Moderators of adherence within a nursing home pragmatic trial of personalized music

Abstract Background and Objectives To describe factors affecting nursing home adherence in an embedded pragmatic randomized controlled trial (ePCT) of a personalized music intervention to manage agitation in residents living with dementia. Research Design and Methods Semi-structured qualitative interviews with four corporate leaders and 27 nursing home staff. We used thematic analysis to develop a codebook and map findings to potential adherence moderators in the Conceptual Framework for Implementation Fidelity (CFIF): recruitment, participant responsiveness, strategies to facilitate implementation, intervention complexity, quality of delivery, and context. Results Recruitment: Corporate leaders noted research participation compensation did support corporate implementation. Resident turnover frequently occurred and led to delays in implementation due to the need to personalize music to each resident. Participant responsiveness (dose received): Interviewees noted the intervention improved dementia behaviors and enhanced engagement with exceptions. Strategies to facilitate implementation: Interviewees voiced differing views on whether nurses or activities staff should lead implementation and how to pilot the program. Intervention complexity: Interviewees described complexities including tailoring delivery to each resident, updating music, and sustainability concerns. Quality of delivery: Champions discussed protocol deviations; e.g., providing residents with music that was not personalized. Context: Interviewees noted how the SARS-CoV-2 pandemic exacerbated turnover, but the intervention did engage residents during staffing shortages. Discussion and Implications Interviewees described contextual barriers associated with pragmatic implementation of a personalized music intervention. While they also described facilitators, our findings highlight limits to pragmatic delivery in nursing homes with chronic under-resourcing and staffing, exacerbated by the pandemic.