Neuropsychiatric symptoms such as depression, anxiety, apathy, agitation, and aggressive behavior are highly prevalent in persons with dementia. The prevalence rates of clinically relevant neuropsychiatric symptoms are over 70% [1,2] and the cumulative 2-year prevalence is about 97% [3]. In persons with dementia, neuropsychiatric symptoms are associated with psychological distress, increased mortality, greater functional impairment, lower quality of life, increased emergency department visits, hospitalizations, and long-term care admissions as well as high caregiver burden [4-9].

Although psychotropic medication is often prescribed to manage neuropsychiatric symptoms in persons with dementia, this type of medication is associated with limited effect and considerable side effects [10,11]. National and international guidelines on the management of neuropsychiatric symptoms recommend psychosocial, personalized, and interdisciplinary interventions for first-line treatment to reduce the inappropriate prescription of psychotropic medication [12-15]. Person-centered care, that is, care that fits wishes, needs, and capabilities of persons with dementia and their (informal) caregivers, is the basic principle in the Dutch guideline “Problem behavior in people with dementia” [15]. Several psychosocial multicomponent interventions have been developed to prevent and treat neuropsychiatric symptoms in persons with dementia and are effective according to the Dutch guideline [15]: Integrative reactivation and rehabilitation (IRR) [16]; Grip on Challenging Behavior (Grip) [17]; and the Stepwise, Multidisciplinary Intervention for Pain and Challenging Behavior in Dementia (STA OP!) [18]. As shown in Table 1, these interventions all consist of a continuous loop of detection; analysis; treatment of physical, cognitive, and psychosocial problems; and evaluation. At the same time, these interventions slightly differ from each other. Multimedia Appendix 1 [12, 16,19-33] includes a detailed description of the 3 methods.

Two recent consecutive audits of quality of care in nursing homes carried out by Dutch Health Inspectorate with an interval of 2 years both showed late, inadequate, or incorrect management of neuropsychiatric symptoms despite the existence of national guidelines and advices based on the first audit [34,35]. A broad analysis of neuropsychiatric symptoms is still insufficiently implemented. As a result, possible interventions are poorly implemented [35]. Although IRR, Grip, and STA OP! have been developed and proven to be effective when actually applied as intended, these programs are not broadly implemented within Dutch nursing homes beyond the research setting [35]. Even though the intervention fidelity of IRR, defined as the adherent and competent delivery of an intervention as set forth in the research plan [36], was rather high (90%) within the studied nursing homes, it showed a limited transferability to nursing homes outside the research setting because of a lack in necessary knowledge and skills. Within Grip, all necessary forms of the program were used in only a small percentage of persons with dementia [37]. The intervention STA OP! was performed in only a small proportion (39%) of persons with dementia [18]. An overview of determined facilitators and barriers to implementation is presented in Table 2. The low level of intervention fidelity of these Dutch programs is in line with results of international studies on intervention fidelity of effective psychosocial interventions to manage neuropsychiatric symptoms. For example, the effective DEMBASE program in Japan was fully implemented in 52% of persons with dementia [38]. The overall intervention fidelity of Dementia Care Mapping was poor [39]. Only 13% of nursing homes completed the fully protocol to an acceptable level [39].

Recent studies have shown that interventions should be aimed at both persons with dementia and their informal caregivers. Specific interventions for informal caregivers have long-lasting effects on depression and anxiety symptoms, increase quality of life, and are cost-effective [42]. When implementing a multicomponent care improvement intervention, it is important to understand the implementation process to improve sustainability in clinical practice [12,43,44] to prevent and treat neuropsychiatric symptoms. Although factors for IRR, Grip, and STA OP! have been investigated, nursing homes did not succeed in implementing these methods.

If taken into account the known facilitators and barriers, to what extent will effective methods be implemented? Are there other facilitators and barriers that have not been taken into account? Therefore, the researchers involved in IRR, Grip, and STA OP! (TJEMB, MS, and WPA) and experts on implementation and management of neuropsychiatric symptoms (DLG, JTS, SUZ) collaboratively developed a joint multicomponent intervention, the STIP-Method: a personalized integrated stepped-care method to prevent and treat neuropsychiatric symptoms in persons with dementia in nursing homes, which is compliant with the current Dutch guidelines to manage neuropsychiatric symptoms [15]. In addition to the overarching elements of the existing 3 methods, the stepped-care model was integrated into the STIP-Method. Stepped care can be defined as a staged, evidence-based system comprising hierarchically delivered interventions linked to patients’ needs: from the least to the most intensive, and stepping down or up when needed [45,46]. The integral STIP-Method especially focuses on interdisciplinary collaboration and shared decision making. Shared decision making between professionals and persons with dementia and informal caregivers is of proven importance to achieve real person-centered care [47]. Finally, the STIP-Method is supported by the use of a web application that finds its roots in Sweden: BPSD Care, in which BPSD stands for Behavioural and Psychological Symptoms of Dementia. In Sweden, it forms a nationwide quality registry that is globally acknowledged as an innovation in the psychosocial dementia care program context [48]. Adaptations of the BPSD-registry program have been developed in both Denmark [49] and Japan [50-52]. The use of BPSD Care has been shown to be supportive in significantly reducing neuropsychiatric symptoms, increasing quality of life in persons with dementia [53], and leading to a lower sense of burden among professionals [51].

This study aims to identify the facilitators and barriers in the implementation of the STIP-Method in nursing homes. Based on earlier studies on intervention fidelity of effective psychosocial interventions to prevent and treat neuropsychiatric symptoms [18,37], we hypothesize that the STIP-Method will be delivered according to protocol to 50% or more persons with dementia (intervention fidelity). Additional aims are to evaluate to what extent the STIP-Method is delivered according to protocol (intervention fidelity), to evaluate the impact of the implementation of the STIP-Method on neuropsychiatric symptoms, restraint use, aggression incidents, and use of psychotropic medication. Furthermore, we assess the contribution of the BPSD Care web application to the management of neuropsychiatric symptoms. We expect the study will deliver an in-depth understanding of facilitators and barriers to the management of neuropsychiatric symptoms to positively influence these implementation aspects through (1) emphasis on interdisciplinary collaboration and involvement of informal caregivers, (2) implementation of the web application BPSD Care, and (3) considering the facilitators and barriers regarding the interdisciplinary implementation of Grip and STA OP!

We used a mixed methods design within a participatory action research. Principles and processes of participatory action research were used during the implementation of the STIP-Method, and mixed methods were applied through data collection stages (qualitative and quantitative). Participatory action research involves a cyclical process of fact finding, action, and reflection, leading to further inquiry and action for change [54]. This approach has frequently been proven to be effective in involving persons with dementia and informal caregivers and blends research with action [55]. Table 2 shows the enhanced awareness of the method as a facilitating factor in implementing Grip and STA OP! To raise awareness, it is essential that all disciplines experience a sense of urgency and autonomy with regard to management of neuropsychiatric symptoms [37,40,41]. To provide this sense, it is vital to actively involve the target group in the implementation process. Therefore, researchers actively collaborated with professionals, managers, and informal caregivers to support the implementation of the STIP-Method. During implementation, explicit attention was given to the lessons learned from the implementation of IRR, Grip, and STA OP!, so as to understand whether implementation will be improved when these lessons were taken into account. When implementation will not be improved, understanding of the underlying causes is of great importance. Qualitative methods were used to examine facilitators and barriers in the implementation of the STIP-Method. Inductive content analysis was performed using the data directly to define codes and themes, which is further explained in the “Analysis” section [56]. Quantitative methods were used to evaluate the impact of the implementation of the STIP-Method and to assess the contribution of the BPSD Care web application to the management of neuropsychiatric symptoms. Data were collected between July 2019 and December 2021 in the Netherlands with a 6-month intermission due to the COVID-19 pandemic.

The STIP-Method was implemented in 4 facilities from 2 Dutch nursing home organizations. Implementation lasted 21 months (from October 1, 2019, to July 1, 2021), including an intermission of 6 months due to the COVID-19 pandemic. In 2017 and 2018, professionals and management employed in these 2 nursing home organizations were trained in step-by-step management of neuropsychiatric symptoms using the stepped-care method. Although the board, management, and professionals of both nursing home organizations indicated that professionals had improved their knowledge about neuropsychiatric symptoms after training, they indicated that they still inadequately involve persons with dementia and informal caregivers in the treatment process. Both organizations recognized the necessity to improve management of neuropsychiatric symptoms and consequently, the STIP-Method was implemented in these 2 organizations.

To identify differences in implementation aspects in and between nursing home organizations, both organizations have chosen 2 participating facilities. On average, a nursing home facility houses 40-50 persons with dementia. Taking into account the number of beds and turnover of nursing home residents, 160-200 persons with dementia were expected to be included within the 4 facilities.

Within each nursing home facility, managers were asked to send an invitation letter, a participant information letter, and a consent form to the legal representatives of persons with dementia. The representatives were asked to allow researchers to access the patient records. Representatives could give permission by signing and returning the written informed consent form to the nursing home in a prestamped envelope. After 4 weeks, a reminder was sent to the managers to motivate their team members to contact representatives about the informed consent forms. Participants had the right to withdraw from participation at any time. No financial incentive to participate was provided. Besides recruitment of persons with dementia, each participating nursing home facility had to form an advisory board. Managers had the freedom to decide whom to invite to the advisory board meetings. Informal caregivers received financial compensation because of the effort required to attend the meetings.

Persons with dementia were included if they met the following criteria: (1) dementia diagnosis; and (2) residing on psychogeriatric wards of nursing homes. Informal caregivers had to be able to understand and communicate in Dutch.

Data extracted from patient records were coded with unique identification numbers to guarantee privacy. All analyses will be undertaken at the level of nursing home and persons with dementia. All advisory board meetings were audio-recorded. Verbatim transcription will be done by a researcher (HMFV) with the support of research assistants. The transcripts will be coded using content analysis, facilitated by the qualitative analysis software ATLAS.Ti.9. Two researchers (HMFV and CZ) will code in vivo the first 3 advisory board meetings together to reach clarity about how to code the board meetings consistently. Hereafter, the researchers will discuss any conflicting codes and ambiguous statements to come to an agreement about the final coding scheme. Then, the identified facilitators and barriers will be categorized into main themes.

The study started after being reviewed by the Medical Ethics Committee of the Erasmus University Rotterdam, under file number MEC-2019-0343.

At the completion of the study, we will present the findings at national and international scientific conferences; professional events for stakeholder group; and at our professional website. Findings will be presented in a summarized form with no identifying information. We will also publish the results in peer-reviewed journals, open access publications, and lay magazines.

This protocol describes a mixed methods study within a participatory action research to implement the STIP-Method to manage neuropsychiatric symptoms in persons with dementia in nursing homes. The STIP-Method is developed from 3 already proven effective methods to manage neuropsychiatric symptoms. Previous research on the implementation of these 3 methods showed a low level of intervention fidelity. A better understanding of the implementation process is necessary to improve sustainability in clinical practice to improve the management of neuropsychiatric symptoms [12,43,44]. We expect the study will deliver an in-depth understanding of facilitators and barriers to the management of neuropsychiatric symptoms to positively influence these factors. Although not an effect study, it aims to measure impact in real-life care settings related to the intervention fidelity.

A strength of this study is that the STIP-Method is more comprehensive, as it uses the key elements from the underlying effective interventions. Furthermore, we aimed to gain insight into the best manner of implementation by using an advisory board of, among others, informal caregivers. A possible limitation is a potential tension in nursing homes between urgency as recognized in the participating organizations and the increased difficulty to implement an intervention with more elements than the already known stepped-care interventions. In addition, BPSD Care was used as an application adjacent to patient records. Within the Grip study, managers prior to implementation indicated a tool adjacent to patient records as a barrier [40]. However, within the Grip study, using 2 systems did not cause any problems. The lack of a connection between systems may be a barrier in our study.

We anticipate that our results can be used to improve the intervention fidelity of multicomponent interventions to prevent and treat neuropsychiatric symptoms in persons with dementia. These improvements may enhance quality of life for persons with dementia and their informal caregivers and may improve job satisfaction and the attractiveness of their profession.