“Working away in that grey area…” A qualitative exploration of General Practitioners’ perspectives on the management of behavioural and psychological symptoms of dementia
Behavioural and psychological symptoms of dementia (BPSD) is an almost universal feature of dementia and has been identified by GPs as a particularly challenging aspect of dementia care. However, there is a dearth of research exploring GPs’ experiences of managing this complex clinical dimension of dementia. The aim of this research is to elicit GPs’ perspectives on the barriers to and facilitators of managing behavioural and psychological symptoms of dementia in order to inform the development of an intervention to assist GPs managing BPSD.
Qualitative semi-structured interviews were conducted with GPs in the South of Ireland. Nursing homes in the area were contacted and the GP who attended the nursing home was identified. From this population of GPs a sample was purposively recruited to include GPs with differing practice locations (urban/rural), years in practice and dementia workload with the goal of achieving maximum variation. The Theoretical Domains Framework (TDF) was used to inform the topic guide. Interviews were audio-recorded and transcribed verbatim. Data analysis was conducted in two phases. Phase one involved two researchers inductively open coding all of the interviews drawing on the principles of thematic analysis. The second phase of the analysis involved mapping the identified codes to the domains of the TDF.
13 of the 17 GPs invited agreed to participate in a semi-structured interview. Theoretical data saturation was apparent at 10 interviews but 3 further interviews were conducted to confirm data saturation. Several themes in relation to the challenges and facilitators GPs experience when managing BPSD in community and residential setting were identified. Challenges identified included; limited resources at nursing home and community level; lack of clinical guidance, in particular, in relation to pharmacological treatments; and perceived lack of support from secondary care. Facilitators identified included; significant experience in managing people with dementia which was found to result in increased knowledge, confidence and a willingness to engage in ‘trial prescribing’; and having positive working relationships with nursing home staff, community-based Primary Care Teams and secondary care colleagues. Eight domains from the TDF were perceived to influence GPs’ management of BPSD and were identified as ‘mechanisms for change’ (environmental context and resources, belief about capabilities, knowledge, social influences, skills, memory attention and decision making processes, social or professional role and identify and beliefs about consequences).
This study has identified challenges that face GPs when managing BPSD. The application of behavioural change theory has identified factors influencing GPs management of BPSD that may be amenable to change. The results of this study will used to inform the selection and design of an appropriate theory-based intervention to assist GPs managing BPSD at community and residential care level.