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Knowledge, motivation, and organizational influences impacting senior living performance goals to reduce antipsychotics: an innovation study

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Knowledge, motivation, and organizational influences impacting senior living performance goals to reduce antipsychotics: an innovation study

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KNOWLEDGE, MOTIVATION, AND ORGANIZATIONAL INFLUENCES IMPACTING
SENIOR LIVING PERFORMANCE GOALS TO REDUCE ANTIPSYCHOTICS:
AN INNOVATION STUDY
by
Colleen E. Hollestelle

A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION

August 2023

Copyright 2023 Colleen E. Hollestelle

iv
Dedication
This dissertation is dedicated to my parents, Franklin and Kathleen, who cultivated my curiosity
and my husband, Patrick, and son, Aidan, with whom I share life’s adventures.

v

Acknowledgements
Thank you to my committee chair and members, Dr. Helena Seli, Dr. Jennifer Phillips,
and Dr. Cathy Krop for guidance and support through this process. I would also like to thank my
various teachers and professors who shepherded my education through grade school, college, and
graduate school.
Author Note
The author has no conflicts of interest to disclose. Funding for incentives to participate in
this research was provided by the author. The author can be contacted at Holleste@usc.edu.

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Table of Contents
Dedication ...................................................................................................................................... iv
Acknowledgements ......................................................................................................................... v
Author Note .................................................................................................................................... v
Abstract .......................................................................................................................................... ix
List of Tables ............................................................................................................................... viii
Chapter One: Introduction to the Problem of Practice.................................................................... 1
Background of the Problem ................................................................................................ 1
Related Literature................................................................................................................ 3
Importance of Addressing the Problem .............................................................................. 5
Stakeholder Group for the Study ........................................................................................ 6
Purpose of the Project and Research Question ................................................................... 8
Methodological Framework ................................................................................................ 9
Definition of Terms............................................................................................................. 9
Organization of the Project ............................................................................................... 10
Chapter Two: Review of the Literature ........................................................................................ 11
Challenges Caring for Older Adults with Dementia ......................................................... 11
Treatment for Dementia-Related Behaviors ....................................................................... 1
Antipsychotic Use in Nursing Homes............................................................................... 18
Clark and Estes' (2008) Knowledge, Motivation, and Organizational Influences
Framework ....................................................................................................................... 22
Conceptual Framework: The Interaction of Stakeholders' Knowledge and Motivation
and Organizational Context……………………………………………………………...33
Summary ........................................................................................................................... 36
Chapter Three: Methodology ........................................................................................................ 37
Participating Stakeholders ................................................................................................ 37

vii
Data Collection ................................................................................................................. 39
Data Analysis .................................................................................................................... 41
Credibility and Trustworthiness ........................................................................................ 42
Ethics................................................................................................................................. 43
Chapter Four: Findings ................................................................................................................. 45
Participants ........................................................................................................................ 45
Findings for Research Question 1 ..................................................................................... 48
Findings for Research Question 2 ..................................................................................... 58
Findings for Research Question 3 ..................................................................................... 64
Additional External Influence……………………………………………………………69
Conclusion ........................................................................................................................ 72
Chapter Five: Discussion and Recommendations......................................................................... 74
Discussion of Findings ...................................................................................................... 74
Recommendations for Practice ......................................................................................... 76
Limitations and Delimitations........................................................................................... 82
Recommendations for Future Research ............................................................................ 84
Implications for Equity…………………………………………………………………..84
Conclusion ........................................................................................................................ 85
References ..................................................................................................................................... 87
Appendix A: Interview Protocol ................................................................................................... 95

viii

List of Tables
Table 1: Field Mission and Goal…………………………………………………………………..8
Table 2: Knowledge Influences Related to Reducing Antipsychotics in Senior Living.………..26
Table 3: Motivation Influences Related to Reducing Antipsychotics in Senior Living……..…. 29
Table 4: Organizational Influences Related to Reducing Antipsychotics in Senior Living…......33
Table 5: Summary of Participants………………………………...……………………………...47

ix
Abstract
Older adults residing in senior living are prescribed antipsychotics for dementia-related
behaviors at a disproportionate rate compared to community-dwelling older adults. Individuals
taking antipsychotics are at an increased risk of negative side effects including falls with injuries,
arrest, constipation, fracture, extrapyramidal disorder, somnolence, gait disturbances, apathy, and
death. As a result, the National Partnership to Improve Dementia Care in Nursing Homes was
established in 2012 to support and encourage senior living to address resident behaviors without
the use of antipsychotics. Despite regulatory focus and the development of The National
Partnership, rates of antipsychotics have remained steady for several years. Since 2018, 13%-
15% of nursing home residents have been prescribed an antipsychotic. This dissertation applies
the Clark and Estes (2008) gap analytic framework with an emphasis on knowledge, motivation,
and organizational influences to explore the clinical phenomenon of administering antipsychotics
to residents with dementia. Thirteen senior living staff members from 11 facilities were
interviewed including nurses, social services workers, life enrichment staff, nursing home
administrators, and directors of nursing to explore their knowledge, motivation, and
organizational influences related to reducing antipsychotics in their facilities. The findings
revealed opportunities for training senior living staff to address behaviors without medications,
the need for better communication of quality goals from leadership to senior living staff, and the
importance of incentives in reducing antipsychotics. Practical implications for this research to
improve senior living organizational outcomes are provided.

1

Chapter One: Introduction of the Problem of Practice
This dissertation addresses the problem of antipsychotic overuse in senior living,
specifically, nursing homes and assisted living residents with dementia. In 2017, 1.3 million
older adults resided in nursing homes (Centers for Disease Control, 2023). Additionally,
800,000 older adults lived in assisted living centers in 2019 (American Healthcare Association,
2023). Older adults living in nursing homes are prescribed antipsychotics at an increased rate
compared to older adults living in the community (Maguire, et al 2013). Antipsychotics are a
concern because they alter brain chemistry to reduce psychotic symptoms in patients with
psychotic symptoms such as hallucinations, delusions, and disordered thinking, but are not
indicated to treat symptoms of dementia (Food and Drug Administration, 2005). Medicare data
highlights that in 2021, 14.5 % of nursing home residents were on an antipsychotic (National
Partnership to Improve Dementia Care in Nursing Homes, 2022). Evidence suggests it is
important to address this problem because the use of antipsychotics in residents with dementia is
associated with increased risk of death (Gill et al., 2007; Ferrah, et al., 2018; Ballard et al.,
2018).
Background of the Problem
The National Partnership to Improve Dementia Care in Nursing Homes was established
in 2012 to improve the overall care of nursing home residents with dementia and reduce
antipsychotic drug use by 15% by the end of 2012 (Centers for Medicare and Medicaid Services,
2012). This partnership includes federal and state authorities, nursing homes and medical
providers, as well as advocates and caregivers. The components of The National Partnership
include nurse training, reporting of nursing home antipsychotic data to the public, a focus on
nonpharmacological interventions to address resident behaviors, and enhanced survey guidance

2
for nursing home inspectors (Centers for Medicare and Medicaid Services, 2012). Since the
founding of this partnership in 2012, there has been a 39% reduction in nursing home residents
with orders for antipsychotics, resulting in the current estimation of approximately 14% of all
nursing home residents still prescribed antipsychotics (Centers for Medicare and Medicaid
Services, 2018). While this reduction is encouraging, it still reflects a significant number of
nursing home residents taking unnecessary and dangerous drugs.
Prior to the partnership, the approach of CMS (Centers for Medicare and Medicaid
Services), which regulates and licenses nursing homes, consisted of regulatory efforts
implemented to reduce antipsychotics in nursing homes (Bonner, 2013). The Nursing Home
Reform Act (in Omnibus Budget Reconciliation Act (OBRA) of 1987) first restricted the use of
antipsychotic drugs in 1987. Under the reform, antipsychotics prescribed to nursing home
residents must be administered for clinically diagnosable conditions, for minimum duration, and
in conjunction with behavioral interventions (Shorr et al., 1994). However, prior to the inception
of the National Partnership to Improve Dementia Care in Nursing Homes in 2011, the Office of
the Inspector General concluded that over 75% of residents who were administered antipsychotic
drugs were for off-label uses, such as management of dementia-related behaviors, despite box
warnings against such prescribing (Lester et al., 2010). Box warnings, often referred to as “black
box warnings,” are visible on prescription drug labels, and these warnings inform the patient of
serious or potentially fatal complications associated with that medication (FDA Consumer
Health Information, 2012). The concern that significant numbers of nursing home residents
continue to be prescribed antipsychotics after regulatory change suggests that there are many
factors affecting nursing homes’ abilities to meet compliance. The section that follows will
discuss factors contributing to inappropriate prescribing of antipsychotic drugs in nursing homes.

3
Related Literature
Use of antipsychotics in older adults is correlated with significant harm to their health
and well-being. The risk for death increases with use of an antipsychotic, and the risk for fatality
is greater with conventional than atypical antipsychotics (Gill et al. 2007). Maust et al. (2015)
concluded that increased mortality rates for residents with dementia taking antipsychotics were
higher than previously believed, and the risk for death increased with higher dosages. Although
death is arguably the dangerous outcome of prescribing older adults antipsychotics, research
points to other adverse events including cardiac arrest, constipation, femoral neck fracture, extra
pyramidal disorder (involuntary muscle movement disorders), somnolence, falls with injuries,
abnormal gait, edema, urinary infection, stroke, and apathy (Farlow & Shamliyan, 2017). Farlow
and Shamliyan (2017) argue that although some antipsychotics provide modest improvements in
neuropsychiatric symptoms, the benefits do not outweigh the harms.
In addition to harming older adults, inappropriate use of antipsychotics disproportionately
impacts residents of color. As a component of The National Partnership to Improve Dementia
Care, Centers for Medicare and Medicaid Services (CMS) added public reporting of
antipsychotics and revised survey guidelines in 2012 and 2013 respectively as strategies to
reduce nursing home antipsychotic use (Lucas & Bowblis, 2017). Public reporting provides the
opportunity for consumers of care to see the percentage of nursing home residents in any one
facility that is taking an antipsychotic. Consumers who can access and afford quality care, as
evidenced by low antipsychotic rates, are likely to do so. However, not all consumers are able to
access and afford quality care. The literature underscores that older adults of color are more
likely to live in nursing homes with fewer staff and more deficiencies than Caucasian older

4
adults, which demonstrates this is an issue of racial equity as well as a problem of poor-quality
care for older adults (Li et al., 2015; Smith et al., 2008).
The National Partnership’s public reporting goal was to enhance transparency for
consumers of long-term care. In addition to consumer transparency, revised regulatory
guidelines provide a foundation from which surveyors can cite nursing homes for overuse and
offer facilities an opportunity to take corrective action, which is also reported publicly and
affects the overall quality rating of the nursing home. Lucas and Bowblis (2017) found that each
National Partnership strategy improved dementia care and offered a significant reduction in
antipsychotics. Public reporting of antipsychotic use and citations incentivizes nursing homes to
develop quality improvement plans to reduce antipsychotics. However, despite the increased
transparency and incentives to reduce their use, some residents are still unnecessarily prescribed
antipsychotic medications, which are harmful to their health and well-being.
The senior living environment includes a host of contributing factors which may foster
the use of antipsychotics for residents with dementia. Nurses, medications aides, and nursing
assistants, who are responsible for daily cares, have the ability to engage in nonpharmacological
interventions to address resident behaviors. However, their background and training are focused
on medically-based treatments, so they are inclined to treat behaviors with medications.
Additionally, they may be unaware of antipsychotic harms, if they have not received sufficient
training. Furthermore, resident behaviors often include the resident posing a threat to themselves
or others, creating a significant patient safety issue. Thus, even if trained on the harms of
antipsychotics and appropriate alternatives, they may consider the medicating a resident a matter
of safety for residents and staff. Finally, nursing homes have many sounds and various stimuli

5
from alarms, general operations, and other patients, which may be triggering to some residents
with dementia, making it a difficult environment in which to manage behaviors.
Importance of Addressing the Problem
It is important to address the problem antipsychotics in senior living for a variety of
reasons. First, antipsychotics are dangerous drugs for seniors. Older adults with dementia who
are prescribed antipsychotics are at an increased risk for falls, fractures, thrombotic (clotting)
events, hospitalizations, and mortality (Ballard et al., 2009; Chiu et al, 2015). Additionally, the
number of residents in nursing homes taking antipsychotics are published for consumers and
affect each home’s quality rating (Nursing Home Compare 3.0: Revisions to the Nursing Home
Compare 5-Star Quality Rating System | CMS, n.d.). The Five-Star Quality Rating System is a
tool for consumers to evaluate the quality of the nursing home and objectively compares ratings
to competitors, making a higher rating not only a quality metric, but a marketing tool for nursing
home operators with high quality ratings (Centers for Medicare and Medicaid Services, 2019).
Specifically, the quality rating system is designed to inform families of the ratings (between one
and five stars) of nursing home health inspections, staffing, and quality measures including falls,
infections, weight loss, skin injuries, and antipsychotics. Addressing the problem of overuse of
antipsychotics in senior living is important to resident safety and quality of life as well as
organizational success and demonstration of quality. Although there have been regulations,
initiatives, and other strategies to end overuse of antipsychotic medications, it continues to be a
problem, which emphasizes the urgency of addressing it.
Performance Goal
The Centers for Medicaid and Medicare Services are committed to reducing
antipsychotics in nursing homes through the National Partnership to Improve Dementia Care in

6
Nursing Homes. Their most recent identifiable performance goal was a national goal to reduce
antipsychotics by 15% by the end of 2019 for long-stay residents (as opposed to short-stay,
rehabilitation-focused residents) in homes with high rates of antipsychotics (Centers for
Medicare and Medicaid Services, 2020). A more recent goal could not be identified as resources
and attention focused on COVID-19 in nursing homes since 2020. Beginning in 2020, the
COVID-19 global pandemic shifted focus from overall senior living quality to infection control
and other pandemic-related issues. In addition to a shift in focus to infection control, there were
significant staffing challenges related to COVID-19. As a result, it was assumed that this goal
was not abandoned, but extended beyond the original goal date. For the purpose of identifying a
performance goal for this dissertation, the existing goal timeline will be extended to the end of
2023. Data published on the National Partnership to Improve Dementia Care in Nursing Home
Website highlights that as of quarter four of 2021, the most recently published data, the industry
has not met its goal. Long-stay resident antipsychotic use has maintained steady within one
percent of 14.5% throughout the pandemic (National Partnership to Improve Dementia Care in
Nursing Homes, 2022).
Stakeholder Group for This Study
The stakeholders for this study were senior living staff. Previous studies focused on
quality assurance initiatives, but not the influence of stakeholders on the performance goal. To
date, this author has not found a study that examines senior living staff’s knowledge and
motivation or organizational influences on antipsychotic reduction goals. The purpose for
selecting senior living staff as the stakeholder group for this study is their ability to engage in
reduction initiatives and implement non-pharmacological interventions. On the interdisciplinary
care team, nurses are the gatekeepers to the physicians and have the role of addressing and

7
reporting behaviors and requesting psychotropic medications. In contrast, senior living
leadership, physicians, and pharmacists are involved in system-wide reduction strategies. Life
enrichment (sometimes called activities staff) and social services staff can recommend and
implement non-pharmacological interventions to address resident behaviors. Nurses and certified
nursing assistants provide resident care twenty-four hours per day, seven days per week.
Although nurses and certified nursing assistants have ability to engage in nonpharmacological
interventions to address resident behaviors, their background and training is focused on
medically-based treatments, so may be inclined to treat behaviors with medications.
Stakeholders may be unaware of harms of antipsychotics if they have not received
adequate training. Resident behaviors often include the resident posing a threat to themselves or
others, causing a significant patient safety issue. Thus, even if trained on the harms of
antipsychotics and appropriate alternatives, they may request for or administer an antipsychotic
medication with good intent to prevent injury. Finally, nursing homes have sounds and various
stimuli from alarms, general operations, and other patients which may be triggering to some
residents with dementia, making the environment a difficult one to manage behaviors within.
This dissertation focused on identifying knowledge and motivation influence related to senior
living staff’s engagement in antipsychotic reduction initiatives, in addition exploring
organizational influences affecting said initiatives. Table 1 outlines the performance goal and
stakeholders.

8
Table 1
Field Mission and Goal
Mission
The mission of the National Partnership to Improve Dementia Care in Nursing Homes
is to reduce the use of antipsychotic medications through the use of non-pharmacological and
person-centered dementia care (Centers for Medicare and Medicaid Services, 2020).
Performance Goal
The National Partnership to Improve Dementia Care in Nursing Homes has established
a goal to reduce antipsychotics by 15% in late-adopter nursing homes by December 31, 2019.
Because this goal has not been replaced, this dissertation will extend the goal to
December 31, 2023.

Purpose of the Project and Research Questions
The purpose of this study was to evaluate the knowledge and motivational influence of
senior living staff and the organizational influences impacting the national goal to reduce
antipsychotics. This research was conducted using Clark and Estes (2008) knowledge,
motivation, and organizational (KMO) gap analysis framework. The following research
questions framed the study:
1. What knowledge and motivation influences affect senior living staff in their
pursuit of reducing the administration of antipsychotic medications for senior
living residents?
2. What organizational influences affect senior living staff in relation to reducing the
administration of antipsychotic medications?
3. What is the interaction between knowledge, motivation, and organizational
influences in relation to senior living staff reducing the administration of
antipsychotic medications?

9
Methodological Framework
The methodology for this study was qualitative interviews. Interviews were conducted
and recorded via Zoom Web Conferencing software with the transcripts analyzed by the
researcher using qualitative methods (Creswell, 2015; Merriam & Tisdell, 2016). This approach
allowed for rich data collection that created a robust picture of the influences of knowledge,
motivation, and organizational influences related to reduction of antipsychotics in senior living,
which was new to study and analysis. Merriam and Tisdell (2016) specified that the qualitative
interviewing reveals the “how” of a research phenomenon, and provides a depth of knowledge
not available through quantitative analysis. Qualitative methodology provided an opportunity for
discovery and a foundation from which to develop recommendations to guide senior living in
launching organizational improvement initiatives and capacity building activities.
Definition of Terms
This section provides definitions of frequently used terms used throughout the research study and
the dissertation.
Nursing home: institution providing long-term clinical care to older adults or adults with
disabilities (Centers for Medicare and Medicaid Services, 2020).
COVID-19: Illness that caused a global pandemic spanning from March of 2020 to May of 2023
that resulted in significant regulatory changes and affecting resident quality of life.
Non-Pharmacological Interventions: treatment for behavioral symptoms of dementia that does
not include prescription drugs; examples include cognitive therapy, music therapy, and other
cognitive or behavioral interventions (Berg-Weger & Stewart, 2017).
Late-Adopter Nursing Homes: Those facilities which continue to have high rates of antipsychotic
use.

10
Organization of the Project
This dissertation is organized into five chapters. The purpose of this chapter was to
provide readers with the contextual foundation to this research, introduce the senior living field’s
goal, review stakeholders, and introduce the framework for this dissertation. Chapter Two offers
a review of the literature including an overview of dementia and treatments for dementia-related
behaviors. Chapter Three outlines the methodology for this study, including the strategy for
selecting participants, the data collection strategy, and analysis. Chapter Four provides
discussion of the analysis. Finally, Chapter Five reviews organizational solutions to addressing
the reduction of antipsychotics and opportunities for future research.

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Chapter Two: Review of the Literature
Reducing antipsychotics has been a focus of the senior living field for over three decades.
Over the last 30 years, legislation, national goals, and partnerships to reduce antipsychotics in
senior living were established. Researching the reduction of antipsychotics in senior living is
valuable to academic and healthcare communities because the use of antipsychotics in older
adults is associated with harms, including death. This chapter reviews the research on the
challenges caring for persons with dementia-related behaviors, explores treatments for behaviors,
and outlines the regulatory response to senior living’s over-reliance on antipsychotic medication.
Then, this chapter explores the assumed knowledge, motivation, and organizational influences
used in this study as informed by the literature review. Finally, this chapter proposes a
conceptual framework for this research.
Challenges Caring for Older Adults with Dementia
The mental health conditions of older adults are not well-treated, which impacts their
physical health as well as their overall mental health and well-being (Bartels & Naslund, 2013;
Byers et al., 2010). Estimates stresses that five million older adults have a mental health disorder,
but there are only 1,800 geriatric psychiatrists, who are psychiatrists specially trained in the
mental health needs of older adults (Byers et al., 2010). This lack of providers negatively
impacts access to mental healthcare. While age alone does not increase the likelihood that
someone will have a mental disorder, the research does highlight specific mental and behavioral
health challenges that occur in late adulthood.
The mental and behavioral healthcare of older adults living in the community is lacking,
but older adults living in nursing homes are especially vulnerable to the effects of inadequate
mental health care. The incidence of mental disorders is higher for older adults living in nursing

12
homes than those in the community, making their need for treatment particularly high (Seitz et
al., 2010). Within nursing homes, dementia, depression, and anxiety disorders are among the
frequently diagnosed and treated psychiatric disorders, in comparison to the diagnoses of bipolar
disorder or schizophrenia in the general population (Seitz et al., 2010). Rather than the nursing
home causing mental disorders; it is likely that older adults with mental disorders are more likely
to be admitted to senior living environments due to lack of treatment or social support for an
existing mental disorder. Of particular concern within senior living is that residents are prone to
being medicated with psychotropic drugs for behavioral health problems related to dementia,
which is the focus of the problem of practice in this dissertation (Cohen-Mansfield & Jensen,
2008; Foebel et al., 2016).
According to the Centers for Disease Control, almost one-half of nursing home residents
have the diagnosis of dementia (Centers for Disease Control, 2021). Psychotropic drugs remain
the primary method of treatment for behavior problems related to dementia, specifically, the
behavior problem of resisting care (Cohen-Mansfield & Jensen, 2008). Although antipsychotic
medications are the primary method of treatment, they are not associated with positive outcomes
for older adults. Prescribing antipsychotic medications to older adults to treat dementia-related
symptoms inhibits their quality of life (Wetzels et al., 2010). Gill et al. (2007) determined
nursing home residents on antipsychotic drugs had over one percentage-point increase in
likelihood for death compared to residents not on antipsychotics, and that increase was slightly
higher with conventional antipsychotic medications. When determining the likelihood for
broader “adverse events” such as falls and hospitalizations, Rochon et al. (2008) found an
approximate 3% increase in events for older adults who were prescribed an antipsychotic.
Cohen-Mansfield and Jensen (2008) determined that physicians support nonpharmacological

13
interventions (interventions without medication), however, their involvement in them is unclear
because nonpharmacological interventions are not a prescribed treatment, so there is no
documentation on their recommendations of interventions, or the intervention attempts.
Overview of Dementia
Dementia is a cognitive disorder that is challenging to treat across settings. The
Alzheimer’s Association estimates that over 6.2 million people over the age of 65 have
Alzheimer’s dementia, which equates to 11% of the population (Alzheimer’s Association, 2021).
Alzheimer’s is the most common form of dementia, which is a condition characterized by
cognitive impairment so profound that it affects every day functioning (Alzheimer’s Association,
2021). Alzheimer’s is a progressive disease, but the early stages do not require a lot of care
(Alzheimer's Association, 2021). If detected early, a person diagnosed with dementia may be
able to work, drive, volunteer, and otherwise function independently, yet still notice lapses in
memory (Alzheimer’s Association, 2021).
By mid-stage dementia, the burden of care for the caregiver increases significantly.
Individuals in mid-stage dementia often demonstrate significant mood and behavior changes,
including delusions, suspiciousness, and withdrawal from social situations (Alzheimer’s
Association, 2021). As procedural memory and judgment decline, individuals with mid-stage
dementia can have difficulty grooming and dressing themselves, sleeping, and executing familiar
tasks. (Alzheimer’s Association, 2021). The final stage of dementia requires total care. During
late-stage dementia, the individual cannot coordinate movement or communicate, and is
dependent upon caregivers for all care (Alzheimer’s Association, 2021). While dementia is a
disorder of cognition, the mood and behavioral changes are often treated by psychiatrists.

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Caring for Persons with Dementia
As older adults progress through the stages of dementia, they become increasingly reliant
on caregivers to support their needs. The Centers for Disease Control estimates that 17 billion
hours of unpaid care is provided by 16 million caregivers annually (Centers for Disease Control,
2019). The CDC (2019) highlights that the caregiving provided to persons with dementia
extends longer than the care provided to loved ones with other chronic diseases; over ½ of
caregivers of persons with dementia provide care in excess of four years. Serving as a caregiver
to a person with dementia is associated with a host of negative health outcomes for the
caregivers, including cardiovascular problems, decreased immunity, slow wound healing, and
other chronic health conditions (Brodaty & Donkin, 2009).
There is a myriad of additional consequences for the caregiver of the person with
dementia. Approximately ⅓ of caregivers meet the diagnostic criteria for depression (Schulz &
Martire, 2004). Compared to caregivers of loved ones without dementia, caregivers to persons
with dementia give more hours of care per week and assist with more tasks (Ory et al., 1999).
Ory et al. (1999) also noted that caregivers to persons with dementia experienced more mental
and physical health outcomes, more caregiver strain, and more employment interference than
other caregivers. While all caregiving is challenging for the caregiver, caregiving for a person
with dementia can be especially challenging due to dementia-related behaviors.
Behaviors Associated with Dementia
Dementia-related behaviors is a term used to capture a wide range of behaviors present in
a person with a progressive cognitive disease (Alzheimer’s Association, 2020). According to the
Alzheimer’s Association (2020) medical conditions, environmental stimuli, and medication side-
effects can worsen behaviors. Examples of dementia-related behaviors include hallucinations,

15
delusions, wandering, restless sleep, or general agitation (Alzheimer’s Association, 2020).
Those behaviors which interfere with the relationship between the caregiver and person with
dementia and make care more difficult to provide are especially challenging (Cheng, 2017).
As the level of behaviors exceed that which the caregiver can manage at home, families
turn to senior living to meet the needs of the person with dementia. Although admitting a person
with dementia to a senior living community removes the hands-on caregiving responsibility from
the in-home caregiver, admission to senior living presents its own challenges. Research suggests
that upon admission, the person with dementia is likely to experience an increase in negative
health-effects including depression, agitation, decreased cognition, and falls, likely as a result of
confusion in a new environment (Sury et al., 2013). Sury et al. (2013) also highlighted that a
person with dementia’s admission to senior living has ramifications for the caregiver. Caregivers
are at an increased risk for feelings of guilt and failure, depression, and continued burden, but at
times, improvement in quality of life (Sury et al., 2013). Of particular concern for caregivers and
nursing home nurses is how to treat dementia-related behaviors.
Treatment for Dementia-Related Behaviors
Treatment for dementia-related behaviors can be nonpharmacological (without
medication) or pharmacological (medicinal); the latter is often in the form of administering
antipsychotics. The Alzheimer’s Association (2021) highlights that nonpharmacological
approaches should be used first, and most often, to treat dementia-related behaviors. Their
guidance states that behaviors are related to the person’s need to communicate a need or
discomfort, and medications should only be used to prevent harm to self or others; if necessary,
medications should be used in conjunction with non-pharmacological interventions. The research
that follows further explains the treatments for dementia-related behaviors.

16
Nonpharmacological Interventions
The first line of defense for dementia-related behaviors are non-pharmacological (non-
medical) interventions. Within senior living, there have been a variety of nonpharmacological
interventions studied. These include the following interventions: sensory interventions, social
contact, behavior therapy, training, activities, environmental adjustments, nursing, and
combination interventions (Cohen-Mansfield, 2001). Cohen-Mansfield et al. (2012) found that
nonpharmacological interventions are effective at addressing behaviors, which are an expression
of an unmet need, not an indication of a treatable psychiatric condition. Cohen-Mansfield (2003)
suggested that the term “psychosis” should not be used in the context of dementia, as many of
the behaviors exhibited by persons with dementia are manifestations of sensory deficits in a
cognitively impaired person.
Nonpharmacological is a term applied to many kinds of interventions which are
inconsistently studied; this presents a challenge in practice as it is difficult to standardize
nonpharmacological treatment options. For example, Wang et al. (2019) argued that the evidence
for the effectiveness of nonpharmacological interventions is unclear in the literature. Wang et al.
's (2019) systematic review found that while 41 of 64 clinical studies of nonpharmacological
interventions reduced symptoms, the quality of evidence was low due to methodological and
reporting issues of the various studies. The studies in this review did not evaluate interventions
from caregivers, which is a limitation as the person with dementia cannot address their behaviors
without external assistance.
Pharmacological Interventions
Pharmacological interventions include any medicinal treatment administered to a person
with dementia to reduce behavioral symptoms (Santaguida et al., 2004). Research suggests that

17
in residents with dementia, even something as simple as the intervention of scheduled Tylenol,
an over-the-counter pain reliever, can reduce behaviors (Koo et al., 2018). Residents with
dementia-related behaviors can also be prescribed psychotropic medications, which affect the
brain and central nervous system, but are not antipsychotics. There is little research on non-
antipsychotic pharmacological interventions, but one article presented an evidence-based
protocol to treat behaviors with psychotropic medications that are not antipsychotics (Birtley,
2016). The evidence-based protocol offered a hierarchy of medications to try prior to offering
antipsychotics, preventing or postponing the most dangerous options. Research suggests a
variety of psychotropic drugs are used to treat behavioral symptoms of dementia; however,
antipsychotics pose the greatest risk of harm to the person (Nørgaard et al., 2017). The section
that follows will outline the discovery of antipsychotic medications and how they became a
treatment option for older adults with dementia.
The discovery of antipsychotic drugs was largely by chance. Through the late 1800s and
early 1900s, physicians and scientists developed antimalarial drugs and antihistamines which
paved the way to develop antipsychotics as these drugs were used in different populations (Shen,
1999). Drug research during that era was more rudimentary than the drug trials conducted in
present day studies. Many of the discoveries were documented observations without large,
controlled studies (Shen, 1999). By 1951, it was revealed that these drugs could be modified to
have a relaxing effect on patients preparing for surgery (Shen, 1999). Shortly after, in the mid-
1950s, these drugs were offered to psychiatric patients, and it was noted that the drugs
interrupted psychotic thoughts and behaviors (Shen, 1999). While the improvement in psychotic
symptoms was significant, early antipsychotics were noted to cause extrapyramidal symptoms

18
(EPS) which are involuntary movements that may present as jerky or restless movements (Shen,
1999).
Without controlled drug trials, assumptions were made about the relationship between
treating psychotic symptoms and extrapyramidal side effects. Initially, it was assumed that the
extrapyramidal symptoms were an indication that antipsychotics were effective at reducing
psychotic thoughts and behaviors, thus they were considered a necessary side effect (Shen,
1999). By the 1990s, atypical antipsychotics were introduced which contradicted that
assumption. Atypical antipsychotic medications address the symptoms of psychiatric illness
while limiting or completely removing the extrapyramidal symptoms produced by the traditional
antipsychotic drugs (Shen, 1999).
Antipsychotics transformed psychiatric care. Together, traditional and atypical
antipsychotic drugs are prescribed to address psychiatric illnesses, primarily schizophrenia.
These drugs offer opportunities to treat individuals in the outpatient setting, thus reducing the
number of individuals in long-term psychiatric hospitals (Cunningham Owens & Johnstone,
2018). How then, have they come to be a problem of practice for nursing homes which care for
older adults with complex medical conditions, including dementia? The next section will provide
a brief history of the use of antipsychotics in nursing homes.
Antipsychotic Use in Nursing Homes
Despite absence of a psychiatric illness, older adults in nursing homes are prescribed
antipsychotics; and this problem is not new. A 1980 study found that 43% of residents in a
sample of Tennessee nursing homes were prescribed at least one antipsychotic (Ray et al., 1980).
If not used to treat a patient with a psychiatric diagnosis, why were they prescribed? Evidence
suggests dementia-related behaviors in nursing home residents are prone to treatment with

19
psychotropic drugs (Cohen-Mansfield & Jensen, 2008). Gillick (2017) argued that the
development of atypical antipsychotics in the 1990s was followed by pharmaceutical companies
marketing new atypical antipsychotics to nursing home physicians for off-label uses, such as
dementia-related behaviors. While at the time, physicians were not restricted from prescribing
atypical antipsychotics to nursing home patients, the marketing of off-label uses was found to be
illegal by the United States Department of Justice; following that ruling, pharmaceutical
companies were penalized for their illegal marketing strategies of antipsychotics (Gillick, 2017).
Subsequently, there was a reduction in the number of nursing home residents prescribed
antipsychotics (Gillick, 2017). However, as evidenced by the establishment of the National
Partnership to Improve Dementia Care, the problem of overprescribing remained.
Regulatory Response to Reduce Dependence on Antipsychotics in Nursing Homes
In 1987, the Omnibus Reconciliation Act (OBRA 1987) federal legislation was enacted
to improve the standards of quality care in nursing homes which receive funding from Medicare
and Medicaid (Turnham, n.d.). This legislation was developed with the vision that nursing home
residents can achieve their best state of well-being physically, mentally, and socially (Turnham,
n.d.). In addition to establishing minimum standards of care, OBRA 87 established resident
rights, which provides basic civil rights to older adults living in nursing homes (Turnham, n.d.).
Among other rights, OBRA 1987 specified that residents have the right to be free from physical
and chemical restraints; antipsychotics and other psychotropic drugs can be considered physical
restraints in the absence of treating a psychiatric illness (Turnham, n.d.). Following the reform,
residents may only take antipsychotics for a clinically diagnosable condition, for the minimum
duration necessary to treat their illness, and in conjunction with behavioral interventions (Shorr
et al., 1994). However, despite the legislative changes, as recently as 2011, 75% of nursing

20
home residents taking an antipsychotic were doing so for off-label uses (Lester et al., 2011).
Thus, the regulation was not enough to prevent nursing home residents from being chemically
restrained through antipsychotics.
In 2012, the United States Federal government made another attempt at reducing
antipsychotics for nursing home residents through the establishment of the National Partnership
to Improve Dementia Care in Nursing Homes. Identifying that regulation alone does not solve
the problem of overprescribing antipsychotics, the Centers for Medicare and Medicaid Services
(CMS) established the partnership to offer providers tools and strategies to reduce antipsychotics
in nursing homes (Centers for Medicare and Medicaid Services, 2012). The partnership includes
a comprehensive approach to quality improvement including the following:
● public reporting of antipsychotic rates by CMS
● state-based coalitions to provide tools and education to help providers improve
antipsychotic rates
● additional research funding regarding reduction of antipsychotics
● training to nursing home leadership and nurses
● revised guidelines for nursing home surveyors related to antipsychotics
The National Partnership to improve dementia care in nursing homes celebrated success
in the reduction of antipsychotics. By 2017, the national percentage of residents taking an
antipsychotic dropped from nearly 25% to roughly 15% (Centers for Medicare and Medicaid
Services, 2020). Since 2017, the national percentage rate has hovered around 15%. The latest
iteration of their reduction goal is to focus on homes which maintain high percentages of
antipsychotics and support them in a 15% reduction (Centers for Medicare and Medicaid
Services, 2021). Due to the 2020 COVID-19 pandemic response in nursing homes,

21
establishment of a new goal has not occurred, but is expected by the national partnership as the
senior living industry recovers from the COVID-19 pandemic.
Despite regulatory and national partnership efforts to reduce antipsychotics in nursing
homes, many homes still face barriers to reduce the number of residents in their nursing homes
that are prescribed an antipsychotic. Research highlights potential barriers to reducing
antipsychotics in nursing homes. Ellis et al.’s (2015) qualitative interviews suggested that
nursing home nurses are willing to reduce antipsychotics, but education of nurses' mental health
support to the residents are barriers to reducing antipsychotics. In contrast, Azermai et al. (2014)
found unwillingness among nurses and general practitioners to discontinue antipsychotic
medications for nursing home residents. The participants in the Azermai, et al. (2014) study
identified barriers of perceived reduced quality of life for residents who discontinued
antipsychotics, as well as the barrier of increased workload for nurses supervising those
residents. However, studies have shown that residents can discontinue antipsychotic medications
without significant negative outcomes to their health and well-being (Ballard et al., 2009; Cohen-
Mansfield et al., 1999).
Thus, a gap has been identified in the literature that can be filled by this research. Why
are senior living staff resistant to reducing antipsychotics when research has shown it can be
done safely and effectively? What knowledge, motivation, and organizational influences impact
senior living staff’s participation in the antipsychotic reduction initiatives? The stakeholders for
this study are the senior living staff including social services workers, nurses, administrators,
directors of nursing or other nursing leaders, life enrichment staff, and pharmacists. Each of the
stakeholders has a role in reducing antipsychotics. The administrators, directors of nursing, and
pharmacists are addressing reduction of antipsychotics on a system level. The nurses, social

22
services workers, and life enrichment staff are addressing reduction of antipsychotics on a
resident-level, often through addressing resident behaviors with nonpharmacological
interventions. The section that follows reviews the literature on the knowledge, motivation, and
organizational influences related to senior living staff’s participation in initiatives to reduce
antipsychotics.
Clark and Estes’ (2008) Knowledge, Motivation and Organizational Influences Framework
This research is informed by Clark and Estes’ (2008) gap analysis framework, which
suggests organizational performance is influenced by three dimensions: knowledge factors,
motivational factors, and organizational factors. Nursing homes frequently base their quality
improvement programs on national goals and regulatory requirements. The KMO framework is
an appropriate problem-solving framework because it is founded in understanding stakeholder
goals in the context of larger goals, and pinpointing assumed knowledge, motivation, and
organizational influences based on literature, theory, and understanding of the field.
Clark and Estes (2008) outlined a framework which identifies performance gaps that are
barriers to meeting stakeholder goals. Organizational performance toward a goal is influenced by
three factors: knowledge factors, motivational factors, and organizational factors (Clark & Estes,
2008). Krathwohl (2002) further described knowledge influences by type including factual,
conceptual, procedural, and metacognitive knowledge. Next, motivation influences encompass
those which influence sustained effort toward a goal (Clark & Estes, 2008; Rueda, 2011).
Motivational influences can include attributions, self-efficacy, values, and goal orientation
(Rueda, 2011). Lastly, organizational influences to performance include policies and
procedures, access to resources, and organizational culture (Clark & Estes, 2008).

23
In this dissertation, Clark and Estes’ (2008) gap analysis is utilized to evaluate
employees’ knowledge, motivation and organizational needs to meet the goal of reducing
antipsychotics. First, expected influences of knowledge of the stakeholder goal will be outlined.
Second, expected motivation influence on achievement of the stakeholder goal will be assessed.
Third, assumed organizational influences on achievement of the stakeholder goal will be
explored. The section that follows will outline the stakeholder specific KMO assumed
influences.
Knowledge Influences
Within the Clark and Estes KMO framework, knowledge influences were the first to be
evaluated for their impact on the performance goal. Krathwohl (2002) suggested there are four
knowledge types: factual, conceptual, procedural, and metacognitive. Factual knowledge
includes objective definitions, policies, and other concrete information. Conceptual knowledge
includes the frameworks and models to describe or explain a field. Procedural knowledge is the
step-by-step information related to the job. Finally, metacognitive knowledge is the reflection of
one’s own thought processes related to a goal. Krathwohl (2002) posited that metacognitive
knowledge, or the awareness and evaluation of thoughts, facilitates reflection and self-awareness
of issues; metacognitive knowledge is important to evaluate as it is useful in problem solving.
The next section will highlight research related to assumed knowledge gaps that influence the
stakeholders’ ability to reduce or eliminate antipsychotics.
Senior Living Staff Must be Knowledgeable About Antipsychotic Regulations, Antipsychotic
Performance Goals, and the Specific Hazards Antipsychotics Pose to Older Adults
Senior living staff need several components of conceptual knowledge to achieve the
performance goal. In order to sincerely engage in initiatives to reduce antipsychotics, senior

24
living team members need knowledge about antipsychotic regulations, the organizational
performance goal, and they need to be able to identify specific harms to older adults who take
antipsychotic drugs. Evidence suggests some of this knowledge is lacking. Lemay et al. (2013)
found only 12-13% of charge nurses could identify a severe adverse effect of antipsychotics.
The same study indicated only 24% of nursing home leadership named at least one adverse effect
of antipsychotics. Without understanding the risk to older adults taking these medications, it is
unlikely that interdisciplinary team members will engage in reduction initiatives. Additionally,
Pitkala et al. (2014) found that when nursing home nurses were given interactive training to
identify potentially harmful medications and adverse drug events, use of antipsychotics,
mortality, and hospital stays all decreased. This evidence presents the knowledge influences that
the senior living staff need related to the performance goal. Research on senior living staff’s
knowledge about regulations and performance goals could not be identified, but given the lack of
knowledge about harms, it is assumed that there may also be a lack of knowledge about
regulations and performance goals. The paragraph that follows offers evidence regarding use,
benefits, and challenges of non-pharmacological treatments.
Senior Living Staff Must be Knowledgeable About the use, Benefits and Challenges of
Nonpharmacological Treatments
Senior living staff must possess knowledge of nonpharmacological treatments as an
alternative, and perhaps first-choice option, for the treatment of dementia. According to Wang et
al. (2019), nonpharmacological treatments were found to be effective in two thirds of cases. This
suggests that nonpharmacological treatments can be effective; however, senior living staff must
be able to align the non-pharmacological intervention with the appropriate resident at the
appropriate time, which is a limitation of the existing body of research.

25
Senior Living Staff Must be Knowledgeable About Strategies to Address Resident Behaviors
While Avoiding Administration of Antipsychotic Medications
In addition to conceptual knowledge, senior living staff need a variety of procedural
knowledge to meet the performance goal of reducing antipsychotics. As behaviors emerge,
senior living staff should be prepared with the steps to take to address the behaviors without
antipsychotics. Lemay et al.'s (2013) study revealed that senior living staff do not feel prepared
with the procedural knowledge to address resident behaviors. According to their research, only
37% of direct care nurses felt they could manage resident behaviors without medications.
Similarly, 56% of nursing home nurses believed medications worked well to manage resident
behavior. Additional research highlights the importance of procedural knowledge to address
behaviors in antipsychotic reduction initiatives. Ballard et al. (2017) found that antipsychotic
reduction reviews without non-pharmacological interventions such as exercise or social
interaction offered in tandem were not as effective as those reviews which included the non-
pharmacological interventions. This research highlights the procedural knowledge pertinent
senior living staff with a performance goal of reducing antipsychotics. A study by Shaw et. al
(2018) found that an intervention educating the nurses to effectively communicate with residents
with dementia led to an over 4% decrease in antipsychotics. This research suggests that gaps in
knowledge about treating residents with dementia may be measurable and impact the
performance outcomes. Table 2 presents the goals and assumed knowledge influences with their
corresponding knowledge influence assessments.

26
Table 2
Knowledge Influences Related to Reducing Antipsychotics in Senior Living
Field Mission
The mission of the National Partnership to Improve Dementia Care in Nursing Homes is to
reduce the use of antipsychotic medications through the use of non-pharmacological and
person-centered dementia care (Centers for Medicare and Medicaid Services, 2021)
Global Goal
The National Partnership to Improve Dementia Care in Nursing Homes has established a goal
to reduce antipsychotics by 15% in late-adopter nursing homes by December 31, 2019.
Because this goal has not been replaced, this dissertation will extend it to December 31, 2023.

Assumed Knowledge Influence Knowledge Type Knowledge Influence
Assessment
Staff must be knowledgeable about
considerations related to
antipsychotics, including the
performance goal, regulations
surrounding antipsychotics use,
and the specific harms to older
adults who take antipsychotic
drugs.

Conceptual Interview staff about
antipsychotic regulations and
harms to older adults who take
antipsychotic drugs.

Staff must be knowledgeable about
nonpharmacological treatments,
including the use, benefits and
challenges of nonpharmacological
treatments.
Conceptual Interview staff about the benefits
and challenges of
nonpharmacological treatments.
Staff must be knowledgeable about
the strategies to address resident
behaviors while avoiding
administration of antipsychotics
(such as non-pharmacological
behavioral interventions).

Procedural

Interview staff about how they
would address resident behaviors
to evaluate their knowledge of
nonpharmacological
interventions.

27
Motivation Influences
Motivational influences are the next domain important to the stakeholder’s execution of
the performance goal. Motivation is the extent to which individuals select and exert effort toward
a goal (Rueda, 2011; Mayer, 2011). Clark and Estes (2008) posited that motivation is a series of
disciplined steps which includes active choice, persistence, and mental effort. Active choice
assumes that an individual has the option to put effort toward a goal, even if it is not a self-
selected goal. For example, senior living staff may not set organizational performance goals, but
they make an active choice to invest time and energy toward tasks to reach the goal. Persistence
toward a goal is necessary because there are competing goals to various interests that make it
easy for people to become distracted and pursue alternative goals. Finally, stakeholders’
motivation is influenced by mental effort. Those tasks which are routine require little mental
effort, while those tasks which are novel or challenging require significant mental effort.
Pintrich (2003) suggests there may be underlying influences affecting motivation. Specifically,
motivational factors including value and self-efficacy all influence motivation. The section that
follows will review the literature which evaluates the motivational influences value and self-
efficacy of antipsychotic reduction.
Senior Living Staff Must See the Value in Reducing Antipsychotics
The first motivational construct influencing reduction of antipsychotics is value.
According to Rueda (2011), utility value is the importance a team member places on a goal or
task. Utility value is a component of expectancy theory, which evaluates the benefits a
stakeholder associates with engaging in an activity (Eccles, 2006; Rueda, 2011). If the senior
living staff do not agree that there is a value in reducing antipsychotics or employing non-

28
pharmacological interventions, it is unlikely that they will demonstrate decisions or behaviors
that facilitate meeting the goal.
Individuals who believe that engaging in the task or working toward the goal will benefit
those served, or the organization are considered to have utility value (Eccles, 2006). Research
suggests that senior living staff may not see the value of reducing antipsychotics for their
residents. Nurses and physicians showed resistance to discontinue antipsychotic medication,
especially in residents who had previous unsuccessful attempts at antipsychotic medication
reduction, or who indicated they may harm themselves or others (Azermai, et al., 2014).
Senior Living Staff Must Have Self-Efficacy to Reduce Antipsychotics
The second motivational construct influencing reduction of antipsychotics is self-
efficacy. According to Bandura (1997), self-efficacy is confidence in one’s ability to affect
one’s life and control outcomes. When organizations bolster self-efficacy of individuals,
motivation improves (Bandura, 1997; Pajares, 2006). Strategies that leaders can use to engage
teams include supporting mastery of experiences and modeling self-efficacy. Presumably, low
self-efficacy undermines motivation. Doyle et al. (2018) found that employees having high self-
efficacy translated into improved job performance through improved motivation. For the
purposes of this study, it can be predicted that improving the self-efficacy of the employees’
ability to reduce antipsychotics will increase their motivation toward achieving that goal.
Research confirms that self-efficacy may be lacking for nursing home staff. Specifically,
Lemay et al. (2013) concluded that only 37% of nursing home direct care nurses felt that they
had enough training to handle residents with behaviors. Self-efficacy is not the only
motivational influence that affects nurses' engagement in the reduction of antipsychotics. The
next section will review incentives and their influence on antipsychotic reduction. Table 3

29
outlines the goals and assumed motivational influences with their respective motivational
influence assessments.

Table 3
Motivation Influences Related to Reducing Antipsychotics in Senior Living
Field Mission
The mission of the National Partnership to Improve Dementia Care in Nursing Homes is to
reduce the use of antipsychotic medications through the use of non-pharmacological and person-
centered dementia care (Centers for Medicare and Medicaid Services, 2021)

Global Goal
The National Partnership to Improve Dementia Care in Nursing Homes has established a goal to
reduce antipsychotics by 15% in late-adopter nursing homes by December 31, 2019. Because this
goal has not been replaced, this dissertation will extend it to December 31, 2023.

Motivational Indicators

Assumed Motivation Influences

Motivational Influence Assessment

Senior living staff need to value the goal to
reduce antipsychotic administration to patients.
Interview senior living staff to evaluate their
value of the performance goal.
Senior living staff need to have the self-efficacy
that they can effectively manage resident
behaviors without the use of antipsychotics.
Interview senior living staff to evaluate their
beliefs about their ability to affect the
performance goal of reducing antipsychotics.

30
Organizational Influences
The final influence related to an organization’s abilities to reach performance goals is
organizational factors (Clark & Estes, 2008). Clark and Estes (2008) argued that even when
employees have high levels of motivation and knowledge related to the performance goal,
lacking processes and resources in the organization prohibits successful achievement of the goal.
Gallimore and Goldenberg (2001) described organizations based on cultural settings and cultural
models. Cultural settings are that which can be observed within the workers, their tasks,
policies, and social context of the work. In contrast, cultural models are the unseen aspects of
the organization such as the shared mental schema of the team. Both cultural models and
cultural settings can experience deficiencies that inhibit achievement of a performance goal.
Within this study, two cultural settings influences and one cultural model influence have been
identified.
The Organization Needs to Have Systems in Place to Address Resident Behaviors and Provide
Non-Pharmacological Interventions
Senior living organizations need systems to address resident behaviors and offer non-
pharmacological interventions. Older adults need trained providers to treat their mental and
behavioral health. Although five million older adults have a mental health disorder, only 1,800
geriatric psychiatrists are available to treat them (Byers et al., 2010). Similar shortages exist
with specially trained social workers in geriatrics. While the field needs 5000 geriatric-trained
social workers annually, only 1000 annually are graduating with that specialization (Wang &
Chonody, 2013). Thus, it is likely that senior living lacks qualified providers to whom to refer
for nonpharmacological interventions.

31
In addition to trained professionals in geriatrics to treat psychosocial health, senior living
organizations also need systems to support the use of nonpharmacological interventions. Cohen-
Mansfield and Jensen (2008) found that physicians support nonpharmacological interventions,
however, their involvement in them is unclear because they are not a prescribed treatment, so
there is no documentation on their recommendations of interventions. Without a system of
tracking behaviors and nonpharmacological interventions, preferably with physician oversight, it
is difficult to measure and improve upon initiatives to enhance nonpharmacological intervention.
Research by Ellis et al. (2015) suggested that nursing homes may need assistance educating their
nurses and providing clinical support to residents to reduce antipsychotics. Nurses are trained in
other elements of their jobs; they may lack a system to train nurses to handle dementia-related
behaviors outside of administering medications.
The Organization Needs to Offer Incentives to Reduce Antipsychotics
In the theory of behaviorism, Skinner (1957) suggests whether or not a person is engaged
in the task depends on the punishments or rewards associated with that task, often referred to as
incentives. Thus, if the stakeholders are offered an incentive, they are likely to work toward the
goal (Clark & Estes, 2008; Skinner, 1957). Incentives for employees to participate in
antipsychotic reduction initiatives can be a tangible reward to the nurses for participation, such
as a gift or celebration, or they can be results related to the initiative, such as resident
improvement or worsening of behaviors. It is hypothesized that offering incentives for
performance would increase employee motivation to participate in the performance goal.
The literature suggests that senior living staff may view there are positive incentives for
treating residents with antipsychotic drugs, rather than reducing them. Specifically, nurses and
nursing assistants agreed that there were positive effects of antipsychotics for residents and

32
nurses, thus incentivizing their use (Janus et al., 2016). The researchers suggested that
improving education to nursing home nurses about the limited effectiveness of antipsychotics,
and harms would help to reduce their requests to have them administered to their residents.
The Organization Needs Leadership Commitment to Reduce the use of Antipsychotics as
Treatment
Leadership’s commitment in establishing, communicating, and participating in the goal to
reduce antipsychotics is imperative to the success of the goal. Nasomboon (2014) found
leadership commitment directly affects organizational performance and employee engagement.
If the Nursing Home Administrator and Director of Nursing are not engaged in leading the
nurses toward the goal, it is not likely that the nurses will work toward that goal. Murphy (2004)
highlighted that the average tenure of a nursing home administrator was 31 months. Considering
that the quality initiatives encouraged by state and federal governments are multi-year, it is
unlikely that commitment to initiatives is maintained throughout the turnover of leadership.
Table 4 outlines the goal and the assumed organizational influences and corresponding
organizational influence assessments.

33
Table 4
Organizational Influences Related to Reducing Antipsychotics in Senior Living
Field Mission

The mission of the National Partnership to Improve Dementia Care in Nursing Homes is to
reduce the use of antipsychotic medications through the use of non-pharmacological and
person-centered dementia care (Centers for Medicare and Medicaid Services, 2021)

Global Goal
The National Partnership to Improve Dementia Care in Nursing Homes has established a goal
to reduce antipsychotics by 15% in late-adopter nursing homes by December 31, 2019.
Because this goal has not been replaced, this dissertation will extend it to December 31, 2023.

Assumed Organizational Influences

Organization Influence Assessment
Cultural Setting Influence 1:

The organization needs systems to address resident
behaviors and provide non-pharmacological
interventions.
Interview staff about their
organizational systems to support
reducing resident behaviors and their
experiences with non-
pharmacological interventions in the
workplace.
Cultural Setting Influence 2:
The organization needs to offer incentives to staff to
reduce antipsychotics.
Interview staff about their
experiences with incentives to
reduce antipsychotics in their
organization
Cultural Model Influence 1:
The organizational leadership needs to demonstrate
commitment to reducing the use of antipsychotics as
treatment.
Interview the staff about leadership’s
commitment to the reduction of
antipsychotics.

Conceptual Framework: The Interaction of Stakeholders’ Knowledge and Motivation and
the Organizational Context
The purpose of this conceptual framework is to provide a foundation for the research
questions and the methods used in this study. According to Maxwell (2013), a conceptual
framework is a group of concepts, suppositions, and constructed theories that serves as the

34
foundation of a research study. Conceptual frameworks are assembled from a combination of
experiential knowledge and review of the research. Although potential influencers to the
stakeholder goal are presented here, it is expected they are not a comprehensive list, nor do they
solely affect the performance toward the stakeholder goal. The author acknowledges there may
be additional variables influencing stakeholder performance that have not been identified. The
influences that follow are hypothesized in accordance with practical experience and scholarly
research of the author.
The symbols represent that the stakeholders are affected by the impact of the senior living
organization’s culture and environment. The interaction of knowledge, motivation, and
organizational influences affects the stakeholder’s ability to meet the performance goal, which is
represented by the arrow pointing away from the organization. See Figure 1 for a visual
representation of the conceptual framework.

35
Figure 1
KMO Influences to Reducing Antipsychotics in US Senior Living Communities

Senior Living Organization
Systems to Address Behaviors and Support Reduction
of Antipsychotics, Leadership Commitment, Incentives

Staff Influences:
Factual knowledge about
regulations and harms
surrounding antipsychotics,
conceptual knowledge related
to effective strategies to
manage behaviors, self-
efficacy, and value for the
performance goal of reducing
antipsychotics

Reduction in administration
of antipsychotics by
December 31, 2023

36
Summary
The purpose of this chapter was to evaluate factors related to senior living antipsychotic
reduction performance goals. Specifically, this chapter revealed the assumed knowledge,
motivation, and organizational factors which influence the senior living organization staff’s
pursuit toward the performance goal as supported in the literature and practice. This chapter
ended with the conceptual framework that is guiding this research. Next, Chapter 3 provides the
methodological approach for this study.

37
Chapter Three: Methodology
The purpose of this study was to evaluate the knowledge and motivational influence of
senior living staff and the organizational influences impacting the national goal to reduce
antipsychotics. This research was conducted using Clark and Estes’ (2008) knowledge,
motivation, and organizational influence conceptual framework. To fulfill the study’s purpose,
the researcher developed three research questions which are listed below.
1. What knowledge and motivation influences affect senior living staff in their
pursuit of reducing the administration of antipsychotic medications for senior
living residents?
2. What organizational influences affect senior living staff in relation to reducing the
administration of antipsychotic medications?
3. What is the interaction between knowledge, motivation and organizational
influences in relation to senior living staff reducing the administration of
antipsychotic medications?
This chapter outlines the methodological approach used in this study. This research
employed a qualitative methodology to gather a rich description of the phenomena studied. This
chapter opens with a description of the stakeholders and the sampling strategy. Second, data
collection is described in detail. Finally, this chapter closes with a discussion of validity and
reliability and methodological limitations.
Participating Stakeholders
The stakeholders for this research study were senior living staff. They were selected
because they are jointly responsible for managing resident behaviors by reducing antipsychotics,
and their ability to do so directly impacts the organization’s success toward the performance

38
goal. Specifically, charge nurses (which may be licensed/vocational or registered nurses) are the
gatekeepers of requests for antipsychotics from primary care physicians. Similarly, direct care
nurses are expected to deliver nonpharmacological interventions, often under the guidance of the
charge nurses or social services professionals. Social workers and social services professionals
are also important to interview as they have special training in nonpharmacological
interventions. Pharmacists are responsible for completing dose reductions and ensuring that the
residents who are prescribed antipsychotics are not receiving them unnecessarily. Finally,
nursing home administrators and directors of nursing are responsible for implementing reduction
strategies on a system level.
To be eligible for this study, participants were currently employed in a nursing home or
assisted living, or providing support on a consultant basis, such as a pharmacist or quality
support nurse. There was no threshold for the length of tenure to participate, as quality
initiatives should be communicated to staff during onboarding and orientation. There was not
an abundance of available participants, so no additional criteria to narrow the participant group
were implemented. The rationale for these criteria is that the purpose is to evaluate the
knowledge, motivation, and organizational influences for staff in their current position, as
opposed to past position experience.
This study recruited a purposeful, convenience, snowball sample of 13 senior living staff
currently employed in nursing homes and assisted living centers. According to Creswell (2014),
snowball sampling is a technique to reach participants who may be difficult to find. Participants
were recruited through contacting them directly and by contacting colleagues in my professional
network to identify potential participants. Additionally, flyers were made for Facebook,
Instagram, and LinkedIn social media sites. Once interviews were completed, participants were

39
asked to refer additional people to interview for the study. The rationale for this strategy is that
the goal is to learn from the senior living staffs’ perspectives, and the participants are likely to
connect the researchers with difficult-to-reach participants. Because this was the first known
study of its kind, it was not beneficial to utilize a random sample, because it would have
excluded some participants by chance. By engaging in purposeful convenience sampling, the
study gained access to more research participants active in the field, and thus, more perspectives.
Once participants were verified as eligible, they were invited to complete the informed consent
document and participate in the study.
Data Collection
This study explored the knowledge and motivation of senior living staff working in
nursing homes and assisted living centers as related to the performance goal of reducing
antipsychotic drugs. This study utilized the qualitative methodology of interviewing. According
to Creswell (2014), in qualitative research, the researcher is the primary instrument of data
collection. Thus, the researcher collected, analyzed, and interpreted the participant data. This
methodology required the researcher to organize the data and look for emerging patterns related
to the knowledge, motivation, and organizational influences surrounding reducing antipsychotic
in assisted living.
The purpose of this research on staff engagement in organizational performance goals
was to reveal relationships between phenomena that cannot be observed. Burkholder et al. (2016)
stated that individual interviews are an effective methodology to reveal information that cannot
be observed. This research utilized the lived experiences of senior living staff members to
understand how senior living organizations were engaging staff in initiatives to address resident

40
behaviors and reduce antipsychotics. The semi-structured interview questions provided a
foundation from which the participants shared extemporaneously about their experiences.
This study included 13, qualitative, semi-structured interviews from nursing home staff
working in a capacity in which they were expected to engage in reducing antipsychotics in senior
living. The interviews were conducted over Zoom web-conferencing and were recorded and
transcribed. Interviews were completed in 30-60 minutes, with most finishing around 45
minutes. According to Merriam and Tisdell (2016), interviews are helpful to determine how the
participants interpret their worlds. The interview questions focused on the knowledge and
motivation of the participants related to the performance goal, and how the organizational
influences impacted staff’s ability to meet the goal.
Interview Protocol
Interview questions were asked in a variety of ways in order to elicit a rich and
descriptive understanding of the phenomena studied. The following types of research questions
were used: experience and behavior, opinion and values, feelings, knowledge, sensory, and
background/demographic questions (Patton, 2015). These question types aligned with the
content of the research questions, conceptual framework, and the knowledge, motivation, and
organizational influences for this study. Probe questions were used to follow up on responses
from the participants. Asking probe questions helped to clarify participant’s perspectives and
discover additional information about the constructs (Merriam & Tisdell, 2016).
Merriam and Tisdell (2016) highlighted that not only are the questions important, but the
tone and manner in which they are asked is also relevant. Establishing a rapport with the
participants is an important first step in the interview process. The researcher sequenced the
questions so that the rapport-building questions were asked at the beginning of the interview.

41
Questions were all developed by the researcher. Each question was worded using a
conversational approach, to help put the participants at ease.
Interview Procedures
Following the approval to begin the research from the University of Southern California
(USC) Institutional Review Board (IRB), the interviews were conducted in January, February,
and March of 2023. For this study, 13 interviews were completed from participants working in
11 total senior living organizations. Each participant was screened via email, text, or phone call,
to ensure that they met the eligibility criteria for this study. Prior to the interview, each
participant reviewed the USC IRB-approved informed consent. Participants were informed that
there were no ramifications if they decided not to participate. The interviews were conducted
remotely via Zoom video conferencing software, for ease and convenience of the participants.
This also allowed participants from the entire United States of America to participate.
Interviews were recorded, and automatically transcribed using the Zoom software transcription.
Additionally, the researcher recorded notes as the participants offered responses. Each
participant was interviewed in one interview session for approximately 30-60 minutes. At the
end of each interview, the participant was asked if they had colleagues or friends who may meet
the selection criteria to participate; potentially eligible participants were contacted via email,
phone, or text.
Data Analysis
Qualitative analysis was employed to evaluate the interviews and develop research
findings. This process requires thorough and systematic analysis is important to maintain the
objectivity of qualitative research (Merriam & Tisdell, 2015). Immediately after the interviews, I
created analytic memos to capture initial reactions to the interviews and responses given.

42
Merriam and Tisdell (2015) suggested this are an important component of the qualitative
research process. The Zoom interviews were automatically transcribed and downloaded, and
then edited for correctness by the researcher. This research employed deductive coding, which
organizes research by preconceived themes (Merriam & Tisdell, 2015). A codebook was
developed in an excel spreadsheet which organized the responses by a priori codes. A priori
codes are codes that are developed prior to beginning the research (Merriam & Tisdell, 2015).
Based on the relationships outlined in the conceptual framework, the researcher used open
coding, scanning for empirical codes.
Credibility and Trustworthiness
The interviews allow the researcher to interpret the meaning of the results that emerge
from the experiences of the participants, but this methodology is not without challenges.
Merriam and Tisdell (2015) highlighted the importance of credibility and trustworthiness in
analysis of qualitative data. The section that follows describes the challenges to credibility and
trustworthiness as they are related to the limitations and delimitations of this study.
Merriam and Tisdell (2015) specified that the researcher is the instrument of qualitative
research, so attempts to reduce bias and the researcher's subjectivity are important in maintaining
credibility and trustworthiness. This study employed the strategies of triangulation and
prolonged engagement with the data to improve credibility and trustworthiness. Utilizing
multiple sources of interviews as a data collection strategy allowed the researcher to triangulate
data by soliciting multiple perspectives through data collection means (Creswell, 2014).
Additionally, prolonged engagement with the data was used (Creswell, 2014). Above all, it was
important to communicate the findings in a way that acknowledges the researcher’s biases. In
this case, the researcher works in senior living operations, which may influence interpretation of

43
the responses from the participants. The researcher acknowledged that perception may affect
interpretation of the data and relied on the results to emerge from the data objectively.
This study utilized semi-structured interview questions, a method which has been
scrutinized for reliability and validity (Creswell, 2014). Several strategies to pretest the
interview questions were utilized. First, the interview questions were piloted with mock
participants who did not meet the criteria to participate in this study. In addition to asking mock
participants the questions, the researcher asked them to discuss what they thought each question
meant, to conduct cognitive interviewing (Robinson & Firth Leonard, 2019). Robinson and Firth
Leonard (2019) suggest pretesting and cognitive interviewing are strategies to enhance validity
and reliability of questions. By pretesting the questions with mock participants who are
employed in a variety of work environments, unclear questions, bias, and questions that do not
reach the target construct for measurement were identified and clarified.
Ethics
This research upheld respect and safety for human subjects. Research was conducted with
prior approval of the USC Institutional Review Board. Participants were invited to participate
through online flyers on LinkedIn and Facebook social media platforms, email solicitation, and
word of mouth from participants. There was no requirement by an employer or other influential
entity to participate. The researcher maintained that participation was voluntary throughout the
course of the study, and participants were able to withdraw at any time without consequence or
questions from the researcher, consistent with ethical principles as highlighted by Glesne
(2011). Prior to beginning the study, all participants reviewed and signed the Institutional
Review Board-approved informed consent. This study examined the knowledge and motivation
of senior staff related to the industry’s goal to reduce antipsychotics as well as organizational

44
influences. Although the questions were asked about the staffs’ experiences, there was low risk
to participate as the information sought was about the organization’s performance, not the
individual staff member’s judgment. Regardless, it was imperative to keep respondents’ answers
confidential to prevent employers from soliciting the participants’ responses from the researcher.
Data from the participants was and continues to be protected to ensure the confidentiality
of their responses and minimize risk of participation, as recommended by Glesne (2011). Only
the researcher for this study was able to access the data that connects a participant to their
responses. All data was housed on a password-protected computer that only the researcher may
access. No employers solicited information about their employees’ responses, if they had, access
would have been denied. Results of the study are reported in this dissertation confidentially by
using gender-neutral pseudonyms.
As the researcher of this study, I had no relevant conflicts of interest to disclose. The
researcher does work in senior living, but did not interview staff employed at the researcher’s
place of employment. Being an outside researcher limited assumptions and biases of the
participants, which is an advantage in this study. However, having worked in the industry for
over 20 years, the researcher had general biases and presumptions about senior living operations
and employees. In the analysis, the researcher searched for objectivity in qualitative responses to
minimize biases. Although the researcher has many years’ experience in the industry, the
conceptual framework and hypotheses on relationships between variables are based on research
and influenced by practice to maintain objectivity. The chapter that follows, Chapter Four,
discusses the findings of this study.

45
Chapter Four: Findings
The purpose of this study was to evaluate the knowledge and motivational influence of
senior living staff and the organizational influences impacting the national goal to reduce
antipsychotics. As examined through the Clark and Estes (2008) knowledge, motivation, and
organizational influences conceptual framework, this study explored three research questions:
1. What knowledge and motivation influences affect nursing home staff in their
pursuit of reducing the administration of antipsychotic medications for nursing
home residents?
2. What organizational influences affect nursing home staff in relation to reducing
the administration of antipsychotic medications?
3. What is the interaction between knowledge, motivation, and organizational
influence in relation to nursing home nurses reducing the administration of
antipsychotic medications?
This chapter summarizes and presents the findings from this study. This research utilized
a qualitative methodology which produces a rich description of the phenomena explored.
Chapter four begins with a description of the stakeholders. Then, the findings are described in
detail. Lastly, this chapter closes with a discussion of the final points.
Participants
The stakeholders in this research study consist of 13 senior living (skilled nursing and
assisted living) interdisciplinary team members from 11 different senior living organizations.
Individuals invited to participate included nurses, social workers, administrators, nurse leaders,
and life enrichment staff; pharmacists were included in recruitment but did not participate in this
study. Participants worked in the United States regions of the Pacific Northwest, Mountain West,

46
and Midwest. Interviews were conducted in January, February, and March of 2023 via Zoom
web conferencing software. Participants included twelve people identifying as female, and one
identifying as male. Twelve participants were Caucasian, and one was African American. Table
5 summarizes the participants by their gender-neutral pseudonyms, their current role in senior
living, years of experience, and the level of care and facility alias in which they are employed.
The following section reveals the specific findings related to the knowledge and motivation of
the participants with respect to organizational goals to reduce antipsychotics in senior living.

47
Table 5
Summary of Participants
Participant
Pseudonym
Role Facility
Pseudonym
Years of
Experience
Years in
Role
Skilled Nursing
Facility,
Assisted
Living, or
Memory Care
Lou Administrator Home 1 8 2 AL
Terry Administrator Home 2 22 1 SNF
Kai Administrator Home 3 40 15 AL/MC
Cameron
Quinn
Finley
Pat
Harper
Frankie
Alex
Dylan
Jamie
Jesse
Social Services
Director of Nursing
Charge Nurse
Administrator
Quality Nurse
Nurse Trainer
Nursing Supervisor
Life Enrichment Director
Social Services
Admissions Nurse
Home 4
Home 4
Home 5
Home 6
Home 7
Home 8
Home 9
Home 10
Home 11
Home 11
10
22
40
10
15
13
17
8
6
12
4
1
2
<1
8
<1
4
4
4
4
SNF/AL
SNF/AL
SNF
AL/MC
SNF
SNF
SNF
AL/MC
SNF/MC
SNF/MC

48
Research Question 1: What Knowledge and Motivation Influences Affect Senior Living
Staff in Their Pursuit of Reducing the Administration of Antipsychotic Medications for
Senior Living Residents?
This study assumed that in order for senior living organizations to be successful in their
initiatives to reduce antipsychotics, team members would need the knowledge and motivation to
effectively engage in the initiatives. The section summarizes the findings related to the
knowledge and motivation of senior living staff with respect to addressing resident behaviors and
reducing antipsychotics. The next section outlines the findings related to stakeholder knowledge.
Knowledge Findings
The findings suggest that global knowledge of non-pharmacological interventions and the
need to reduce antipsychotics is evident in the stakeholders. However, they may lack specific
knowledge related to regulations and organizational performance goals. The findings highlight
that the knowledge base of stakeholder may differ, depending on the role the stakeholder plays in
the organization.
Senior Living Staff may Lack Knowledge About Specific Performance Goals, But are
Generally Knowledgeable About Performance Expectations Related to Antipsychotics
Interview data revealed that senior living staff lack knowledge of the specific goals to
reduce antipsychotics, but seem to have a general understanding that their facilities are engaged
in initiatives to reduce antipsychotic use rates. Of the 13 participants interviewed, only one
participant could specify that their facility had goals related to antipsychotics. Terry, an
administrator in skilled nursing, stated there was not an organizational goal per se, but the
organization was expected to fall beneath state and national averages for all quality measures,
including antipsychotics. According to Terry, values that are determined to be above state and

49
national averages require a quality improvement project to reduce the quality metric and improve
patient outcomes. Terry further explained that the antipsychotic goal was more involved than
reducing antipsychotics below a certain percentage, but ensuring there was an appropriate
diagnosis to align with the use of the medication. Terry stated, “We’re not allowed to use
dementia as the diagnosis for an [antipsychotic] medication.” The medication needs to be
treating a diagnosable mental illness.
The use of QAPI or Quality Assurance Process Improvement goals emerged throughout
the interviews with several participants. Jesse, an admissions nurse said the goals were less about
individual organizational goals, but aligned with QAPI benchmarks. “Our team checks the star
rating and quality measures. Because of that, I review referrals [for admission] and I see if they
just started an antipsychotic.” Jesse was suggesting that the QAPI team determined unnecessary
antipsychotics are often prescribed in the hospital, and one of their team’s strategies to reduce
antipsychotics is to request they be eliminated prior to transfer to skilled nursing for
rehabilitation or long-term care. Similarly, Cameron, a social services team member in assisted
living and skilled nursing stated her team is “made aware through QAPI '' that they should focus
on various aspects of improving resident care, like reducing antipsychotics. Although none of the
participants knew the specific antipsychotic goals, they were aware that there was a goal and
initiative to reduce or eliminate that the facility was working toward as a result of QAPI.
Two participants stated they were not aware of the community's goals to reduce
antipsychotics. Pat, an assisted living administrator new to their position, stated they were not
aware of any goals to reduce antipsychotics, but the general approach was to “fix resident
behaviors without the use of drugs.” Dylan, a life enrichment coordinator for different assisted
living shared a perspective similar to Pat’s with regard to not working toward a specific goal,

50
“I’m not aware of goals, per se, but we are trained on interventions to try before we get to that
point.” Dylan stated her organization utilizes an “engagement plan” for each resident to address
behaviors with non-pharmacological interventions rather than medication. Dylan specified, “The
engagement plan tells you how to soothe them, calm them down. It shows what riggers or excites
them. You should go directly to the plan.” This finding suggests that even in the absence of
knowledge of the goal, the entire interdisciplinary embraces the culture of nonpharmacological
interventions as the best approach to resident behaviors.
Senior Living Leadership Were More Likely Than Other Team Members to be Knowledgeable
About the Regulations Surrounding Antipsychotics and The Harms They Pose to Older Adults
Team members who were knowledgeable about the regulatory relevance of reducing
antipsychotics tended to be leadership team members such as Directors of Nursing or
Administrators. Other interdisciplinary team members were likely to understand the process in
which they should engage to avoid unnecessary use of antipsychotics. Similar to the previous
finding that the team knows the practical execution of the goal without knowing the goal,
likewise, they describe understanding the practical execution of the regulation without knowing
the regulation. Cameron, a social services designee in skilled nursing and assisted living,
indicated they were not knowledgeable about the performance goals, but was familiar with the
processes in which they, as a member of the care team, should engage. Cameron explained that
when people are admitted or behaviors emerge, “[The process is to] involve social services and
activities to identify coping skills and things they like to do.” Cameron described the importance
of knowing the resident, trialing interventions to help reduce behaviors, and the value of the
interdisciplinary team working together to address resident behaviors and reduce antipsychotics.

51
Similarly, Alex, a nursing supervisor in skilled nursing, described the importance of
trialing behavioral interventions with the care team and the provider prior to requesting a resident
be treated with an antipsychotic. Specifically, Alex mentioned that “Sometimes when a person is
agitated, step back, re-approach later, distract, try music, try sweets, or see if they like warm
washcloths.” Alex’s reflection highlights that even if senior living staff do not know the
specific regulation, they do know the first approach is to address behaviors without medications.
The findings in the next section offer additional support for the staff’s knowledge of integration
of a nonpharmacological intervention culture, which supports reduction of antipsychotics.
Senior Living Staff are Knowledgeable of Safe Alternatives to Using Medication for Residents
With Dementia
All of the senior living staff demonstrated knowledge of non-pharmacological
interventions to reduce resident behaviors, as well as the importance of using them as a first line
of treatment for residents with behaviors. While some participants did not use the term “person-
centered,” each of the participants offered examples of person-centered care they or a colleague
had used to address resident behaviors without the use of medications, indicating that there is not
a lack of knowledge preventing nursing homes from effectively addressing resident behaviors
and reducing antipsychotics. Lou, an assisted living administrator, offered an example of a time
her team used a person-centered approach to help a resident who would not sit down for lunch
due to his delusion. The resident was a former CEO (Chief Executive Officer) and thought they
were supposed to give a presentation and that concern prevented the resident from sitting down
to eat. Lou’s team invited the resident to give a presentation, the resident fielded from the
“audience,” and then the resident’s delusion about the presentation ended. After the presentation,
the resident was seated for their lunch. By joining the reality of the resident, Lou’s team

52
prevented further escalation of behaviors, and the resident ate a balanced meal. Lou mentioned
several times in their interview, “Behavior is communication,” and their role was to identify the
need being communicated.
In addition to joining the resident’s reality, other resident-specific interventions were
revealed by participants. Quinn, a Director of Nursing, discussed therapeutic use of dolls in
residents who showed affection toward children. Quinn explained, “We have one resident who
was very anxious and always crying. We gave her the doll and she suddenly became, you know,
mothering.” In Quinn’s experience, the therapeutic dolls have been helpful to some residents
with dementia to reduce their anxiety and searching behaviors. Quinn also reported their team
utilizes practical activities such as sorting, folding, and chore-based work for residents who are
anxious, exit-seeking, or going into other resident rooms. Quinn stated, “We had this one
resident who came to the nurses station every day asking about her job. We finally gave her
some papers to sort, and she was productive for two or three hours.” Quinn’s examples highlight
how interventions can improve the mood and reduce anxiety of residents with dementia.
Music, in particular, is a nonpharmacological intervention ten of the senior living staff
described as a helpful nonpharmacological intervention. Harper, a quality improvement nurse
working with several skilled nursing facilities, discussed the importance of music in helping to
calm residents with behaviors. They described a patient with a traumatic brain injury who could
not calm themselves when upset, but through trialing different genres of music, they found a
playlist to help the person relax when triggered. Harper stated this was their “proudest moment”
as a nurse when this patient’s behaviors were reduced with a personalized playlist. Pat, an
assisted living administrator, shared remarks that echoed the importance of music as a
nonpharmacological intervention. Pat described a resident who was paranoid and afraid to be in

53
her apartment alone, but once the team discovered she was soothed by Aretha Franklin, they had
a new intervention for when she was upset. “It was like she was a different person when Aretha
was on,” Pat described. Dylan, an assisted living and memory care life enrichment coordinator,
shared many of their programs are centered around music. They described utilizing personalized
playlists, sing-a-longs, and live music performances to reduce or avoid behaviors on an
individual and group basis.
Knowledge that behavior is communication is a common theme that emerged through
discussions with senior living staff about addressing behaviors through non-pharmacological
interventions. Jesse, an admissions nurse in skilled nursing described a phenomenon of
mislabeling residents' communication challenges as behaviors, “A lot of what is happening can
be stopped if you slow down and talk to the patients.” While all of the participants could label at
least some of the common nonpharmacological interventions such as validation, redirection, and
therapeutic activities, Pat, an assisted living administrator described the difficulty of knowing
what intervention to use when. This was their description of the complexity of knowledge when
assessing resident behavior:
[When a resident is having behaviors] I put on my thinking hat. I want to know
everything. What is happening? What happened in the last two hours, and how was it
handled? That gives you a good idea of the environmental factors….You need that
[information] to figure out which intervention to put into place.
The thinking that must occur in response to resident behaviors is “complex, critical
thinking,” according to Pat. When a resident is experiencing behaviors, staff make swift
judgments to respond, which will positively or negatively impact the resident’s behavior. While
no other participants offered this insight into the complexity of the judgment executed in senior

54
living in response to resident behaviors, several participants mirrored this response by discussing
trial and error, joining the resident’s world, and validation as nonpharmacological strategies.
Lou, an assisted living administrator stated their approach is to “Investigate. What precipitated
the behaviors? [That] might be a trigger. Did they have visitors, a call? Noise? Something else?”
Trial and error as a strategy to address resident behaviors aligns with the finding that judgment is
necessary to experiment with interventions to address resident behaviors. In the field of caring
for residents with behaviors, trial and error represents the successive attempts by the same staff
member, or different ones, attempting to offer an intervention or response to reduce the resident
behavior, knowing that the resident may not remember the interaction a few minutes later. The
findings suggest that senior living staff are familiar with nonpharmacological interventions to
reduce resident behaviors.
Motivation Findings
This section reveals the findings related to motivation of the senior living staff to work
toward the goal of reducing antipsychotics in nursing homes. The findings suggest that the
participants have confidence in their ability to manage resident behaviors and reduce
antipsychotics. However, they vary in their perceived value of the goal. Next is a review of the
findings on confidence to reduce resident behaviors.
Senior Living Staff are Confident in Their Ability to Manage Resident Behaviors Without the
use of Medication
Senior living staff communicated high levels of confidence to address resident behaviors
on an individual level, but several mentioned they had reduced confidence in some of their
colleagues or their team members to address resident behaviors. Eleven of 13 participants
described feelings of confidence when treating residents with challenging behaviors. Three

55
described a passion for working with residents with dementia which fuels their drive to learn
more about interventions and safe approaches. Lou, an assisted living administrator, stated, “I
feel confident in my ability because I’m passionate about this.” Similarly, Quinn, a Director of
Nursing, stated with a laugh, “I enjoy working with patients with dementia. I have multiple
personalities and get to use them all every day,” meaning that they adapt their style of interacting
to match something that will be well-received by her residents. Terry, a skilled nursing home
administrator said they had confidence in their personal ability, but had concerns about their
team’s ability to manage resident behaviors, “I give confidence in my staff a five on a scale of
one to ten. It isn’t even a lack of knowledge. Overall energy in the staff has shifted [since
COVID-19 pandemic began] and they’re burned out.” Terry’s remark underscores larger system
issues that will be discussed later, but highlights the importance of the entire organization being
aligned with strategies to reduce resident behaviors as a prerequisite to successfully reducing
antipsychotics.
Several of the participants described their experience working with residents with
behaviors as precipitating their confidence level. Cameron, a social services worker in skilled
nursing and assisted living, had a high-level of comfort with the “trial and error” approach to
addressing resident behaviors. They described trying different responses to resident behaviors to
see what works with addressing residents who are worried about going home or looking for a
loved one. “Usually something eventually sticks, but then again, it might not work the next
day,” meaning that there is usually a response that will satisfy a resident with exit-seeking
behavior, but it may not work every time. Jesse, an admissions nurse described a high level of
confidence because time and empathy are her first-approach, and often works without resorting
to medications. Jesse connects their confidence to the extra time spent with residents and the

56
empathy shown toward them when they are having behaviors. Jesse explained, “I’m very
confident. I feel like talking to them and listening is the best thing I can do.” Although Jesse
attributes the confidence to the amount of time she spends with residents, it is likely that she is
relying on experience that talking with residents is a helpful strategy. Given the connection with
experience and confidence addressing resident behaviors, it is not surprising that the two
participants who had the least amount of experience had the least amount of confidence.
Senior Living Staff Vary In Their Perceived Value Of The Goal To Reduce Antipsychotics
Perceived value of the goal to reduce antipsychotics varied among senior living staff.
Participants agreed that the end goal is quality of life, a phrase that all participants used at least
once in their interviews. Lou, an assisted living administrator stated the ultimate value in
reducing antipsychotics is, “[A sense of] calm, engaged in life, quality of life.” Still, some
participants indicated medications were necessary to achieve the goal of a quality life. Pat, an
assisted living administrator, highlighted this value:
I see the meaning behind reducing antipsychotics; we can’t solve a problem with a drug.
Obviously, they have side effects and are used excessively. Here’s the thing, these people
didn’t choose this path for themselves. It's a rough path for them and their families. It is
important to try interventions that don’t include medication, but if the medication is going
to improve their quality of life, it is a good thing.
While all participants agreed that medications should be a last resort, several questioned
the meaning behind and overall intent of initiatives to significantly reduce or eliminate
antipsychotics. An administrator of skilled nursing, Terry, stated she questions the intent of
initiatives to reduce antipsychotics, and wondered if it was “financially driven.” In her opinion,

57
it seems extreme to have such significant limitations on antipsychotics that, when used with
caution, can improve quality of life.
The findings suggest non-pharmacological interventions have multiple benefits. First,
they benefit the individual resident who has assistance addressing behaviors. Second, they
benefit the organization through designation for excellent care. Participants described
nonpharmacological interventions as offering a holistic approach, one that reduces behaviors,
engages families in problem solving, improves overall mood, and improves quality of life. Kai,
an assisted living administrator, suggested:
[Non-pharmacological interventions] help them live a normal life, as best they can.
They’re alert, activating brain cells like before they were sick. It’s a more natural way to
respond to the changes in the brain, rather than manipulating it with medication.
Participants described that non-pharmacological interventions instill calmness in
residents with behaviors, staff, and fellow residents. However, participants discussed there is also
value in using antipsychotics to treat resident behaviors. In addition to calmness and reduction in
behaviors, participants suggested that the value of antipsychotics is that it offers a more
immediate reduction in behaviors than nonpharmacological interventions. Terry, a nursing home
administrator, said the true value of an antipsychotic is it stops the behavior quickly, “You aren’t
taking a wait-and-see-approach to see what happens after you redirect the individual. It helps
you control the situation.” Terry said sometimes immediate control of the situation is necessary
for the safety of that resident and other residents in that community. Several other participants
described resident safety as a value of antipsychotics, and the safety as not just the individual
resident with behaviors, but other residents and staff in the environment. Other ways that
participants explained value is reducing delusions and hallucinations and helping residents

58
remain in a state they can eat, sleep, and accept assistance with other activities of daily living
like dressing or showering. Thus, even though participants see the value in using
nonpharmacological interventions, they wish to reserve the use of medications for their value in
reducing resident behaviors that affect safety.
Research Question 2: What Organizational Influences Affect Nursing Home Staff in
Relation to Reducing the Administration of Antipsychotic Medications?
Not only do senior living staff need knowledge and motivation to engage in antipsychotic
reduction initiatives, organizational influences must also support the organizational goal. This
section highlights the findings related to organizational influences supporting reduction of
resident behaviors and antipsychotics. Training, staffing, and communication of leadership
commitment emerged as salient influences in the findings.
Training in Senior Living is not Sufficient to Ensure Staff Have a Practical Working
Knowledge to Prevent Administration of Antipsychotics
Staff training to treat residents with behaviors with nonpharmacological interventions is
lacking and inconsistent, which likely contributes to unnecessary administration of
antipsychotics. Of the 13 participants in this study, 11 stated that they had received training to
address resident behaviors without antipsychotics; the remaining two participants did not feel
they were trained on resident behaviors or non-pharmacological interventions. Both participants
who stated they did not receive training worked in skilled nursing, where the federal government
does require training.
Of the 11 participants who received training, four described basic compliance-oriented
training, such as a monthly in-service or Relias training, the latter of which is an online training
platform specializing in senior living topics. Frankie, a nurse, who had just accepted their new

59
role as nursing trainer described the training at their organization as the “bare minimum
compliance training.” Frankie stated, “They took the training, but didn’t seem to learn anything.”
In their new role, Frankie hopes to offer more interactive training to help staff know what to do
in situations in which residents have behaviors. Frankie also noted there was recently a training
which offered an interactive module on resident behaviors, but “the staff who needed it the most
were taking care of residents and did not attend the training.” Frankie shared this about trainings:
It feels like we just focus on compliance here….give the training and check the box that
someone received training. However, a hurried training to check a box rarely sticks.
What we need is a way to train staff away from their work assignments so they can digest
the information. People aren’t paying attention to an in-service in-between answering
call lights and phone calls.
Seven participants described more thorough and in-depth training than compliance
training, but it was seldom from their employer. Three of the participants described college
coursework that prepared them to address behavior with non-pharmacological interventions.
Two participants described in-depth training through continuing education or conference
courses. One participant stated her organization had a solid onboarding and orientation training
that utilizes the “Best Friends” approach, of engaging with residents in a friendly partnership
rather than the through the power dynamic of a caregiver vs. patient. In addition to training upon
hire, there is yearly training as a refresher course to cover the same material. Two participants, a
Director of Nursing and Social Services staff from skilled nursing, described a two-day,
interactive training to address resident behaviors, but it was initiated prior to the COVID-19
pandemic and has not been mentioned since the training was launched over three years ago.

60
From the reports of the participants, training designed to improve outcomes is rare, and when it
does occur, it does not have a history of maintaining consistency.
Staffing Challenges Negatively Impact Senior Living Organizations’ Ability to Adhere to
Antipsychotic Initiatives
Staffing challenges in senior living emerged as an unanticipated organizational influence
negatively impacting organizations’ abilities to execute antipsychotic medication reduction
initiatives, according to the participants. Although staffing was stated several times as a barrier to
employing non-pharmacological interventions, a few participants offered more detail as to their
perception of the barrier. Finley, a charge nurse in a skilled nursing facility stated that their
organization only had two full time staff nurses, and the rest were agency employees. Given that
many of the participants offered person-centered care and consistent staffing as strategies to
reduce resident behaviors, a large proportion of agency staff is a barrier to reducing resident
behaviors through non-pharmacological means. Jesse, an admissions nurse stated, “We’re
supposed to know our residents, but that is hard to do when most of your staff is [from an]
agency.”
Other participants echoed the concerns about burn out, staffing challenges, and agency
staff being barriers to reducing antipsychotics. Harper, a quality nurse consultant who is
partnering with facilities to enhance their quality, reiterated the significance of agency staff as a
barrier to implementing antipsychotic reduction projects. Across their partner organizations,
many facilities have a high percentage (example, 50%) of agency staff, and those facilities are
struggling to execute their quality initiatives. In addition to the agency staff, Harper noted
nursing burnout post-covid as another staffing-related barrier to reducing resident behaviors and

61
antipsychotics. Terry, a skilled nursing administrator offered her perspective on staff burnout and
engagement in quality improvement initiatives:
The overall energy in the staff is lacking. There has been a shift, it’s more about money.
They have so many options for places to work, but they don’t see their own burnout. It’s
like an unhappy marriage. You’re staying, but there isn’t love or compassion. Staff are
task-oriented and just doing one thing, and then the next.
Terry specified that they have over 50% agency staff in their facility, and there is a lack
of engagement, motivation, and quality in their care due to lack of engagement in their
organization. Terry suggested that the care provided in nursing homes hinges upon person-
centered care. Terry stated, “Staff should know residents” and use that knowledge about their
personhood and care to guide care and interventions. Terry and other participants illuminated the
hazards of having “warm body” agency staff over their own staff who tend to be more invested
in the care provided to residents.
The Lack Of Communication of Commitment From Leadership has a Ripple Effect on Senior
Livings’ Ability to Reduce Antipsychotic Medication in Residents With Dementia
Few participants in this research study expressed that their organization’s leadership
communicated their commitment to reduction of antipsychotics. Lou, an assisted living
administrator, reported the most robust leadership commitment to reduction of antipsychotics of
the participant group. Lou shared several strategies that their organization used to show their
commitment to reduction in antipsychotics. Lou’s company embraces the “Best Friends”
approach to caring for residents with dementia. Instead of adhering to a healthcare model, staff
are trained to interact with residents using a social framework, as if they were friends, to reduce
resistance with care and uphold personhood. The “Best Friends” approach includes a robust

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training program upon hire, with the expectation that the staff sign a “Best Friends Bill.” The
Best Friends Bill highlights what it means to be a best friend in their environment, and the
employee is committing to that practice. Lou also felt the building design at their facility, which
avoids long corridors and resemble a more home-like environment than other communities, is a
way that Lou’s leadership demonstrates their commitment to reducing resident behaviors and use
of antipsychotics.
Three participants stated adherence to a standard of practice is a way of communicating
commitment to antipsychotic reduction. When Lou described their antipsychotic goals, they
suggested elimination is a standard of practice, not a goal, “Our claim to fame is that zero
antipsychotics is the standard.” In Lou’s company, if a resident is on an antipsychotic, regardless
of if they are in skilled nursing or assisted living, the team is required to submit a plan to reduce
the antipsychotic. Lou felt the strict adherence to this standard of practice, the act of signing the
Best Friends Bill, and architectural design all demonstrated leadership’s commitment to the
reduction of antipsychotics.
Cameron, a skilled nursing and assisted living social services worker, offered a
perspective that coincided with the sentiments of Lou’s experience. Cameron described her
organization making significant investments of time and money into training programs aligned
with quality initiatives as a way of communicating what is important, “You can tell what is
important by how money is spent.” Cameron said their organization also spends additional
money to ensure access to providers to help address residents with behaviors. Cameron’s
organization pays a regular fee to provider groups for psychology and psychiatric services to
ensure their spot is held for regular rounding on patients, even if there are few patients to be seen
for billable care by the provider.

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Although no other participants felt a strong commitment from leadership to reduce
antipsychotics, several felt the level of engagement from leadership in the QAPI process and
process improvement projects was indicative of their commitment to reducing antipsychotics.
Quinn, a skilled nursing Director of Nursing stated, “What you focus on tells your staff what is
important. We discuss it at every QAPI meeting, whether we need to or not.” Quinn is stating
that even if their antipsychotic rates are below state and national averages, they review adherence
to their reduction plans at the QAPI meeting. Frankie, a staff development nurse stated the QAPI
project of a monthly psychotropic meeting was the only way the leadership team demonstrated
their commitment, but they felt it was strictly adherence to a regulatory mandate. Terry, a
nursing home administrator, stated there is a strict adherence to regulation at her organization,
but the company that owns their facility balances high expectations with an approach of
openness and sentiment of “What do you need to do your job well.”
Not all participants felt their leaders communicated their commitment to reducing
antipsychotics. Three participants felt there was no commitment communicated to them, and two
more felt it was strictly from a regulatory perspective. Kai, an administrator in assisted living and
memory care, stated there was a regional clinical director who was responsible for working with
Directors of Nursing at the facilities in their company to reduce antipsychotics. Kai explained,
“[We have a] regional director. Requests data from the DON in our communities. What are the
antipsychotics? He asks for the data, but I’m not sure what he’s doing with that?” Kai’s example
highlights that there is some initiative happening, but there is a lack of communication back to
the community about progress toward that goal.
Participants highlighted that leadership showing their commitment to reducing
antipsychotics is imperative to effective reduction projects. Harper, a quality nurse and former

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Director of Nursing who is partnering with homes to assist with quality improvement initiatives,
said her observation is when the Director of Nursing and Administrator are involved, the quality
initiatives are executed more effectively. “Facilities are most successful [at their antipsychotic
reduction initiatives] when administrators are on the floor guiding the process. The DON,
ADON, and Administrator all need to be out there helping.” Several participants shared a
negativity toward reducing antipsychotics for a sole purpose of meeting regulations. Jesse, an
admissions nurse in skilled nursing, said quality initiatives seem to focus on the wrong thing: the
quality metric instead of the people affected by the metrics. According to Jesse, “We should be
more concerned about how the drugs affect patients themselves, not the perception of the facility
because of their quality ratings [related to antipsychotics.” Jesse went on to question, “Is that the
whole point of this? That we are more about the numbers than the patients?” Jesse’s question
highlights the significance of focusing on the initiative and forgetting that the quality numbers
represent potential harms to older adults.
Research Question 3: What is the Interaction Between Organizational Influences and
Stakeholder Knowledge and Motivation?
This section summarizes findings related to the interaction between organization
influences in senior living and senior living staff’s knowledge and motivation related to the goal
to reduce antipsychotics. The findings in this section highlight that senior living has systems in
place to manage resident behaviors without medication, but does not incentivize achieving
antipsychotic reduction goals. The findings also underscore the importance of the
interdisciplinary team and the significant role of regulation.

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Senior Living Organizations Have the Systems in Place to Provide Non-Pharmacological
Interventions, but Lack Incentives to Utilize Non-Pharmacological Interventions
A promising finding in this research was that senior living staff were familiar with the
processes their organizations used to address resident behaviors. Twelve of the 13 participants
described the procedure for addressing existing or emerging resident behaviors. Coworkers
Cameron and Quinn, a social services staff member and Director of Nursing, respectively,
discussed the importance of the interdisciplinary team to assess and address behaviors. Their
teams included nurses, social workers, chaplains, physical, as well as occupational, and speech
therapists who collaborate to assess residents with behaviors and create person-centered
interventions to address resident behaviors and prevent them from escalating to a point of
personal safety for the resident, or staff and other-resident safety. Lou, an assisted living
administrator, described the care plan as the “individualized guidebook” of addressing resident
behaviors. Other participants’ comments reflected Lou’s remarks and discussed either the
personalization of the care plan as a means to address resident behaviors or the interdisciplinary
team as the group which intervenes in resident behavior. Finley, a charge nurse in skilled
nursing, was the only participant who did not describe a facility-level procedure for addressing
resident behavior. “There isn’t a procedure. It’s a matter of nursing judgment.” Finley’s remarks
may indicate their facility lacks systems to address resident behaviors.
None of the participants disclosed receiving personal or organization-wide incentives for
reducing antipsychotics. Several participants described avoiding unnecessary antipsychotics as a
basic standard of practice, which should not be incentivized, it is a rule. Quinn, a Director of
Nursing in skilled nursing stated this about incentives, “No, the best care is standard, and you
shouldn’t get an incentive for doing the right thing.” Another participant, Lou, an assisted living

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administrator, stated, “The care standard is zero antipsychotics. There are no incentives for the
standard.” Some participants described incentives for other behaviors like good attendance to
work, meeting census goals, or completing in-services timely, but none for quality measures.
Regulations are an Effective Means to Limit the use of Antipsychotics in Residents with
Dementia
In the absence of the knowledge of regulations or knowledge of the specific
organizational performance goals to reduce antipsychotics, all of the participants articulated
processes in which their organization engaged to reduce antipsychotics given to residents,
regardless of the level of care. This suggests that regulation is an effective means of engaging
nursing homes in reduction strategies. Several of the participants could identify specific
strategies that their organizations were implementing to reduce antipsychotics. Jesse, an
admissions nurse in skilled nursing stated that even though she was no longer a direct care nurse,
she had an important role in the reduction of antipsychotics. Jesse’s organization identified the
proclivity for older adults to be prescribed the antipsychotic Seroquel during a hospitalization, as
a driver in their antipsychotic rates. Jesse’s organization maintains a high census of short-stay
rehabilitation residents with many admissions to skilled nursing directly from the hospital.
Jesse’s role in reducing antipsychotics is to ask the hospital providers to discontinue unnecessary
antipsychotics prescribed for “behaviors or sleep” prior to admission, or look for an alternative
means to reduce behavior. Jesse’s example highlights the impact of regulation on their
organizations’ screening process for potential admissions.
Several participants named QAPI (Quality Assurance Performance Improvement) as a
process the team utilizes to stay informed of antipsychotic administration trends and create
strategies to improve the antipsychotic metric. Nine of the 13 participants named QAPI as

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influential in their reduction strategies. QAPI is federally mandated by CMS to ensure that
skilled nursing facilities are engaged in a process of reviewing metrics and engaging in
performance projects to improve resident outcomes. In addition to the initial pre-admission
screenings that Jesse, the admission coordinator, discussed, there were other QAPI-based
strategies that participants discussed. Eight of the 13 participants named gradual-dose reductions
as a strategy their facility employed to reduce antipsychotics. Gradual dose reductions are
required to be attempted if a patient has been on a psychotropic drug for a long period of time,
unless there is a documented contraindication, or medical reason not to do so. The process that
most organizations adopt is that the consulting pharmacist for the nursing home or assisted living
will make a recommendation to the primary care physician to attempt to reduce the dosage of, or
eliminate, one or more psychotropic medications. At their discretion, the physician may decline
to attempt a gradual-dose reduction if they feel it is unsafe to do so, or if that patient has a history
of failed GDR attempts. Not only are there regulations surrounding antipsychotics, there are also
regulations surrounding QAPI. Jointly, these regulations appear to pressure nursing homes to
comply with reduction initiatives.
To further illuminate the importance of regulation, participants offered additional insights
into the ways that regulation, specifically, QAPI, drives reduction of antipsychotics. A quality
nurse, Harper, is partnering with several homes to help them improve their quality metrics
related to antipsychotics. They described three organizations who were actively engaged in
QAPI projects to reduce antipsychotics. One of the organizations targeted seven specific nursing
home residents with behaviors emerging on night shift. The organization engaged their night
shift staff in new nonpharmacological interventions to address behaviors without the use of
medications. Two nurses at other organizations, one a floor nurse, and one a Director of Nursing,

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discussed QAPI projects related to ensuring there was a 14-day stop date on psychotropic drugs,
which aligns with other regulations related to antipsychotic drugs. These findings highlight that
in the absence of identifiable organizational goals, the organizations engage in strategies to reach
quality goals aligned with state and national benchmarks and comply with state and federal
regulations.
Provider Access is Important, but the Interdisciplinary Team is a Dynamic Collaboration that
Holds Great Power tn Reducing Antipsychotic Use
This study expected to find access to providers an important resource in the quest to
reduce resident behaviors and eliminate antipsychotics. As such, participants described access to
psychologists and psychiatrists as necessary partnerships for overall behavioral health quality
improvement projects. Only three participants described consistent access to psychologist or
counseling services in their senior living communities. They described the psychologist services
as regular, consistent, and a next referral step if the internal interdisciplinary team could not curb
the behaviors to a safe level by themselves. One social worker at a skilled nursing facility, Jamie,
stated they previously had a psychological services provider, but due to their low patient volume,
the provider was unwilling to continue serving their building. The same social worker described
that their facility does have psychiatrist services, but they were via telehealth due to in-person
provider access limitations. Participants who lacked provider access were more likely to describe
treatment scenarios that included transferring the patient to a geriatric psychiatric treatment
center, or to call 911, emergency services to restrain the resident and transfer them to a hospital
for evaluation.
More salient than the need for providers was the importance of the interdisciplinary team
in evaluating and addressing the behaviors. Cameron, who worked in social services for skilled

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nursing and assisted living, described the interdisciplinary team as central to all of their quality
initiatives and resident approaches. They described a nursing assessment as the first step to
addressing resident behavior, to rule out an acute infection that could be contributing to the
change in condition. Cameron described the next piece in the interdisciplinary process is to
engage the life enrichment and social services teams to complete assessments and offer
interventions to curb behaviors. The chaplain may also be consulted if appropriate. Cameron felt
this overall process was effective, but “Even if we don’t stop all behaviors, we do make them
more manageable.” Quinn, a Director of Nursing from the same organization, shared similar
remarks to those from Cameron’s summary of the process and specified that the interdisciplinary
team meets weekly to discuss various high-risk residents including those who have fallen, have
wounds, infections, behaviors, among others. Quinn felt that in addition to having many
interdisciplinary team members involved in the care, they actively work together toward an
interdisciplinary care plan in the weekly high-risk meeting. Quinn felt there was an advantage to
this approach because there is ongoing interdisciplinary activity going on throughout the week
that is reviewed with all relevant team members at once, which eliminates siloed care.
Additional External Influence: Residents with Extreme Behaviors Are Difficult to Treat
and A Threat to Staff, Residents, and Themselves
Throughout the interviews, an external influence related to engagement in initiatives to
reduce antipsychotics emerged. Several participants described threats to resident and staff safety
if behaviors were not managed. The section that follows explains this influence.
How to treat residents with extreme behaviors was an unexpected external organizational
influence. Even though all of the participants articulated the positive intent to reduce
antipsychotics, several discussed residents with extremely difficult-to-manage behaviors that are

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not managed without medications. They described these behaviors that have effects on
organizations and the patients themselves with respect to their personal safety, safety of other
residents, and staff safety. The most challenging-to-treat resident behaviors include resistance to
care, combativeness, yelling or making noise that is disruptive to the environment, resident-
resident aggression, resident-staff aggression, and sexually inappropriate behaviors. Participants
described that residents with these behaviors pose significant threats to the staff, residents, and
the legal and regulatory standing of the organizations if one resident harms their self or another
person. Kai, an assisted living administrator, has practiced in the field of aging services since the
1970s described how care has changed and the danger of uncontrolled resident behaviors:
I remember, you know, catatonic residents in the 70’s… they had waist restraints. People
were chained to the wall by their wheelchairs. They drugged them up. Give them this,
give them that. It’s good that we’re taking a look at this. But then you have people who
you can’t control, physically. They’re combative, hitting staff, hitting residents, smashing
doors, hitting walls. What do you do?
Of concern to five of the participants is that resident behaviors can result in an abuse
citation. Terry, a nursing home administrator, described a recent citation for resident-resident
abuse. Even though the resident determined to be the aggressor had dementia and the facility had
taken measures to separate the residents in an altercation, the facility was cited with resident-to-
resident abuse. Terry stated, “State doesn’t consider ill-intent or malice anymore. That’s new.
We used to be able to say it was due to dementia, but that doesn’t happen anymore. We got cited
[for resident-resident abuse].” Recent regulatory updates have further complicated the
challenges of residents with behaviors by citing facilities who have resident-to-resident
altercations with abuse.

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Residents with behaviors are also a significant safety threat to other residents and staff.
As Harper, a quality nurse, stated, “Most nursing homes aren’t staffing 6’5” football players, you
know. There is nobody to protect the staff.” Kai, an assisted living and memory care
administrator described a patient who was physically strong enough to pick up chairs and throw
them at staff, among other dangerous or combative behaviors. Similarly, Dylan, a life enrichment
director, described an experience in which a chair was thrown at her by a confused resident.
Several participants felt that the goal to reduce antipsychotics is important, but there are still
people who need access to medication to reduce dangerous behaviors. When asked what is the
ultimate treatment for a resident who is physically dysregulated and threatening to others, Jesse,
an admissions nurse suggested she had witnessed the use of intramuscular antipsychotics, as long
as someone could hold the patient down to administer them. According to participants, behaviors
can be so dangerous that their facility would call 911 for help controlling the situation. Five
participants stated they would call emergency medical services and have the patient sent out for
treatment and not admit them back if they exhibited dangerous behaviors.
In addition to physically violent behaviors, two participants described sexually
inappropriate behaviors as difficult to manage in residents with dementia. Residents who do not
have their mental faculties to make informed decisions, and who are attempting to be sexually
involved with other residents pose major concerns from legal and care standpoints. Jamie, a
social worker in skilled nursing, described a resident who showed interest in having physical
relationships with other residents at the nursing home. The patient was eventually discharged
from the facility to a geriatric-psychiatric stay, and was not admitted back.
Of lesser concern, but still notable by several participants was the concern of yelling or
moaning residents. As people progress through the latter stages of memory loss, some make

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noise in the form of yelling, moaning, or repeating phrases. While not a direct threat to others, in
a communal environment, this is disruptive to other persons living with memory loss who are
likely to have impaired coping mechanisms. The participants felt these were challenging
behaviors because there were few effective treatments. Quinn, a Director of Nursing in skilled
nursing and assisted living, expressed that sometimes addressing hearing loss, lack of
stimulation, or pain can help curb noise-related behaviors, but some are seemingly untreatable.
The consensus from the individual participants was there is a time and place for
nonpharmacological interventions, but the reality of senior living is that residents with behaviors
pose a significant threat to the health and safety of other residents and staff in that environment.
Alex, a nurse leader from skilled nursing, described a patient who was prescribed antipsychotics
and had a 1:1 sitter as a treatment plan for a resident with behaviors. With a history of behaviors
including trying to take a security officer's gun and attempting to choke another resident, this
resident did not have an alternative accepting facility. Alex’s remarks reiterated the remarks of
the other participants that there are some patients that need medical interventions to enhance the
safety of staff and other residents.
Conclusion
Senior living owes their patients and their quality programs a renewed focus on reduction
of antipsychotics in patients with dementia. These findings suggest that nurses, administrators,
social workers, and life enrichment staff are aware of the importance of treating resident
behaviors with non-pharmacological interventions, and they are aware of the best practices to do
so. The findings offer that well-communicated performance goals, linked with additional training
may provide leverage for organizations to meet their quality goals. However, even with the most
well-crafted interventions, it appears that there are some residents for whom non-

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pharmacological interventions are not enough. The chapter that follows highlights the discussion
of the findings and provides evidence-based recommendations for improvement and best
practices to reduce antipsychotics in senior living.

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Chapter Five: Discussion and Recommendations
Chapter five outlines the discussion and practical recommendations that emerged from
this research. This study examined the knowledge and motivation of senior living staff with
regard to organizational performance goals to reduce dementia-related behaviors and
antipsychotic medication administration, and the organizational influences that affect
performance toward the goal. This chapter begins with an alignment of the literature with the
findings and then outlines recommendations to enhance senior living organizations’ performance
reducing antipsychotic medications.
Discussion of Findings
This section compares the research findings to existing research. Following discussion of
findings, recommendations for practice are offered. This section ends with a final conclusion.
Regulation Provides a Foundation for Reduction of Antipsychotics, but Senior Living
Organizations can do More to Improve Performance
The findings of the study indicated that regulation offers a foundation from which to
begin antipsychotic reduction initiatives, as evidenced by their basic compliance with reduction,
but senior living organizations can improve their engagement of their teams to enhance
performance. The findings suggested that regulation is an effective means of encouraging senior
living to engage in the reduction of antipsychotics. Despite lack of clear communication from
leadership about organizational goals to reduce antipsychotics, all of the participants could
articulate a strategy or process from their organization that aligned with reduction of
antipsychotics. Research highlights that regulation alone does not solve the problem of
overprescribing antipsychotics. Even after the introduction of legislation significantly limiting

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the use of antipsychotics in nursing homes, seventy-five percent of nursing home residents who
were prescribed antipsychotics were for off-label uses, such as addressing behaviors in residents
with dementia (Lester et al., 2011). The findings and literature suggest that although responding
to regulatory changes is a foundation for reducing antipsychotics, senior living leaders need to
engage in robust performance-improvement initiatives to further reduce or eliminate
antipsychotics.
Barriers to Reducing Antipsychotics Include Staff Lack of Understanding About the
Harms of Antipsychotics and Perceived Reduction in Quality of Life
Lack of understanding about the harms antipsychotics pose to older adults and concern
for quality of life for nursing home residents emerged as barriers to successful reduction of
antipsychotics, which aligns with the literature. The findings of this study revealed that senior
living staff lack knowledge about the harms antipsychotics pose to older adults. Only 15%
participants in this study articulated the true harms that antipsychotics pose to older adults. Both
of the participants who discussed the harms had worked in senior services for over 30 years, and
they explained the negative effects of antipsychotics being administered to older adults from
their early experience working in nursing homes, including witnessing the use of medications as
chemical restraints. Research suggests the mortality rates increase for nursing home residents
taking an antipsychotic, and that risk increases as the dosage increases (Maust et al., 2015).
Other adverse effects include cardiac arrest, constipation, hip fracture, extra pyramidal disorder,
somnolence, falls with injuries, abnormal gait, edema, urinary tract infection, stroke, and apathy
(Farlow & Shamliyan, 2017). Senior living organizations could benefit from educating their
teams on the potential harms to older adults who are prescribed antipsychotics to assist staff with
understanding the urgency of antipsychotic reduction initiatives.

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Fear of reduced quality of life for older adults with behaviors who were prevented from
taking antipsychotics emerged as a finding in this research. This aligns with previous research
which found fear of reduced quality of life as a barrier for reduction of antipsychotics in nursing
homes (Azermai et al., 2014). Although all of the participants acknowledged the positive-intent
of regulations limiting the use of antipsychotics in senior living, several expressed concerns
regarding residents with aggressive behaviors that pose threats to other residents and staff. Fifty-
three percent of participants in this study expressed concern over resident-to-resident aggression
or sexually-inappropriate behaviors that result in the facility being cited with abuse. One
hundred percent of participants mentioned “quality of life” at some point in their interviews, and
several specifically named enhanced quality of life as a reason to prescribe antipsychotic
medications. The alignment of these findings and previous research suggest that senior living
organizations can communicate goals of antipsychotics initiatives, train staff about harms of
antipsychotics and how to address behaviors without medications, and incentivize the staff to
meet organizational performance goals.
Recommendations for Practice
Emerging from the findings of the study are a set of practice recommendations, outlined
in the section that follows. The findings of this study globally highlight that senior living’s
approach to reducing antipsychotics is reactionary to regulatory requirements. Although facilities
may have integrated antipsychotics reduction into their Quality Improvement Initiatives, staff
lack awareness about the specific organizational goals that pertain to antipsychotic reduction.
Furthermore, staff lack knowledge about the dangers that antipsychotics pose to older adults, and
appear to engage in reducing or eliminating the use of antipsychotics in senior living as a
regulatory response, rather than seeing an opportunity to enhance the lives of the older adults

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they serve. The findings underscore that by responding to the regulation, they are operating out
of compliance, rather than seeing the human impact of overprescribing antipsychotics. The
participants described staff training in their organizations that aligns with regulatory
responsiveness rather than discussing the impact on older adults. Finally, this research highlights
there are no incentives for staff to engage in antipsychotic reduction initiatives. Thus, the
findings suggest communication about reduction initiatives, enhanced training, and incentives to
achieve performance goals are practical recommendations to assist senior living organizations
with meeting their antipsychotic reduction goals.
Recommendation 1: Senior Living Should Have a Strategy for Communicating
Antipsychotic Reduction Initiatives
Few participants reported their organizations communicated with the staff about the
organizational goals to reduce antipsychotics. Specifically, 76% of participants were unable to
identify organizational goals surrounding antipsychotics were shared with the senior living staff.
Three participants reported communication about antipsychotic goals, but described it was
embedded in QAPI and was not communicated with direct-care staff such as nurses or certified
nursing assistants. Clark and Estes (2008) highlight Dixon’s (1994) research on successful
change and improvement plans. Dixon (1994) advises clear and candid communication about
performance goals as a necessary component to organizational change. Communication
establishes trust between leaders and their teams, as well as provides opportunities to evaluate
progress toward performance goals and adjust the course of action. Additional research
highlights the importance of communication during organizational change. Schneider et al.
(1996) suggested that leaders should invest in human interaction and capitalize on cooperation

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and shared learning as a strategy to enhance organizational change efforts. Thus, regularly
scheduled interactive, bi-directional meetings between leaders and stakeholders may enhance the
likelihood of senior living organizations achieving their performance goal. This suggests that
senior living leadership should host monthly meetings with stakeholders to ensure clear, candid
communication regarding the organizational goal and current performance.
Recommendation 2: Senior Living Should Include or Enhance Training Regarding How to
Address Resident Behaviors and Supplement Training with Job Aides
The research from this study highlighted that senior living staff do not receive training
that is aligned with the organizational performance goal to reduce antipsychotics. Of 13
participants, only 1 reported receiving thorough, interactive training about resident behaviors and
reduction of antipsychotics upon hire at their current position. The remaining participants either
reported they did not receive training, had only computer-based compliance modules, or noted
training from previous employers or their collegiate education. Thus, training staff regarding
antipsychotic reduction goals, strategies to reduce antipsychotics, and treating resident behaviors
without medications should improve organizational performance toward that. What is surprising
is that the participants did demonstrate knowledge related to reducing antipsychotics, even if
they reported not having been thoroughly trained by their current employer. This is likely due to
self-selection bias. Specifically, it is likely that senior living staff who were knowledgeable about
nonpharmacological interventions and reducing antipsychotics were more likely to be willing to
be interviewed and participate in this study.
Information Processing Theory, which focuses on the objective process of learning and
organizing information, can be employed to address the training gaps (Rueda, 2011). Rueda
(2011) highlighted that when the trainer applies learning strategies such as rehearsal, chunking,

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and elaboration, the learner can recall and apply the information. Schraw and McCrudden (2006)
posited that in order to demonstrate proficiency, learners must acquire foundational knowledge
and skills, rehearse them, and know when and how to apply them. In addition to providing the
information to stakeholders, trainers should provide an opportunity to practice applying that
knowledge in various situations during the training, such as with a game, quiz, or group activity.
One of this study’s intentions was to explore senior living procedural knowledge to
address resident behaviors in non-pharmacological ways. The findings indicated participants
relied on experience and “trial and error” to address resident behaviors, which suggests that
interactive training with novel situations may be beneficial to their practice. Sociocultural
Theory, which focuses on the social nature of learning, provides a framework for the interactive
training component for senior living organizations (Rueda, 2011). Through application of
Sociocultural Theory, learners construct their knowledge through interacting with others and
working with more highly skilled role models (Scott & Palincsar, 2006). This assumes that
learners will benefit from a training series (as opposed to a singular training) regarding non-
pharmacological interventions that are socially interactive and offer opportunities to learn from
more skilled mentors. For example, if senior living offered a three-part series of training, each
session could include structured, but interactive, scenarios that build upon the knowledge
constructed in the previous training, while taking advantage of experienced trainers modeling
solutions for training participants.
In addition to training existing staff, senior living should find ways to better train and
engage agency staff. Participants described the challenge of staff burn out, agency staff, and
generally staffing challenges as they related to reducing antipsychotics. Although the findings
from participants suggested that the staffing numbers declined throughout the pandemic, so did

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the number of people residing in senior living throughout the pandemic; thus, the numbers of
staff were reduced, but the minutes of care per day did not decrease significantly (Werner & Coe,
2021). In many cases the staffing ratio increased slightly. The authors speculate the staff may
continue to feel overburdened and there may be a perception of less staff due to the increased
needs of residents throughout the pandemic, which are difficult to quantify. Regardless of the
actual staffing ratios, the findings allude to staff burnout and, in some cases, reliance on agency
staff to provide resident care. While a challenge, it is recommended that senior living
organizations critically examine how agency staff are trained and oriented to their organizations
to ensure the organization is achieving their performance goals.
Following the mastery of the information from the training sessions, Clark and Estes
(2008) highlighted the importance of job aides. Job aides are an effective and affordable strategy
to retain knowledge and implement what has been learned. To supplement the training sessions,
Clark and Estes (2008) suggested that job aids in the form of concrete reference guides for the
learners to utilize post-training will enhance retention and application of knowledge for the
stakeholders. Appropriate job aides in this situation may include a staff guide for preventing
behaviors or a list of suggested-interventions to try when behaviors occur. Clark and Estes
(2008) pointed to the versatility and effectiveness of combining training and job aids as a
solution to enhance procedural knowledge. Training creates an opportunity to provide more than
information; it offers an opportunity to practice newly learned skills and engage in constructive
criticism, and ultimately judgment and understanding. Evidence supports this as an effective
strategy for teaching staff about non-pharmacological interventions. Research highlights when
nursing home staff were offered an interactive training program to manage difficult behaviors,
the result was reduced days of antipsychotic use for the residents (Ray et al., 1993); this suggests

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that the interactive training solution is likely help senior living organization meet their goals to
reduce antipsychotics.
Recommendation 3: Senior Living Should Adopt the Work Process of Interdisciplinary
Team Review of Resident Behaviors
This research underscored the need for access to psychological providers in senior living
organizations to assist with the development of behavioral interventions. The findings suggested
that only three participants reported their organizations had consistent access to psychological or
psychiatric providers due to lack of providers available or willing to see patients or clients in
senior living organizations. What emerged in the discussion of provider access was that the
senior living organization’s interdisciplinary team meeting is an important work process to
address resident behaviors. According to Clark and Estes (2008), a work process outlines how
“people, equipment, and materials must link and interact over time” (p. 104) to achieve success.
Two participants noted that the interdisciplinary team was essential in reviewing all resident
condition concerns that could affect the residents’ well-being and the organizational quality.
Their work processes reflected a weekly meeting to review all resident falls, behaviors,
infections, weight loss, transfers to the hospital, and resident and family complaints. The
interdisciplinary teams included nurses, care plan nurses, social workers, life enrichment staff,
and the dietitian. Their weekly meeting was to review the cases, identify potential interventions,
and monitor progress over time. The participants who reflected upon the importance of the
interdisciplinary team work process indicated it was an opportunity to ensure the interventions
were not only offered, but effective over time and documented in the plan of care.

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Research supports the interdisciplinary team as a work process in nursing homes to
enhance patient outcomes. Nazir et al.’s (2013) systematic review of interdisciplinary team
interventions suggested patient outcomes improved with an interdisciplinary approach. Due to
provider shortages regionally and nationally, it is expected that nursing homes will continue to
name lack of access to providers as a barrier to treating resident behaviors. However, the
interdisciplinary team work process can address some resident behavior that would otherwise be
referred to a provider by problem solving resident behaviors with a multidisciplinary team
perspective.
Limitations and Delimitations
This study acknowledges several limitations and delimitations. Limitations include
design elements that could not be controlled by the researcher. This research included a small
sample size which presents generalizability of this study. Additionally, this research relies on
self-report data, which is subjective. Beyond subjectivity, the participants could offer responses
that they expect are correct or appropriate to appease me based on my position as a researcher.
There is evidence of self-selection bias in this study. This research acknowledges there may be
an unknown difference between the perspectives of the study’ participants and those individuals
who were recruited, but unwilling to participate, or those not reached by the recruitment
attempts. The participants were experienced in their roles, and this likely influenced their
willingness to participate in an interview, as well as their responses. Similarly, the COVID-19
pandemic continues to impact senior living organizations through regulatory requirements and
staffing challenges, which may have impacted participation or responses. Attempts to find a
single-site for this study were made, but the organizations contacted were not willing to

83
participate. Therefore, this study examined antipsychotic reduction in licensed senior living
communities including skilled nursing, assisted living, and memory care. Because this was an
exploratory study, the goal was not to examine one type of licensure, but to gain an
understanding of how senior living was engaging in antipsychotic reduction goals.
Delimitations in this study reflect decisions made related to the theoretical and
methodological design that could influence the findings. Participants were limited to nurses or
members of the interdisciplinary team including social services workers, life enrichment staff,
administrators, nurse leaders, and pharmacists. Direct caregivers and certified nursing assistants
were not included in the participant group, but may have a valuable perspective in the
exploration of how senior living is addressing the reduction of antipsychotics. The theoretical
framework of examining Clark and Estes (2008) knowledge, motivational, and organizational
influences impacting the performance goal also narrowed the scope of what was studied in this
research. Thus, only those aspects of the performance goal that align with the theoretical
framework were studied. The study design of recorded, video-conference interviews was helpful
to gain insight into organizational practices, but a method that caused some potential participants
not to engage in this research. Finally, this research did not examine all aspects of antipsychotic
reduction initiative, just a subsect of the knowledge, motivation, and organizational influences
impacting organizational performance goals. Because this was a novel way to study reduction in
antipsychotics in senior living, the findings hold value and offer a foundation for future research.

84
Recommendations for Future Research
Additional research subsequent to this study will aid in further exploring performance
gaps and providing a foundation from which to offer recommendations to senior living to reduce
antipsychotics. Future research can build upon this study by studying a larger sample size,
examining participants by their roles, and employing a quantitative methodology. The findings
from this study provide a foundation from which to develop quantitative instruments to measure
knowledge, motivation, and organizational influences in senior living. Research that employs the
use of focus groups of interdisciplinary team members at different organizations would give a
robust look at how individual teams are performing. Additionally, the Clark and Estes
framework could be applied to additional quality measures, such as skin injuries, falls,
infections, and weight loss. A large quantitative study would enhance the generalizability of
results, however, additional qualitative research which examines the same organization from
several perspectives would further explain how senior living organizations are executing
initiatives to reduce antipsychotics.
Implications for Equity
This research offers implications for equity by positively impacting the care provided to
older adults and enhancing their quality of life. This research may also enhance the lives of older
adults of color, in particular. Previous research suggests that nursing home residents of color are
more likely to live in facilities with more deficiencies in care than Caucasian older adults (Smith,
et al., 2008). Finally, this research has a positive impact on fostering equity for the care of older
adults with cognitive impairment who are less able to advocate for themselves.

85
Conclusion
This research examined the knowledge, motivation, and organizational influences which
affect senior living organizations’ performance toward the goal of reducing or eliminating
antipsychotics. This research explored the clinical issue of addressing resident behaviors and
reducing or eliminating antipsychotics as an organizational issue. Knowledge findings highlight
that while the participants demonstrated global knowledge about antipsychotics, they lacked
specific knowledge about organizational performance goals and regulations surrounding
antipsychotics. The motivational findings underscore that participants are confident in their
ability to address resident behaviors without the use of medication, however, they differ in their
perceived value of working toward the goal of reducing antipsychotics. Organizational findings
reveal that organizations have procedures to address resident behaviors with non-
pharmacological interventions, but do not incentivize staff to use them. Finally, the research
revealed the positive influence of the interdisciplinary team in executing the performance goal.
This research brings to light how organizational influences have a human impact on
senior living residents. Although this research was framed about organizational performance
goals, at the root of every goal to reduce antipsychotics is the potential for an improved quality
of life for senior living residents within that organization. The failure to engage in initiatives to
reduce antipsychotics could result in reduced quality of life at a minimum, but could even lead to
death. Senior living organizations in this research are licensed and bound to regulations; they are
operated by individuals with federal and state licenses to ensure they are operating the facility
aligned with state and federal regulations. However, being bound by regulations appears to
address overuse of antipsychotics on a superficial level. In order to be successful at addressing

86
resident behaviors and reducing antipsychotics, senior living organizations must engage with
their staff with intentionality. Leaders must communicate directly and often about the goal to
reduce antipsychotics. Senior living leaders must train their staff thoroughly to understand the
true harms of antipsychotics, and how to handle novel resident situations. Finally, they must
offer incentives for the team to engage in the antipsychotic initiatives. In short, following
regulation does not circumvent the need for leadership, communication, and commitment in the
pursuit of reducing antipsychotics in senior living to improve quality of life for senior living
residents.

87
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Appendix A: Interview Protocol

The interview questions were asked in a semi-structured approach. In addition to the
probe questions listed, additional probe questions to clarify or illuminate points were asked of
the participants.
Demographics questions
1. How many years have you worked in healthcare?
1. How many years have you worked in a nursing home?
2. How many years have you worked for your employer?
2. Tell me about your training or educational background.
3. I would like to know a little about your employer size and location. How many residents
live there?
4. Do you know how many staff work for your employer?
5. Is your organization for profit or not-for-profit?

Knowledge Influence Questions

6. Are you aware of any goals at your nursing home to reduce resident antipsychotic drug
use?
7. The Federal Government has limited the circumstances in which nursing homes can
administer antipsychotics to older adults. How do you feel about that limitation, and why
do you think it exists?
8. Could you describe a time you or someone on your team needed antipsychotics to help
resolve resident behaviors?
9. Could you tell me about a time when you or someone on your team was able to de-
escalate a resident's behaviors without the use of medication?

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10. What are some difficult-to-treat resident behaviors that you have experienced?
11. When a resident is having behaviors, what is your procedure to address that behavior?
Are you aware of other methods to treat behaviors? If so, what are they? What barriers
do you see to alternative methods being effective?

Motivation Influence Questions

12. What has been your experience treating patients with dementia?
13. How confident do you feel that you can treat resident behaviors without the use of
medications?
14. What benefits have you witnessed by the use of medications for residents with
behaviors?
15. What benefits have you witnessed from the use of non-pharmacological interventions to
resident behaviors?
16. When it comes to treating resident behaviors, what do you think incentives some people
to offer medications to address behaviors?

Organizational Influence Questions

17. What, if any, training have you received about antipsychotics in older adults?
18. What, if any training, have you received on treating resident behaviors without
medications?
a. How frequent were those training sessions?
b. What was the training like?
c. How is it delivered?
d. How long did it last?

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19. In what ways does your supervisor demonstrate their commitment, if at all, to reducing
the number of antipsychotics administered to residents?
20. What makes you think that? How is the commitment (or lack thereof) demonstrated?
21. Are there other ways that your employer has communicated a commitment (or lack
thereof) to reduction of antipsychotics?
22. Imagine as of tomorrow, you wouldn’t be able to give antipsychotics to any residents
with dementia. How would that change the work you do?
23. If antipsychotics were eliminated as an option to treat behaviors in residents with
dementia, would your organization have as tools to address behaviors of residents with
dementia?
24. Does your employer offer any rewards for meeting performance or quality goals?
25. Does your employer offer incentives to reduce the number of antipsychotics administered
to residents?

Abstract (if available)

Abstract Older adults residing in senior living are prescribed antipsychotics for dementia-related behaviors at a disproportionate rate compared to community-dwelling older adults. Individuals taking antipsychotics are at an increased risk of negative side effects including falls with injuries, arrest, constipation, fracture, extrapyramidal disorder, somnolence, gait disturbances, apathy, and death. As a result, the National Partnership to Improve Dementia Care in Nursing Homes was established in 2012 to support and encourage senior living to address resident behaviors without the use of antipsychotics. Despite regulatory focus and the development of The National Partnership, rates of antipsychotics have remained steady for several years. Since 2018, 13%-15% of nursing home residents have been prescribed an antipsychotic. This dissertation applies the Clark and Estes (2008) gap analytic framework with an emphasis on knowledge, motivation, and organizational influences to explore the clinical phenomenon of administering antipsychotics to residents with dementia. Thirteen senior living staff members from 11 facilities were interviewed including nurses, social services workers, life enrichment staff, nursing home administrators, and directors of nursing to explore their knowledge, motivation, and organizational influences related to reducing antipsychotics in their facilities. The findings revealed opportunities for training senior living staff to address behaviors without medications, the need for better communication of quality goals from leadership to senior living staff, and the importance of incentives in reducing antipsychotics. Practical implications for this research to improve senior living organizational outcomes are provided.

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University of Southern California Dissertations and Theses

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Asset Metadata

Creator Hollestelle, Colleen Evelyn (author)

Core Title Knowledge, motivation, and organizational influences impacting senior living performance goals to reduce antipsychotics: an innovation study

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2023-08

Publication Date 08/01/2023

Defense Date 07/10/2023

Publisher University of Southern California. Libraries (digital)

Tag antipsychotics,dementia,Nursing Home,OAI-PMH Harvest,quality

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Seli, Helena (committee chair), Krop, Cathy (committee member), Phillips, Jennifer (committee member)

Creator Email holleste@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113291850

Unique identifier UC113291850

Identifier etd-Hollestell-12178.pdf (filename)

Legacy Identifier etd-Hollestell-12178

Document Type Dissertation

Rights Hollestelle, Colleen Evelyn

Internet Media Type application/pdf

Type texts

Source 20230802-usctheses-batch-1077 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA

Repository Email cisadmin@lib.usc.edu