109Influences on Appropriate Antipsychotic Prescribing in Residents with Dementia: A Qualitative Exploration Using the Theoretical Domains Framework

Abstract

Background: Antipsychotics are often inappropriately prescribed to nursing home residents with dementia despite evidence of increased risks and limited effectiveness, but can be effective when used for correct indications. The Theoretical Domains Framework (TDF) is a theory-based approach to understanding key aspects of healthcare professionals' behaviours and developing improvement interventions to target those behaviours. This study aimed to explore the influences on appropriate antipsychotic prescribing in residents with dementia using the TDF. Method(s): Twenty-seven semi-structured qualitative interviews were conducted with a purposive sample of participants involved in the care of residents with dementia (four consultants, five general practitioners, eight nurses, two pharmacists, five healthcare assistants (HCAs) and three family members). An interview topic guide was developed using findings from our previous systematic review. Participants provided written informed consent. Interviews were audio-recorded and transcribed verbatim. A qualitative framework analysis informed by the TDF, involving two coders, was conducted to identify the relevant barriers and facilitators. Result(s): Eight TDF domains were identified as relevant to antipsychotic prescribing behaviour: social/professional role and identity, social influences, beliefs about consequences, environmental context and resources, knowledge, behavioural regulation, beliefs about capabilities and emotion. Barriers to appropriate prescribing included inadequate resources and education, pressure to prescribe, an expectation that behaviours can be "cured", reliance on antipsychotics to reduce nursing demands, and the belief that residents are suffering because of their behaviours. Facilitators included specialist care units, advocacy and leadership by staff, knowledge of cardiovascular risks, and inclusive decision-making. There were conflicting views as to the influence of national regulatory bodies on prescribing; some believed they have enabled a blanket "anti-antipsychotic" climate. Conclusion(s): This detailed qualitative analysis demonstrates that appropriate antipsychotic prescribing is a complex behaviour influenced by several domains. Our study has generated much needed evidence to inform improvement efforts in this field.