Implementing antipsychotic reduction in long-term care: interdisciplinary and lived-experience insights into system-level barriers and facilitators

Abstract

Background and Objectives

Despite the availability of evidence-based antipsychotic reduction strategies, implementation of these strategies in long-term care (LTC) often stalls. Understanding how change occurs in real-world practice requires perspectives from interdisciplinary team members. This study interviewed interdisciplinary team members, a family caregiver, and a person living with dementia in LTC in Vancouver, Canada, to explore how they operationalize antipsychotic reduction in LTC homes and examine their perceived barriers and facilitators to implementation.

Research Design and Methods

Semi-structured interviews were conducted with 20 participants: 18 interdisciplinary healthcare providers, one dementia advocate, and one family caregiver. Data were analyzed using reflexive thematic analysis. To preserve inductive insights, the Consolidated Framework for Implementation Research (CFIR) was applied post hoc to the emergent themes. We examined the extent to which the findings were aligned with the CFIR, thereby deepening the analysis.

Results

Identified strategies included person-centered care planning, non-pharmacological interventions, medication review with behavior monitoring, and education. Barriers were: (1) challenging work environments, (2) safety concerns and unconscious dismissive attitudes, and (3) communication gaps. Facilitators included: (1) supportive leadership and frontline champions, (2) team communication, and (3) persistence. Each factor aligns with different CFIR constructs and domains to varying degrees.

Discussion and Implications

The main contribution of this study is that, drawing on CFIR, it found barriers to antipsychotic reduction in LTC are not merely individual but also systemic. Sustained improvement depends on policies that enable and resource effective interdisciplinary teamwork. This includes adequate staffing, education, team communication, and culture change.

Inappropriate use of antipsychotics is a persistent concern in long-term care (LTC) homes, which provide 24-hr support for individuals with complex physical and cognitive needs. Such use refers to prescribing antipsychotics to residents without a psychosis diagnosis, often as a means of managing behavioral and psychological symptoms of dementia (Tampi et al., 2016). Such use is associated with serious adverse outcomes, including increased risk of death, fall risk (Coe et al., 2025), and a decline in cognition (Sun, 2021). Although antipsychotics may provide short-term relief of behavioral symptoms, recent evidence indicates that these symptoms often worsen over the long term (Leme et al., 2024).

Inappropriate antipsychotic use in LTC is a global concern. Although there is no universally accepted benchmark on antipsychotic use in LTC, in Canada, the Canada Drug Agency (2025) suggests keeping the inappropriate use of antipsychotics below 15% with the resident population. Yet, 2023–2024 data by the Canadian Institute for Health Information (2024) show a national average of inappropriate use of antipsychotics in LTC of 24.5%. In the United States, approximately 40% of residents with dementia in LTC were prescribed antipsychotics, most without a diagnosis of psychosis (Committee on Ways and Means Majority, U.S. House of Representatives, 2020). Beyond North America, across eight European countries, antipsychotic prescribing among newly admitted residents ranged widely, from approximately 12% to more than 50% (de Mauleon et al., 2014), underscoring the global variability and persistent challenge of inappropriate use.

The literature identifies a range of strategies to reduce antipsychotic use in LTC and evaluates their effectiveness. These include person-centered care planning (Ballard et al., 2018) and non-pharmacological interventions (Richter et al., 2019), as well as modifications to the physical environment, such as creating calmer, less stimulating surroundings (Kirkham et al., 2020; Muñiz et al., 2020). Staff training that emphasizes antipsychotic reduction and a person-centered care approach is also commonly reported (Shaw et al., 2018). Medication reviews have been highlighted as another key strategy (Vanker et al., 2025). Regulatory measures, such as external audits and public reporting of prescribing rates, which allow LTC homes to compare performance and enhance accountability, have also been implemented (Bowblis et al., 2015). Although effectiveness varies across studies, most strategies are generally found to be effective, with regulatory measures showing more mixed results (Gerlach et al., 2022). However, many studies focus primarily on effectiveness, providing limited insight into implementation factors. Consequently, even when evidence-based reduction strategies exist, their integration into everyday practice remains challenging. Understanding how interdisciplinary teams navigate these factors is key to successful implementation.

A body of research has examined barriers and facilitators to implementing strategies to reduce antipsychotic use in LTC. A systematic review by Moth et al. (2021) identifies challenges such as limited staffing and education, staff resistance due to fears of behavioral escalation, and communication gaps between different professional disciplines, as well as facilitators such as supportive leadership and strong team communication. Empirical studies using qualitative, survey, and mixed-method designs report similar factors related to staffing (Jørgensen et al., 2024; Rosenthal et al., 2022), education (Almutairi et al., 2018; Sawan et al., 2017), leadership (Jørgensen et al., 2024), communication (Ellis et al., 2015; Guzmán et al., 2024), as well as staff and family resistance (Crystal et al., 2020; Simmons et al., 2018; Walsh et al., 2018), alongside perceptions that non-pharmacological approaches are ineffective or resource-intensive (Simmons et al., 2018).

Understanding implementation factors in the real-world conditions requires different voices of those closest to care. However, most related studies focus on the perspectives of administrators, nurses, and physicians, with limited attention to other healthcare providers, such as allied health professionals. Attention is even less given to family caregivers and people living with dementia. Their perspectives are often inferred from staff accounts (Rice, 2014). These frontline and lived-experience perspectives reveal relational, cultural, and contextual factors that quantitative measures and administrative data may not capture. This study will therefore address this gap by integrating perspectives from interdisciplinary healthcare providers, a family caregiver, and a person living with dementia. It will explore how antipsychotic reduction is operationalized in LTC homes in Greater Vancouver, Canada, and examine the barriers and facilitators to implementation. To preserve inductive insights, we first conducted reflexive thematic analysis and subsequently applied the Consolidated Framework for Implementation Research (CFIR) to emergent themes to deepen the analysis. The research questions guiding this study are:

1. What strategies are used to reduce inappropriate antipsychotic use?

2. What barriers affect the implementation of these strategies?

3. What facilitators support successful implementation?

Research design and methods

Research team

Our team comprises two researchers and six healthcare providers from diverse disciplines, including pharmacy (one), nursing (four), public health (one), recreational therapy (one), and social work (one), all of whom have practice and research experience in LTC homes. These experiences strengthened the study by grounding the analysis in real-world practice and enhancing the credibility of the findings. The interdisciplinary composition of the team further enriched the quality of analysis by enabling the integration of diverse healthcare perspectives.

Context

In Greater Vancouver, there are 38 LTC homes (Vancouver Coastal Health, 2017). Of these, 23 are operated directly by the health authority, while not-for-profit or private providers operate the remainder. Publicly operated homes typically have greater access to resources compared to their not-for-profit and private counterparts. Given its exploratory nature and limited research resources, this study focuses on the 23 LTC homes operated by the public sector.

Sampling and recruitment

We employed purposive sampling to capture diverse perspectives, a strategy well suited to exploratory research, as it ensures data that is rich, relevant, and varied (Robinson, 2014). This study included 20 participants. They were recruited through the dissemination of posters and word of mouth within the health authority. We continued recruitment until the data adequately addressed the research questions. Eighteen were healthcare providers across different positions and disciplines. The inclusion criterion for these participants was at least 6 months of experience in LTC. For these participants, the collected demographic information included their position, discipline, and work sites. Recognizing the lack of voices from people with lived experience in the existing literature, we intentionally included two such participants. One is a person with early-stage dementia living in the community. Another is a family caregiver. Both have experience in caring for family members with dementia living in LTC and are active advocates for reducing the use of antipsychotics in LTC.

Among 18 healthcare providers, 10 worked in different LTC homes, while the remainder worked across multiple homes concurrently. Representation across positions was balanced, with managers (five), mid-level leaders (seven), and frontline staff (six) each comprising approximately one-quarter to one-third of the sample. Regarding disciplines, eight were from nursing, reflecting the central role of nurses and care aides in LTC. We also ensured the participation of physicians (one) and pharmacists (three), given their critical involvement in prescribing practices and medication management. In addition, allied health professionals, including those in rehabilitation (one), social work (one), and recreation (two), were represented, offering valuable insights into interdisciplinary approaches and non-pharmacological interventions. The remaining two were from healthcare administration, offering policy-level perspectives.

Data collection

We conducted semi-structured interviews with participants, using an interview guide (see Figure 1) to ensure key topics were addressed while allowing space for participants to share their own perspectives (Nathan et al., 2019).

Figure 1.

Interview guide.

The interviews were carried out by K.W., the first author, who is a social worker with practice and research experience in LTC. Each interview was conducted via Zoom, by phone, or in person, depending on participants’ preferences. Interviews lasted an average of approximately 60 min, ranging from 40 to 90 min depending on participants’ availability. Although most interviews were one-on-one, two were conducted in small groups, one with two participants and one with three. The small-group interviews involved participants who already worked together in similar nursing leadership roles. They requested this format to learn from each other’s reflections. The interviewer monitored the discussion, invited quieter members to contribute, and encouraged participants to build on one another’s comments to foster open, balanced discussion. With consent, all interviews were audio recorded, and notes were taken during the sessions. The recordings were subsequently transcribed verbatim.

Data analysis

We conducted reflexive thematic analysis, guided by the framework outlined by Braun et al. (2019). Each transcript was coded independently by at least two team members to enhance rigor. After initial coding, team members independently reviewed the codes and proposed preliminary categories. These categories were then discussed collectively in analytic meetings, where the team compared perspectives, refined category definitions, and organized categories into themes (see Table 1 for an example of the thematic analysis). It is important to note that, although team members coded openly and were grounded in the data, their analysis was influenced by their diverse research and practice experiences and disciplinary backgrounds. For example, nursing team members tended to focus on care practice factors, whereas allied health team members paid greater attention to non-pharmacological interventions. Such differences were managed through discussions to reach a consensus. The themes are presented in the Results section.

Table 1.

An example of thematic analysis.

Examples of quotes	Code	Category	Theme
“Patients come with a lot of chronic diseases … Patients become a lot sicker than before.”	Residents with chronic diseases	Increased residents’ medical complexity	Barrier: challenging work environment
“[Residents have] alcohol-related issues, past drug-related issues, on top of behaviour issues.”	Residents with substance use issues
“A lot of homes have mentioned this sort of post-COVID era. They have had a really hard time retaining staff.”	Post-COVID staff retention challenge	Staff retention challenge
“[LTC pharmacists have] ten minutes to review a resident’s medications, while hospital pharmacists can actually spend a few hours reviewing the chart, talking to the nurse, talking to the family.”	Lack of time for medication review	Lack of capacity to implement antipsychotic reduction strategies
“Gentle or relational conversations can be skipped because [residents] are trying to climb out of bed.”	Lack of time for relationship building
“Our nurses and care aides were like, that’s [non-pharmacological intervention] very nice, and we would love to be able to do that. But we have to make sure ten people have used the bathroom.”	Lack of time for non-pharmacological intervention

Note. COVID = coronavirus disease; LTC = long-term care.

Building on the themes developed, the team applied the CFIR (2023) to deepen the analysis. We intentionally applied CFIR after reflexive thematic analysis, as we wanted the data to speak for itself without being constrained by predetermined constructs. As Collins and Stockton (2018) suggested, introducing frameworks too early in the analytic process can limit the emergence of novel insights. We compared and mapped each theme to relevant CFIR domains and constructs, and discussed the extent to which the themes aligned with the CFIR. We resolved divergent interpretations until consensus was reached. The alignment was evident in the results, in which themes were categorized as barriers or facilitators, thereby yielding more actionable implications. We applied CFIR specifically to barriers and facilitators because they are most directly relevant to implementation practice and policy.

CFIR was applied because it is a widely adopted framework in implementation science that provides guidance for identifying and analyzing contextual factors influencing the implementation of interventions (Damschroder et al., 2022). It is particularly suited to this study’s focus on exploring the facilitators and barriers to implementing antipsychotic reduction strategies. The framework comprises five domains: innovation, inner setting, outer setting, individuals, and implementation process, covering a total of 48 constructs (CFIR, 2023).

The following will illustrate each domain in the context of this study. The “innovation” domain refers to the intervention itself, specifically antipsychotic reduction strategies. The “inner setting” domain refers to the organizational environment in which the intervention is implemented, specifically, LTC homes. Extending beyond the organization, the “outer setting” domain encompasses the broader external context that influences implementation, such as the health authority’s policies. The “individuals” domain focuses on the people involved in delivering and making decisions about the intervention, including interdisciplinary healthcare providers and leaders. Finally, the “implementation process” domain focuses on actions undertaken to implement the intervention, exemplified by team collaboration and communication aimed at reducing antipsychotic use.

Rigor

We followed the guidance of Guba and Lincoln (1994) to ensure the rigor of this qualitative study. To enhance credibility, analytic rigor was strengthened through team practices: each transcript was independently coded by at least two team members. During analytic meetings, different disciplinary perspectives were compared and challenged to refine categories and themes. In addition, participant quotes were included in the presentation of findings. To support transferability, detailed information about the study context and participants was provided, enabling readers to assess the relevance of the findings to their own settings.

Ethics

This study was approved by the University of British Columbia Research Ethics Board. All participants provided informed consent prior to participation, and their confidentiality was maintained throughout the study. The names of participants mentioned in the selected quotes were pseudonyms. The pseudonyms were either selected by participants or randomly assigned if participants had no preference.

Results

This section presents the findings addressing the following three research questions: (1) What strategies are used to reduce inappropriate antipsychotic use? (2) What barriers affect the implementation of these strategies? and (3) What facilitators support successful implementation? Alignment with CFIR analysis was conducted only for research questions 2 and 3, which examined barriers and facilitators to implementation.

Strategies for antipsychotic reduction

Person-centered care planning

The first strategy identified by participants is person-centered care planning. They emphasized the importance of understanding each resident as a whole person, not merely as their medical conditions, a core principle of person-centered care. Nora (nurse) described talking with residents and their families to learn “what interests them and what would make them happy, like preference of coffee or tea.” Similarly, Ella (recreation aide) said, “We want to know what they like to do, their interests, who their family is.” Mabel (administrator) explained that interdisciplinary teams, including nurses, care aides, and allied health professionals, hold move-in huddles for new residents, starting with “sharing the social backgrounds about the resident, and then the medical information.” Andrew, a person with early-stage dementia, dementia advocate, and a former family caregiver, emphasized simple human connection as meaningful care that may prevent behavioral escalation: “You can say hello… You can say I hope you have a good day. You can just acknowledge them.”

Participants highlighted that when a resident exhibits challenging behaviors, it is essential first to understand any unmet needs that may underlie the behavior before considering antipsychotic use. Dr. Brown (physician manager) stated, “We can’t just automatically order or increase medication. We need to look at the whole person and see why this behaviour is happening.” Ruby (nurse leader) added, “Behaviours are not just behaviours … They have meanings. It could be that they are hungry, in pain, or missing their family.”

Participants also emphasized the importance of identifying environmental triggers and adjusting care accordingly. Mia (physiotherapist) explained, “Some clients like being surrounded by people in a noisy environment. For some, that can be a trigger. So, [I] take them into a quiet environment to see if that helps.”

By understanding the resident as a whole person, including their needs and triggers, staff can incorporate these insights into individualized care plans, thereby helping to prevent and manage behaviors without relying on antipsychotics. Grace (nurse educator) suggested that understanding these “makes the care planning more patient-centered, individualized.”

Non-pharmacological interventions

Another key strategy is the use of non-pharmacological interventions tailored to residents’ preferences, interests, abilities, and conditions. These interventions aim to keep residents emotionally calm, meaningfully engaged, and prevent or manage responsive behaviors. Participants described a variety of approaches, including music, volunteer visits, walks, and light household tasks such as folding towels. Ivy (recreational therapy lead) shared an example of using natural light to improve residents’ sleep and reduce their nighttime restlessness: “We tried to implement a 1-hr outdoor time during the day to get them more natural light to help them sleep at night.”

Medication review and behavior monitoring

The third strategy involves regular medication reviews combined with ongoing behavior monitoring. Physician and pharmacist participants described reviewing medications, including antipsychotics, to determine whether adjustments or reductions are appropriate based on residents’ conditions. These reviews are also conducted collaboratively with healthcare providers from other disciplines, typically at an annual interdisciplinary care conference, where different professionals review each resident’s condition together and consider opportunities to reduce medications as part of the broader care planning. Dr. Brown (physician manager) described it as “the biggest point of collaboration” and “an important time to try to reduce the medication.” Diane (family caregiver) described how the LTC also held regular meetings with family caregivers to explore what might be driving residents’ behaviors: “we do have our internal behaviour support team… and try and figure out what’s going on with this person.” This dialogue created space to resist medicating first by focusing on underlying issues.

Participants also emphasized that monitoring residents’ behavior is essential for assessing both the need for and the effectiveness of antipsychotic medication. Lucy (nurse) described using a structured observation tool to document behavior: “We have to monitor the behaviours of those [on antipsychotics] for seven days and have a monitoring sheet–dementia observation strategy.”

Education and training

The last strategy involves education and training for healthcare providers and, occasionally, family caregivers on various related topics. Participants, including nurses and pharmacists, noted that one topic is understanding antipsychotics. Hazel (nurse educator) explained, “Education is another huge approach that we have had. Because not a lot of people know the side effectsz of antipsychotics.” Another topic is understanding the person-centered care approach and how to prevent and manage residents’ behaviors. Nurse educators cited related training frameworks and approaches, such as the PIECES (Physical, Intellectual, Emotional, Capabilities, Environment, and Social) framework and the GPA (Gentle Persuasive Approaches).

The above strategies are interconnected. For instance, non-pharmacological interventions are rooted in the person-centered care approach. The effectiveness of person-centered care planning and non-pharmacological interventions relies on medication review and behavior monitoring. Education and training reinforce staff’s knowledge and skills of the above strategies. It is therefore important to consider these strategies as an integrated set.

Barriers and facilitators

The barriers and facilitators to implementing antipsychotic reduction strategies identified by participants are largely structural and systemic. As suggested, CFIR was used to examine the extent to which the findings can be interpreted through CFIR constructs, thereby deepening our understanding and conceptualization of them. The barriers and facilitators, and interpretation by CFIR, are summarized in Table 2.

Table 2.

Barriers and facilitators, alignment with the CFIR domain and construct, and further explanation if the CFIR does not sufficiently explain the themes.

Barriers	Facilitators
Challenging work environment This barrier aligns with the “work infrastructure” construct under the “inner setting” domain.	Supportive leadership and frontline champions This facilitator aligns with the “high-level leaders” and “mid-level leaders” constructs within the “individuals” domain.
Staff’s reservations due to safety concerns and unconscious dismissive attitude Staff’s safety concerns align with the “work infrastructure” construct within the “inner setting” domain. Staff’s unconscious dismissive attitude aligns with the “culture” construct within the “inner setting” domain. However, CFIR may not account for how competing cultures, person-centered and dismissive cultures, operate simultaneously.	Effective team communication This facilitator aligns with the “teaming” construct within the “implementation process” domain.
Interdisciplinary communication gaps This barrier aligns with the “communication” construct within the “inner setting” domain.	Persistence and continuous reassessment This facilitator aligns with the “reflecting and evaluating” construct within the “implementation process” domain. However, this construct mainly evaluates the “success of implementation,” which may not fully capture the learning derived from less successful implementation experiences.

Note. CFIR = Consolidated Framework for Implementation Research.

Barrier 1. Challenging work environments

Participants consistently described the LTC work environment as increasingly difficult. Resident populations are becoming more complex, while staffing shortages make it challenging to implement antipsychotic reduction strategies.

Winnie (pharmacist) explained that population aging has increased residents’ medical complexity: “Patients come with a lot of chronic diseases … Patients become a lot sicker than before.” She added that Vancouver’s substance use crisis compounds this complexity, with some residents entering LTC with “alcohol-related issues, past drug-related issues, on top of behaviour issues.” Jane (nurse leader) similarly noted that residents are “highly complex [not only] in terms of physical, cognitive and mental conditions but also their social background.”

Despite residents’ growing needs, staff retention remains difficult. Hazel (nurse educator) commented, “A lot of homes have mentioned they have had a really hard time retaining staff.” As a result, even when staff are motivated to implement non-pharmacological strategies, they often lack the capacity to do so. Anna (social worker) recalled that her team had many good ideas but “might not always have the capacity.” Similarly, staff who wish to conduct more thorough medication reviews often cannot do so because sufficient time is unavailable. John (pharmacist manager) noted that LTC pharmacists often have only “ten minutes” to review a resident’s medications, whereas hospital pharmacists “can actually spend a few hours reviewing the chart, talking to the nurse, [and] talking to the family.”

Staff shortages are particularly acute among nurses and care aides, the largest workforce group in LTC. They expressed frustration that time pressures prevent them from building the relationships necessary for person-centered care. Lucy (nurse) explained, “It is very challenging to give a lot of time, because there are so many of them [residents]” requiring care. Mabel (administrator) added that “gentle or relational conversations can be skipped because [residents] are trying to climb out of bed,” with safety taking immediate priority.

Other participants, including family members, expressed understanding of the challenges of care staff. Diane (family caregiver) remarked, “You [care staff] just have so many things to do that it’s hard to think about anything else. It’s more survival.” Ivy (recreational therapy lead) echoed this: “Our nurses and care aides were like, that’s [non-pharmacological intervention] very nice, and we would love to be able to do that. But we have to make sure ten people have used the bathroom.”

Findings suggest that the barrier challenging work environment is attributable to staff shortages, aligning with the “work infrastructure” construct within the “inner setting” domain of CFIR, which examines “structural” workplace components that influence implementation, including “general staffing levels.” CFIR affirms staff shortage as a “structural” deficit that constrains the implementation of antipsychotic reduction strategies.

Barrier 2. Staff’s reservations due to safety concerns and unconscious dismissive attitude

Another barrier to implementing antipsychotic reduction strategies, especially medication adjustment, is staff reservations. The challenging work environment described earlier, characterized by heavy workloads and unpredictable resident behaviors, contributed to concerns about personal safety. These safety concerns, in turn, reinforced the reluctance to reduce antipsychotic use. Nurses emphasized that these reservations stem from a “real fear” of being harmed. Hazel (nurse educator) explained that concerns are “related to previous hurt, like getting hurt, or being yelled at or called names.”

As John (pharmacist manager) noted, “We do not have as many nurses to follow the patients … They might only have one nurse … so there’s reluctance [from care staff] … Sometimes it is easier to give the medication than having to reduce it and monitor the patients.” Ruby (nurse leader) raised doubts about the feasibility of avoiding antipsychotics in cases of severe behavior:

You know it’s hard to intervene when there is really a behaviour … sometimes we end up in chemical restraint … those residents who really don’t have a [psychosis] diagnosis. What can we do other than pharmacological intervention? What else can we do to mitigate this behaviour?

Education and training, particularly in managing responsive behavior, were identified as ways to reduce fear. Nora (nurse) observed, “We are starting to get educated more about it … we are getting trained, and I hear our team is now willing to try changes in medication. The team has [more] confidence–education helps!” However, staff capacity to attend training is limited. Fiona (nurse educator) explained, “It is two days for you [administrator] to release that staff–who will cover them?” Similarly, Sophia (administrator) noted that staff vacancies and turnover mean “education may not be the first thing that they [LTC homes] attend to, because they have to make sure to fill the vacant positions.”

The above findings indicate that education on managing residents’ behaviors could alleviate staff safety concerns; however, staff often cannot attend training due to limited staffing capacity in LTC facilities. These factors can be interpreted by the CFIR “access to knowledge and information” construct within the “inner setting” domain, which emphasizes the role of access to education in implementation, alongside the “work infrastructure” construct, which captures staffing constraints. Together, these constructs reveal a dilemma in LTC: education is needed to build implementation capacity, yet sufficient capacity to access education is unavailable. Although CFIR identifies each relevant factor, it may not fully account for their tension, which may be obscured when constructs are considered in isolation.

Beyond safety concerns, staff’s reservations about reducing antipsychotic use may be linked to their unconscious “dismissive” attitude in LTC settings. Andrew, a person living with early-stage dementia, reflected on dismissive behaviors he had observed in LTC:

I’ve also read many, many accounts of people living with dementia in LTC walking down the hall. A care staff member goes by and just looks the other way, or ignores them, not even acknowledging them. It’s that kind of … dismissive behaviour by care staff that suggests that if you have that attitude of just walking away, your go-to is going to be an antipsychotic.

Andrew described such unconscious dismissiveness as a form of “stigma,” reflecting a view that people with dementia are less fully recognized as people, which reinforces reliance on medication. He argued that even in a busy environment, staff can take small but meaningful steps toward person-centered care, such as simply greeting residents: “There’s always time, even time to say hello, even time to acknowledge.” Ella (recreation aide) similarly highlighted the importance of greeting residents:

I will always acknowledge them regardless of time, date, place, anything, even if I’m super busy … I’d rather stay an extra five minutes than forget to acknowledge someone’s day.

This dismissive attitude aligns with the “culture” construct within the “inner setting” domain of CFIR. CFIR defines “culture” as the “shared values, beliefs, and norms” within an organization. Although participants emphasized their commitment to person-centered care, they may act dismissively, unconsciously, due to a stressful work environment, thereby creating a coexistence of two contradictory cultures, person-centered and dismissive, within the same care setting. Although CFIR captures the role of culture, it may not account for how competing cultures operate simultaneously.

Barrier 3. Interdisciplinary communication gaps

The final barrier is communication gaps among staff, particularly across disciplines. Successful implementation of antipsychotic reduction strategies requires collaboration. For example, care staff implement person-centered plans and non-pharmacological interventions while monitoring and documenting residents’ behavioral changes, and physicians and pharmacists rely on this documentation to adjust medications. However, David (pharmacist lead) noted that pharmacists often lack clear or accessible documentation from care staff: “It’s hard to know when the care plans are done, and some of these non-pharmacological strategies are employed … It’s really hard to differentiate, really, whether or not the care plan still requires the antipsychotics.” He also added that when antipsychotics are reduced or changed, pharmacists are uncertain “whether or not they [care staff] can monitor the change.”

Although pharmacists lack access to care staff documentation, nurses face the same challenge with prescribers’ records. As Emma (nursing manager) explained, fragmented documentation systems limit visibility between disciplines: “Some homes document on one system and then the prescribers document on another system. And that’s a barrier between the two.”

Communication gaps also extend beyond LTC homes, particularly during care transitions. When residents are admitted on antipsychotics from the hospital, the LTC team needs background information to design reduction plans. Dr. Brown (physician manager) noted:

There are often communication barriers where documentation doesn’t come with the residents. It’s just that the medication will come, or the documentation comes later … When people come from acute, they’re on a lot of antipsychotics because it’s a noisy, unfamiliar environment. So there often isn’t a process for when this medication was increased. Did the person come with this medication? Was it increased in the hospital? Was it decreased? So that’s a barrier where we don’t see the trend of the medication.

Similarly, Hazel (nurse educator) emphasized that incomplete information from acute care leaves the LTC team uncertain about the rationale for antipsychotic use:

They [residents] are often put on medications to stabilize behaviour, and then they come into LTC. Why are they on these medications? Staff often lack clarity on prescribing decisions made in acute care and must guess the original intent.

The interdisciplinary communication gaps directly map onto the “communication” construct within the “inner setting” domain of CFIR. This construct emphasizes the importance of “high-quality formal and informal information-sharing practices”. Using CFIR, we can see that the challenge is not only about whether information is shared, but also about the “quality” of that sharing. Participants reported sharing information via documents but noted that much information was often missing. As a result, later in the Results section, in the facilitator “effective team communication,” they mentioned relying on in-person interactions, face-to-face discussions, or phone handovers, either individually or in team meetings, which they found more effective, that is, “higher-quality information-sharing practices.” This helps us reflect on how we could improve the “quality” of communication through documentation, and that in-person and phone interactions remain essential to ensure completeness and clarity.

Facilitator 1. Supportive leadership and frontline champions

A key facilitator is having leaders in management who actively support the implementation of antipsychotic reduction strategies. Ivy (recreational therapy lead) highlighted the importance of leadership in uniting staff: “If it [the antipsychotic strategy program] was put forward by leadership as a whole home initiative, I think that we would be more successful.” Hazel (nurse educator) noted that engaged leadership influences staff behavior: “If the leader is really involved and wants to reduce antipsychotics and they mentor their staff well, then that trickles down to the staff, right?” Supportive leadership also empowers frontline care staff, who may hesitate to implement time-intensive person-centered care planning and non-pharmacological interventions amid numerous daily tasks. As Emma (nursing manager) explained: “Those [supportive] leaders who have the mindset of, ‘If it [a care task] is not done today, don’t worry about it. Make sure the person is cared for.’ That’s a huge enabler.”

Beyond management, participants highlighted the importance of frontline “champions” who both implement and support others in implementing antipsychotic reduction strategies on the floor. Dr. Brown (physician manager) described their role:

The key to success is having a champion on site to support the team, and also to support the philosophy [of person-centered care] … Whether it [the champion] is a clinical nurse, an educator, a head nurse, a social worker, someone who believes and can reinforce [the strategies].

Similarly, Emma (nursing manager) highlighted the value of having “care aides who are bold enough to say, ‘No, we have to consider this [non-pharmacological intervention]’—those people are enablers [of implementation].”

CFIR includes the “high-level leaders” and “mid-level leaders” constructs within the “individuals” domain, both of which correspond to the management leaders identified in our findings. Frontline champions, meanwhile, align with the “opinion leaders” and “implementation facilitators” constructs: their advocacy for non-pharmacological interventions during team meetings illustrates their role as opinion leaders, while their active implementation of these interventions on the floor reflects their function as implementation facilitators. Using the terms “opinion leaders” and “implementation facilitators” helps us better conceptualize the important roles these frontline champions play.

Facilitator 2. Effective team communication

Another facilitator is effective team communication, which addresses the communication challenges mentioned earlier. Participants highlighted several strategies. Given gaps in documentation, they emphasized the importance of face-to-face communication. Winnie (pharmacist) prioritizes working “on the floor” to “put a face on the nurse” and communicate directly. Similarly, Mia (physiotherapist) speaks with nurses frequently “just to know what the day-to-day situation is like, how the client is doing on that particular day.”

Daily interdisciplinary in-person rounds were identified as an efficient way for teams to develop antipsychotic reduction strategies and design implementation plans. Ivy (recreational therapy lead) explained: “Having those round meetings was sort of the fastest way to get everybody’s opinion, buy-in, thoughts, concerns all in one place.” She gave an example of how the team collaboratively addressed a resident’s responsive behaviors without antipsychotics:

The OT would put up their hand and say, ‘Is it pain that’s bothering them? Is it a physical thing? Is it emotional?’ … That’s probably nobody better on the floor than recreation therapy assistants to know what we could do that might bring them down without having to PRN [referencing giving antipsychotic medication] them.

David (pharmacist lead) encourages pharmacists to attend these care planning meetings, so everyone in the team is on the same page: “I’m trying to encourage a pharmacist to be present more around these care planning meetings so that everyone’s seeing the same thing.”

Participants also stressed the importance of including people who are often overlooked in person-centered care planning discussions. Ella (recreation aide) mentioned that, in addition to care staff, she would also approach housekeeping and food service staff to exchange information about residents to provide better person-centered care planning. She told housekeeping staff, “Hey, this person needs to be able to see this blanket on their bed.” She also learned from food service staff that “some people want a different cup” due to their preference. Jane (nurse leader) highlighted including family members as a team member: “We include the interdisciplinary team … it’s a collaborative effort including the family … We include family in care planning if they can do visits or do companionship.” Ruby (nurse leader) emphasized the contributions of care aides, who are often excluded due to staff hierarchy: “Actually, the whole team thinks of better ideas sometimes … not from us [nurse leaders] … from care aides themselves … they have better ideas and share them with the team, and we put them into the care plan.”

Finally, communication with healthcare providers outside the LTC home can be challenging, but phone handovers help. Dr. Brown (physician manager) explained:

Usually, with phone handover, I get much more information than has ever been written on a discharge summary. What’s helpful to me is a little bit about the past… with the trigger and the medication, and then the future… so I could carry on with that plan to change this medicine or taper it.

The “teaming” construct within the “implementation process” domain of CFIR affirms that effective implementation depends on collaboration across disciplines. “Teaming” refers to team members “joining together to intentionally coordinate and collaborate on interdependent tasks to implement the innovation.” This construct highlights the importance of team members “joining together”: The success of implementation of each anti-psychotic reduction strategy relies on “collaboration.”

Facilitator 3. Persistence and continuous reassessment

A third facilitator was persistence, combined with ongoing reassessment. Participants emphasized that sustained effort was essential for implementing antipsychotic reduction strategies. Ivy (recreational therapy lead) explained that her team experimented with various non-pharmacological interventions with different residents: “[For] some people, it worked really well, and [for] some people, it did not work at all.” Despite mixed outcomes, they did not give up, believing it was still “well worth a try.” Dr. Brown (physician manager) highlighted the importance of not being discouraged if antipsychotics need to be increased after trying all non-pharmacological interventions, emphasizing continuous reassessment:

If we tried everything [non-pharmacological intervention] and it still doesn’t work, we have to get the right antipsychotic medication at the right time, right dose to keep the resident in the [care] home. Hopefully, not send them back to acute care… with the idea that we’re going to increase that in a few weeks, we’re going to reassess and try and decrease it.

Sophia (administrator) reiterated the importance of continuous reassessment: “What is important is that we have review, reassessment, and monitoring.” Similarly, Jane (nurse leader) emphasized that antipsychotic reduction is “not an overnight success,” adding that it involves “gradual evaluation and assessment.”

This facilitator aligns with the CFIR construct of “reflecting and evaluating” within the “implementation process” domain. This construct emphasizes “assessing the success of implementation,” which resonates with participants’ focus on reassessment. However, in this study, participants examined not only “successful” implementations but also less successful ones, learning from both experiences. The construct alone may not fully capture the learning derived from less successful experiences.

Discussion and implications

Comparison with the literature on implementation of antipsychotic reduction

As noted in the Introduction, a body of literature identifies strategies to reduce antipsychotic use in LTC and the barriers and facilitators to implementing them. Here, we revisit that literature and compare it with our findings to highlight convergence and divergence.

Antipsychotic reduction strategies implemented in this study resonate with those described in the broader literature, particularly person-centered care planning (Ballard et al., 2018), non-pharmacological interventions (Richter et al., 2019), medication review (Vanker et al., 2025), and education and training (Shaw et al., 2018). However, there are also divergences. First, participants rarely mentioned physical modifications to the care environment, which are discussed in the literature (Kirkham et al., 2020; Muñiz et al., 2020). At most, some participants described moving residents who were sensitive to noise to quieter areas. Yet this approach emphasizes helping residents adapt to the existing environment rather than modifying it. A possible explanation is that many LTC homes in Vancouver are older buildings for which substantial environmental adjustments are not feasible. Second, participants did not mention regulatory measures, such as external audits or public reporting of antipsychotic use, which the literature debates as strategies for care homes to compare among themselves and keep them accountable (Bowblis et al., 2015). These measures have been criticized for overlooking contextual differences among LTC homes (Rosenthal et al., 2022), and participants may have similarly regarded them as irrelevant or unhelpful in practice. Another possible explanation is that all participating LTC homes were publicly operated under the health authority, where oversight and accountability were embedded in organizational policies rather than framed as separate regulatory measures.

Consistent with the literature (Jørgensen et al., 2024), participants emphasized the importance of supportive leadership and effective team communication and collaboration in facilitating the implementation of antipsychotic reduction strategies. At the same time, participants highlighted barriers that were also reported in the literature: a challenging work environment, shaped by staff shortages and heavy workloads (Moth et al., 2021), staff’s concerns about potential behavioral changes of residents and safety risks following medication adjustments (Crystal et al., 2020; Walsh et al., 2018), and team communication gaps (Guzmán et al., 2024).

This study, however, offers several contributions beyond prior findings. The study highlights a more emphatic interdisciplinary culture than is reported in the literature: Previous research suggests that staff may perceive colleagues from other disciplines as obstructing their efforts on antipsychotic reduction (Ellis et al., 2015). In contrast, participants in this study, across disciplines and positions and including family caregivers, demonstrated understanding of one another’s constraints, particularly those of frontline care staff. Similarly, while some literature suggests staff’s questioning other disciplines about the effectiveness of non-pharmacological interventions (Simmons et al., 2018), participants here generally accepted the value of these interventions. This suggests that the main challenges in implementing antipsychotic reduction strategies arise from systemic and structural barriers rather than interpersonal tensions or personal disbelief.

Although literature identified family resistance, driven by worry that reducing antipsychotics would lead to residents’ behavioral change, as a barrier to the implementation of non-pharmacological intervention (Simmons et al., 2018), this was not prominent in our findings. Instead, participants emphasized the involvement of families in person-centered care planning to support non-pharmacological approaches and often described families as important members of the interdisciplinary team. These accounts suggest that, rather than a barrier, families can be a facilitator in advancing antipsychotic reduction initiatives.

This study identified the presence of staff’s unconscious dismissive attitude in some LTC settings, where residents are overlooked as a person, possibly due to workload pressures. This finding is less discussed in the literature as a barrier to implementing antipsychotic reduction strategies, likely because most studies rely primarily on healthcare providers who may not be able to see their dismissiveness in practice.

The divergences between our findings and prior literature may reflect the study’s context and design. Because all participating LTC homes were publicly operated, stronger interdisciplinary collaboration and family involvement may have been supported by greater organizational resources, compared with privately operated homes. Including a family caregiver and a person living with dementia also brought perspectives less represented in prior research.

The application of CFIR advanced our interpretation by situating implementation factors within systemic constructs rather than merely individual shortcomings. Staff shortages aligned with the “work infrastructure” construct, communication gaps with “communication,” and dismissive attitudes with “culture,” all within the inner setting domain. Linking findings to CFIR domains also clarified that implementation barriers require systemic solutions, informing future practical implications—particularly the need for investment in staffing, integrated communication systems, and educational strategies to support cultural change.

Although most factors in this study were systemic or structural, some reflected individual or attitudinal dimensions. Staff fears of harm and dismissive attitudes toward residents were personal factors that nonetheless intersected with systemic pressures such as staff shortages. Recognizing this distinction is important: systemic constraints shape personal factors, yet personal factors also influence how staff engage with the reduction of antipsychotic use. Interventions, therefore, need to address both levels—strengthening organizational infrastructure while fostering attitudinal change.

Implications for practice, policy, and research

Human resource investment

The findings show that LTC faces a dilemma: while staff wish to attend education sessions, implement non-pharmacological interventions, or conduct more thorough medication reviews, limited time and staffing constrain their ability to do so. A key implication of this study is the need for sustained investment in human resources. The government may consider increasing subsidies to LTC homes to recruit additional staff and fund more staff care hours.

Education for cultural change

Findings suggest the need for education that extends beyond technical skills to address unconscious dismissive attitudes toward residents living with dementia. As suggested, these attitudes can be understood as part of an implicit culture within LTC. This study highlights these attitudes through the voices of people with lived experience of dementia and family caregiving. Education should therefore integrate these perspectives, for example, by inviting people with lived experiences to serve as guest speakers and, through reflective practice, to challenge unconscious attitudes.

Strengthening interdisciplinary communication

Findings reveal that while staff are willing to share information across disciplines, current documentation systems are siloed, forcing them to rely on workarounds such as in-person conversations or phone calls. This challenge highlights the need for integrated communication platforms in the long term during transitions of care and within LTC. Prior studies similarly show that fragmented communication during transitions of care (Rosenthal et al., 2022) and in LTC (Ellis et al., 2015; Guzmán et al., 2024) contributes to inappropriate prescribing.

Participants emphasized the importance of in-person interdisciplinary meetings, which many LTC homes already do. However, explicitly requiring these meetings for all care homes in policy would help ensure consistency across homes and guarantee protected time for them. This aligns with prior findings that structured interdisciplinary meetings improve care coordination and support deprescribing efforts (Kirkham et al., 2020).

Participants noted the involvement of multiple disciplines and positions in person-centered care planning, including those often overlooked. Notably, residents were rarely identified as “team members.” This gap echoes critiques that residents are often excluded from LTC (Davies et al., 2025; Staempfli et al., 2025). This suggests a need to explicitly name and include residents as equal partners in policy and practice guidelines about care planning.

Empowering frontline champions

Supportive leadership at both management and frontline levels is a facilitator for implementing antipsychotic reduction strategies. Although frontline champions play a key role, participants did not mention support or training specifically for them. Policy initiatives should therefore go beyond identifying champions to investing in their development. Emerging initiatives, such as Sparking Change by Healthcare Excellence Canada (2025), are promising, as they offer workshops that strengthen champions’ communication and team-building skills.

Future research: Examining policy and systems

This study underscores that barriers and facilitators to implementation are not merely individual but also structural. Future research may therefore consider moving beyond exploratory interviews to investigate how systemic factors shape implementation. For instance, examining policy documents and practice guidelines on antipsychotic reduction strategies could reveal how they influence, align or contradict with frontline experiences. The findings also suggest that implementation requires continuous reassessment, resembling a learning cycle in which teams reflect on prior implementation experiences to inform future planning and action (Kolb, 2015). Future research could further investigate how this cycle functions in the implementation of antipsychotic reduction strategies.

Strengths and limitations of the study

The study has several strengths. It involved team members and participants from diverse positions, disciplines, and backgrounds. These different perspectives helped capture a broader range of experiences and identify nuanced factors affecting implementation, enhancing the quality of the findings. In addition, applying CFIR deepened our understanding of the barriers and facilitators, enabling interpretation beyond the immediate findings.

There are also limitations. All participants had experience in publicly operated LTC homes. Although these homes face resource constraints, in the Vancouver context, they may be comparatively better resourced, suggesting that barriers in not-for-profit or privately operated LTC homes may be even greater. Future studies may consider including participants from these homes. In addition, although the study included participants from multiple disciplines, some roles considered important for person-centered care planning, such as housekeeping and food services, were not represented. Future research could explore these team members’ perspectives. Finally, the demographic information for healthcare provider participants was limited to professional role, discipline, and work sites. We did not collect other sociodemographic data such as age, gender, or years of experience. Future research could incorporate additional sociodemographic data to examine how these factors shape perspectives on antipsychotic reduction and its implementation.

De-implementation science offers another direction for future research. It focuses on reducing or discontinuing low-value or harmful practices (Flynn et al., 2026). In the context of antipsychotic reduction, this means identifying practices that can be done less often to reduce medication use. Future research could explore which practices should be de-implemented, the barriers and facilitators of doing so, and how these differ from or overlap with the implementation factors.

Conclusion

This exploratory study examined the implementation of antipsychotic reduction strategies in Vancouver’s LTC homes, highlighting person-centered care planning, non-pharmacological interventions, medication reviews, and staff education as key approaches. Participants identified barriers, including challenging work environments due to staff shortages and increased resident complexity, staff’s reservations about antipsychotic reduction due to safety concerns and unconscious dismissive attitude, and interdisciplinary communication gaps. In contrast, supportive leadership and frontline champions, effective team communication, as well as persistence and continuous reassessment emerged as facilitators. The findings have implications for practice and policy. Findings reveal that barriers to antipsychotic reduction in LTC are not merely individual but also systemic. Sustained improvement depends on policies that enable and resource effective interdisciplinary teamwork. This includes, for example, adequate staffing, ongoing education, and leadership committed to culture change.

Funding

This work was supported by the Health System Impact Fellowship, co-funded by the Canadian Institutes of Health Research, Michael Smith Health Research BC, and Vancouver Coastal Health (grant number 520624).

Conflicts of interest

None declared.

Data availability

The original data used in this study are not available to other researchers due to the sensitive nature of qualitative data and the risk of identification. De-identified excerpts may be shared upon reasonable request with ethics approval. The study is not pre-registered.

Author contributions

Karen Lok Yi Wong (Conceptualization [equal], Data curation [lead], Formal analysis [equal], Funding acquisition [equal], Investigation [lead], Methodology [equal], Project administration [lead], Supervision [equal], Writing—original draft [lead], Writing—review & editing [equal]), Lillian Hung (Conceptualization [equal], Formal analysis [equal], Funding acquisition [equal], Methodology [equal], Supervision [equal], Writing—review & editing [equal]), Jason Wong (Conceptualization [equal], Formal analysis [equal], Writing—review & editing [equal]), Adebusola Adekoya (Conceptualization [equal], Formal analysis [equal], Writing—review & editing [equal]), Joey Oi Yee Wong (Conceptualization [equal], Formal analysis [equal], Writing—review & editing [equal]), Erika Young (Conceptualization [equal], Formal analysis [equal], Writing—review & editing [equal]), Cromwell Acosta (Conceptualization [equal], Formal analysis [equal], Writing—review & editing [equal]), and Krisztina Vasarhelyi (Conceptualization [equal], Formal analysis [equal], Funding acquisition [equal], Methodology [equal], Supervision [equal], Writing—review & editing [equal)

Disclosure on the use of AI

The AI tool Grammarly was used to check grammar and spelling during manuscript preparation.