research and was therefore unable to reflect on processes and change in this nursing home. There was no physician present in the focus groups only a nurse practitioner functioning at the level of a physician, although many barriers mentioned concern actions of the physician. This might lead to a skewed interpretation of barriers. Finally, some barriers found in other research did not emerge in the focus groups in this study, such as culture on the care unit and complexity of the change or intervention trying to be achieved [14 -16]. This might be a result of exploring barriers independent from implementing an intervention, including a solitary nursing home, not being able to work according to the principle of data saturation or simply a difference in perspective on the definition of the barrier. The two latter aspects are limitations to this study implying that it is too early to generalize the results.
Nevertheless, it prompts investigation whether culture on the unit should be added to the model or whether it is reflected in barriers already present in the model, such as the 'organizational barriers', 'inadequate (multidisciplinary) collaboration' and 'personal barriers'. Therefore, we suggest to broaden the scope to other nursing homes and to look into all barriers encountered in nursing home research, not only barriers related to NPS and psychotropic drugs use. Furthermore, we suggest to repeat our method of organizing different mono-disciplinary focus groups and analyze the data deductively, according to our framework, next to performing inductive analyses. In this way it can be assessed if our framework is complete or if some other (known) barriers or themes arise during the new analysis, complementing the framework. Lastly, we suggest research into facilitators to change. Although, it is possible that the facilitators are the opposite of the barriers found, there is no certainty on these findings yet. This will result in a more complete picture of the possible extent to change in nursing homes and will provide practitioners with tools to implement changes and overcome barriers.

Conclusions
In summary, we can conclude that we have provided a basic framework explaining the relationships between different overarching themes of barriers towards achieving change in nursing homes. The framework may be used as a fundament to assess and to classify barriers to change. It can assist in future research in the determination of steps to be taken when wanting to either improve the extent of change possible, or to establish the current extent to which change may be hindered.  Tables   Table 1 Overview of all themes reflecting the mentioned barriers by participants, barriersubthemes supporting these themes and relevant secondary quotes grounding the barriersubthemes.

Themes of barriers
Supporting barriersubthemes Relevant quotes

A. Organizational barriers
Use of temporary staff A1, pa7: "Well I expect, if I agree to notify the behavior coach when there is agitati coach wasn't contacted. So, I think that's very frustrating. Part of the reason was p A2, pa8:"Especially the regular staff, they show more commitment. {…} Especially our research [about involuntary care and restraint measures]. One time one of the ignored it completely and just walked past the resident." N A3, pa20: "There are some things that remain undone when temporary staff are pr again." LPN Insufficient staff on the unit A4, pa8: "There was one evening, there were two (LPN's) from the employment ag {…}." N A5, pa2: "You know, of course you want to please every resident and everyone… b A6, pa2: "I came from one unit to the other and at the end of the week oooh there Staff turnover A7, pa18: "Relatives sometimes have complaints about us, that there is a lot of tur Pa17: Yes, that is the only complaint they have. UM Pa18: Fortunately!" NA A8, pa8: "With constantly changing staff especially in the ranks of the physicians, y present very little or… not present fulltime, either there is someone else all the tim A9, pa2: "But of course you also have the turnover of the physicians. Disorganization of processes 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 s F2, pa8: "Also the past period there have been many changes here, which caused need continuous people to consult with each other and to… to apply policies, that i changing staff especially in the ranks of the physicians, you get a very ad hoc appr present fulltime, either there is someone else all the time, you have to make new a change… There is more of a clear line now." P F3, pa9: "Yes except we have no clear timespan, how long will you keep trying? I th credit of the teams. People can be willing to keep investigating things, because ma much clarity about that and sometimes that would be very important. If that doesn pattern with medication. P Pa7: Yes, I think that can be more structured too. I think so too. And maybe we can F4, pa10: "Yes, there are many good ideas, that is not the problem, but in one way Ambiguity of division of responsibilities and tasks F5, pa1: "I think that with a new team you have to make very clear agreements. Li supporting role and to take up some tasks together and I think that is very good fo especially if you like to arrange some stuffs. Then this is a moment to put our head Pa3: "Yes. Because otherwise I think it's too much work for an RLPN to do everythin each other." LPN F6, pa6: "I think it is important, that they are in their position… from which you can coordinator? Is the physician the main point of contact in case of NPS or is it the nu 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 ro what is each other's role in that way?" P F8, pa5: "To extract the life history. But in clinical practice it is found that it is hard execute it, or does the psychologist it, the social worker that we have had here for expressed by everyone. But the execution and time, that is a major problem." P F9, pa7: "That does happen, but I think that there… That feedback to the RLPN on that. Yes, I think so. I can't name a specific example, but I can imagine that someti F10, pa10: "I don't know what kind of role you [registered nurses] have exactly. I th extension of the physician." BC F11, pa6: "Well, for example if there is resistance with care staff to… to do certain guide that? Who is responsible then? Of course I can address, but if it's a motivatio located." P F12, I: "So you expect something of the unit manager? Pa6: Coaching of the team, really guide them, to pep them up and give them energ Pa9: But for that you see them too little on the unit, the unit managers. I think that Pa6: The unit managers are too busy with the planning in my opinion. That kind of Pa8: Every day you hear scheduling, scheduling. N Pa6: Yes. While to me, that's not their primary task. So that part is something they also the support of the management for the unit manager." P Decision-making culture consensus F13, pa1: "Because of course we want to do the whole order ourselves and do som to… whomever we want. Our own budget and eh… But okay then we are here with {…} Pa1: Before you have managed to make a change. Everybody thinks something ab residents." UM G.  Framework depicting relations between themes to explain the extent of change (black box). The round box depicts that this theme is mentioned by participants as well as observed through memo's.

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