Site-level factors affecting nursing home implementation of a personalized music intervention: Qualitative analyses from Music & Memory: A Pragmatic Trial for Nursing Home Residents with Alzheimer's Disease (METRIcAL).

Background: Non-pharmacological interventions (NPIs) are preferred alternatives to using antipsychotic medications to manage disruptive behaviors in nursing home (NH) residents living with dementia. However, the implementation of these interventions is often complex in the NH environment. In this qualitative analysis of data from an embedded pragmatic clinical trial (ePCT) of a personalized music intervention, we describe NH-level implementation barriers and facilitators.

Methods: In a 54-facility trial, we randomized 27 NHs from four US corporations to the personalized music intervention. In this qualitative analysis, we analyzed barriers and facilitators at 9 of the 27 intervention NHs, using (1) routinely collected data collector observations and (2) semi-structured interviews with NH staff. We iteratively developed codes to best describe these data and generated themes.

Results: We found five qualitative themes related to the variation of intervention implementation across NHs: (1) turnover and institutional changes interfered with implementation; (2) consistent with pragmatic implementation, delivery strategies varied across NHs; (3) family members influenced residents' participation; (4) non-clinical program champions needed clinical buy-in, which was challenging and required demonstrating the intervention's clinical benefits; and (5) technological barriers among staff and residents impeded implementation.

Conclusions: Qualitative results from nine facilities participating in a NH ePCT of personalized music intervention highlight the importance of identifying an intervention's key components to ensure fidelity, while allowing the flexibility necessary for pragmatic implementation. Engaging family caregivers may improve the implementation of NPIs in the NH setting. Results may be helpful to other researchers implementing NPIs to manage neuropsychiatric symptoms for people living with dementia in NHs.

Highlights: This was a real-world trial of a personalized music for nursing home (NH) residents with dementia.Pragmatic adaptations to intervention delivery may have compromised fidelity.Family caregivers are important to the success of behavioral interventions in NHs.