Table 3.

Barriers and enablers to BZRA deprescribing for NH HCPs according to relevant TDF domains.

Relevant TDF domains	Belief statements	Barrier (B) or Enabler (E)?		Quotes
		GPs	Other HCPs	GPs	Other HCPs
TDF domains relevant for both GPs and other HCPs
Skills	Lack of practical training on how to deprescribe BZRAs	B	B	“We are told that they [BZRAs] are bad, that we must avoid them, but I have never attended a workshop on BZRA deprescribing. That would be interesting.” 1106 “But I think that what we need above all is to be guided by plans or detailed protocols that explain properly how to do it.” 1104	“[Have you been trained in BZRA deprescribing?] Me? Certainly not, 40 years ago. Those were things we didn't talk about. - We were trained in… techniques but none that related to deprescribing benzos.” 1412 and 1451 (nurse and occupational therapist)
	Lack of training on non-pharmacological alternatives		B		“Perhaps if we were better informed [about non-pharmacological alternatives] ourselves, we could say ‘Hey Doctor, I heard that…’.” 1411 (nurse)
	Good communication skills (with other health care providers and with NHRs)	E	E	“You have to discuss things with the patient, you have to make arguments in favour.” 1106	“Communication in general is the only thing that helps a lot.” 1312 (nurse)
Beliefs about capabilities	Low self-efficacy	B	B	“I am not very confident. I am not very confident because I know that it's a lot of work.” 1202	“It's true that I don't feel very comfortable either, I should argue“1141 (physical therapist)
	Difficulties to convince other stakeholders (including the resident)	B		“The most difficult part is starting the deprescription and the withdrawal, because sometimes you are faced with a patient who just refuses, who is categorical and says, ‘No, I've been taking this [BZRA] for 20 years, you cannot take it away from me, … I categorically refuse to have it taken away or reduced’. And that's what sometimes causes the most difficulty.” 1104	“You will never be able to persuade those people that they need to give it up [the BZRA]. As long as they are convinced that it is doing them some good, we will never be able to deprescribe it. It's not possible.” 1211 (nurse)
Goals	BZRA deprescribing should be a long-term goal	E	E	“It is clear that it is very important to reduce these medicines so that they can get the best possible results and really take proper care of themselves there.” 1104	“What I think would be helpful is if you really saw sleep medication and anxiety medication as something temporary, just when a resident needs it.” 1531 (pharmacist)
	Competing goals (including NHR well-being, acute conditions, keeping a smooth NH environment).	B	B	“If there is something else, more serious, well, it [BZRA deprescribing] will come later.” 1104 “It is important, but not important enough to completely destabilise the existing overall [NHR] balance.” 1205	“Because we need them to sleep. When you have 138 [NHRs] who aren't sleeping … the button, as I call it [the call bell], goes constantly when they aren't sleeping.” 1412 (night shift nurse) “As long as it has a positive effect on the person, I am for continuing it.” 1211 (nurse)
Memory, Attention and Decision process	BZRA refilling is part of an automatism of GPs	B	B	“No, on a normal visit, I ask him [the resident] how he is, I measure his blood pressure, and I renew his BZRA prescription.” 1202	“We don't even think about it [deprescribing].” 1211 (nurse)
	BZRA are seen as an easy solution	B		“Unfortunately, I think that doctors sometimes prescribe a BZRA out of convenience, because it is easy to say “Having a panic attack? Take a Temesta®, take one every day to be sure not to have one.” 1104
	Triggers for BZRA deprescribing: Other stakeholders' suggestions, balance issues, over sedation, confusion…	E	E	“Systematically, if they tell me that they are confused, that they have experienced falls, well, the side effects of medication come to mind, starting with BZRAs. It's automatic.” 1105	“For example, we have residents who take that and we see that they are always very quiet, so we try to stop or reduce it.” 1515 (nurse)
Environmental context and resources	Collective living, with strict time schedule, noise and disturbances	B	B	“The problem is that we are in a place that is not their normal environment. There are more people passing by, nurses, noises. They might also be less comfortable sleeping there than at home.” 1105	“In shared accommodation, of course, it is complicated. There is a lot of noise, even at night, there are patients walking around, people shouting, bells sounding frequently. … It is difficult for residents to get quality sleep.” 1121 (head nurse)
	Lack of time and NH staff	B	B	“We don't have the time, and you need to sit with them, and explain things and review their treatments.” 1202 “I think there is a severe shortage of staff and patients suffer because of that shortage.” 1105	“For us, at night, it is even worse. Three [care staff] for 138 [NHRs].” 1412 (night shift nurse)
	Difficulties to implement non-pharmacological alternative (limited access, low practicability for NHRs or interest from them)	B	B	“For minor anxiety, I don't push too hard for a psychologist, because I know that, unfortunately, it is really difficult to access that kind of care.” 1104	“We don't have the time [for non-pharmacological approaches]. It's not possible, it's not feasible.” 1411–1421 (nurses) “It's also generational. I think that if I spoke to today's residents about Snoezelen, essential oils, lights… I think they would be more reassured by a drug than by our new techniques.” 1252 (occupational therapist)
	High number of visiting GPs	B		“Creating a NH policy is very difficult, for benzodiazepines, for the use of antibiotics, for anything. It is difficult to reach a consensus or unanimity or even to get a large majority of doctors to follow it.” 1203
	Multidisciplinary work	E	E	“Team decisions. Having the collaboration and support of the care staff. Because they are truly on the front line and they are the ones who can tell us how the residents feel.” 1203	“We always consult with colleagues. Yes, colleagues first. Because it's multidisciplinary, the care staff, the cleaners – yes, they will be there too – and we go on from there. To the team head, then meetings, and then we go to the doctor.” 1513 (nurse)
	Need for an alternative/substitute	B		“At that point, we try to find alternatives, because patients do not want to go from taking something to taking nothing.” 1105
	Use of non-pharmacological alternatives, including phytotherapy, daytime activities	E	E	“I think that any activity during the day will make them [NHRs] think about something else, so it is beneficial.” 1202	“Going on trips, going out, they expend energy so they get a good sleep. If, however, you don't change anything in their lives and you take away the sleeping pills, then…” 1112 (nurse)
	Patient characteristic/ context: Long-term BZRA use (years)		B		“Sometimes they arrive with them, they have used the medication for years and, when they arrive here, we continue it.” 1211 (nurse)
	Use of a brochure to raise NHRs' awareness		E		“We have a brochure, an information brochure and we go around the residents. So we explain the disadvantages and consequences of using psychotropic drugs. And yes, some people have taken it on board because we have good results here with stopping sleep medication.” 1513 (nurse)
	Automated medication delivery system reduces the opportunity to review medications		B		“When we prepare the drugs, well, we look at the drugs that we need to prepare. The others are in the automated dispensing system. We don't look at them as closely as when we prepare them.” 1421 (head nurse)
Social influence	Perceived NHRs' reluctance to deprescribe BZRA/ NHRs' pressure to have BZRA	B	B	“We often hit a wall with patients: ‘No, not that one’. We can stop anything we want, we can stop their anti-arrythmia medicine, we can stop their anti-cholesterol medicine, but not their Zolpidem or their Alprazolam.” 1202	“People who are lucid sometimes cling to their medication. What time is my Temesta®? What time is my Zolpidem®? What time will it come at?” 1211 (nurse)
	Other HCPs' pressure on GPs to prescribe BZRA	B		“There is sometimes intense pressure from the care staff to calm these patients.” 1105
	HCPs triggering GPs to deprescribe	E		“When the care staff speak up and say, ‘everything is going very well, do they really need this medicine?’, it makes the doctor's job easier to be aware of that.” 1101
	Residents relatives' influence	B/E	B/E	“There are people who will say to you, ‘don't you think that Dad or Mum is taking a bit too many kinds of medication?’ 1205	“Ask the doctor to come by, my mother is not sleeping, perhaps he can prescribe something to help her sleep.” 1211 (nurse reporting on a conversation with a relative)
TDF domains relevant for HCPs other than GPs only
Knowledge	Lack of familiarity with BZRA, BZRA side-effects and BZRA deprescribing		B		“There are lots of drugs [names] there that I know …, and I am shocked to discover that they are in fact benzos. So, that just goes to show that it's really not my field at all.” 1141 (physiotherapist)
	Non-pharmacological alternatives unknown or not well known		B		“You see, there may be things we could do to help some people that we don't know about.” 1451 (occupational therapist)
	Lack of familiarity with deprescribing guidelines and tools	B		“We perhaps lack information on how to do it. How to do it so that it works properly. We know that we need to deprescribe them [BZRAs], but how, that's where it gets complicated.” 1103
Social/professional role and identity	Difficulties for GPs to accept remarks and advices from colleagues	B	B	“Doctors are very touchy. Doctors, I'm generalising of course, are quite sensitive and not very open to criticism regarding their practice. Myself included.” 1101	“They [GPs] should start listening to us, to everything we have to say, and agree to review their diagnoses. But for every ten doctors, there may be one who will do that.” 1131 (pharmacist)
	Feeling of depending on GPs' decision		B		“We are dependent on the doctor's prescription.” 1121 (head nurse)
	Perceived role of nurses or other HCPs (e.g. physical therapist) to report NHRs' behavior/status to the GP or nurses		E		“We observe and report back to the doctor. We will say he is quieter now… but, on the other hand, there are issues because he is sleeping a lot.” 1411 (nurse)
Beliefs about consequences	Increased workload at the NH level	B	B	“I think that could be difficult for the nursing home to manage, er… If there were withdrawal symptoms, recurring anxiety, or recurring insomnia… I think all that would be complicated.” 1103	“Caring for someone who hasn't had a good night's sleep, you can take a beating! Anxiety sets in, agitation sets in. It's harder to treat the person during the day too. - It's not easy.” 1211 and 1212 nurses
	Easier management of NHRs on the long-term	E	E	“If a patient has fewer falls, less care is required for that patient. If the patient is less confused, it may be easier for the nurses to care for them. Yes, it's positive.” 1105	“It is not in our interest to give people that kind of medicine: anything that calms them down, anything that inhibits them. […] Because anything like that will also complicate our care.” 1411 (nurse)
	Potential negative outcomes for NHRS (Withdrawal symptoms, insomnia, anxiety, anger, …)	B	B	“Well, we will have angry and grumpy people and there will still be insomniacs and anxious people too…” 1202	“You are obliged to give it to the person so that they can rest. Otherwise, they are tired during the day and at risk of falls and so on.” 1212 (nurse)
	Potential positive outcomes for NHRs (reduction of falls, cognitive and mobility improvement, …)	E	E	“The recovery of certain cognitive functions and a reduction in falls in particular.” 1102	“If we have someone who falls frequently, it would be a good idea to reduce them [BZRAs].” 1321 (head nurse)
Other TDF domains (beyond most relevant domains)
Optimism	Varying views	B/E	B/E	“Long-term, it [BZRA deprescribing] certainly appears to be beneficial.” 1101 “I don't believe that BZRAs destroy patients.” 1205	“No, it [BZRA deprescribing] would be a disaster.” 1211 (nurse) “That [BZRA deprescribing] would be nice. It would be great.” 1131 (pharmacist)
Reinforcement	Bad perception of policies and incentives	B		“Doctors are a bit… Well, they don't like constraints, sometimes they can react badly.” 1106
	Influence of past experiences	B/E		“When you get a little bit of positive feedback, you tell yourself that things can go well and it encourages you to try to repeat the experience.” 1101 “I had a lot of bad experiences, well failures, so maybe I'm a bit more reluctant to try. Because I tell myself that it's a losing battle.” 1103
Intention	Intention to review medication and to prescribe the less possible	E		“The intention is always there, but I try with the patients.” 1105
Emotion	Satisfaction	E		“It's always gratifying to say that we did things well.” 1102
Behavioral regulation	Visual reminder	E		“I think that even just one poster in the medical office would help a lot. Even just a good visual reminder.” 1104

Legend: B = Barrier, BZRA = Benzodiazepine receptor agonists, E = Enabler, GP = General practitioner, HCP = Health care provider, NH = nursing home TDF = Theoretical domains framework.