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Grip on challenging behavior: process evaluation of the implementation of a care program

Sandra A Zwijsen1*, Martin Smalbrugge1, Jan A Eefsting2, Debby L Gerritsen3, Cees MPM Hertogh1 and Anne Margriet Pot45

Author Affiliations

1 Department of General Practice and Elderly Care Medicine/EMGO + Institute for Health and Care Research, VU Medical Center, Amsterdam, the Netherlands

2 Zonnehuisgroep IJssel-Vecht, Zwolle, the Netherlands

3 Department of Primary and Community Care: Centre for Family Medicine, Geriatric Care and Public Health, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands

4 Department of Clinical Psychology, Faculty of Psychological and Educational Sciences, EMGO + Institute for Health and Care Research, VU University, Amsterdam, the Netherlands

5 Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands

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Trials 2014, 15:302  doi:10.1186/1745-6215-15-302

Published: 25 July 2014



The Grip on Challenging Behavior care program for managing challenging behavior was implemented in the dementia special care units of 17 Dutch nursing homes. A process evaluation of the implementation of the care program was performed to determine the quality of the implementation and the lessons to be learned for future implementation.


The care program was implemented according to a stepped wedge design. First-order data (data on recruitment, reach, relevance and feasibility) were used to determine the validity of the study, and second-order data (intervention quality and the barriers and facilitators for implementing the care program) were used to describe the implementation process. Two structured questionnaires were administered to care staff and key stakeholders and semi-structured interviews were held in the units.


University affiliated and non-affiliated nursing homes from different parts of the Netherlands participated. The resident participation rate was over 95% and the participation rate for the training sessions was 82%. Respondents considered the care program relevant and feasible. The degree of implementation was not optimal. The barriers and facilitators in implementing the care program could be divided into three categories: organizational aspects, culture on the unit and aspects of the care program itself.


The recruitment, reach, relevance and feasibility are sufficient to allow for analysis and generalization of the effects of the care program, but the degree of implementation should be taken into account in further analysis. Future projects that involve implementation should consider the specific features of the organization and the cultural orientation of the unit to better adapt to specific needs.

Trial registration

The Netherlands National Trial register under number NTR2141 registered on 11 December 2009. Randomization took place in November 2010, and the first intervention group started using the intervention in February 2011.

Nursing home; Dementia; Behavior; Process evaluation; Implementation; Intervention