Barriers to Supporting Deprescribing Benzodiazepines in Older Adults: A Survey of European Non-Physician Healthcare Professionals

Barriers to Supporting Deprescribing Benzodiazepines in Older Adults: A Survey of European Non-Physician Healthcare Professionals | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL Basic & Clinical Pharmacology & Toxicology This is a preprint and has not been peer reviewed. Data may be preliminary. 9 April 2025 V1 Latest version Share on Barriers to Supporting Deprescribing Benzodiazepines in Older Adults: A Survey of European Non-Physician Healthcare Professionals Authors : Vladyslav Shapoval 0009-0005-0209-1879 [email protected] , Perrine Evrard , François-Xavier Sibille , María López-Toribio , Olivia Dalleur , Carole E. Aubert , Lucy Bolt , … Show All … , Vagioula Tsoutsi , Maria Ntafouli , Laura Fernández Maldonado , Ramon Miralles , Adam Wichniak , Katarzyna Gustavsson , Torgeir Wyller , Enrico Callegari , Jeremy Grimshaw M , Justin Presseau , Séverine Henrard , and Anne Spinewine Show Fewer Authors Info & Affiliations https://doi.org/10.22541/au.174420655.50928069/v1 453 views 195 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract While physicians are primarily responsible for Benzodiazepine Receptor Agonist (BZRA) deprescribing, non-physician healthcare professionals (HCPs) can support deprescribing. This study explored barriers to BZRA deprescribing faced by non-physician HCPs. We surveyed 258 HCPs (63.2% nurses) across six European countries using a Theoretical Domain Framework (TDF)-based questionnaire. Logistic regression assessed associations between TDF domains and HCPs’ intention to support deprescribing and their routine support of BZRA deprescribing. Major barriers (defined as TDF items with a mean<3) were found in the Goals (competing priorities), Environmental Context and Resources (time and staff lack), and Social Influence (patient reluctance) domains. Five TDF domains were associated with a stronger intention to support deprescribing: Social/Professional Role and Identity (odds ratio [OR], 3.08; 95% confidence interval [CI], 1.77-5.46); Beliefs about Consequences (OR, 1.91; 95% CI, 1.07-3.34); Memory, Attention and Decision Processing (OR, 1.80; 95% CI, 1.16-2.82); Intention to promote alternatives (OR, 1.63; 95% CI, 1.07-2.49) and Reinforcement (OR, 1.57; 95% CI, 1.08-2.29). Knowledge was the only domain associated with routine BZRA deprescribing support (OR, 1.16; 95% CI, 1.06-1.27). Different categories of HCPs face similar major barriers, but barriers vary across HCP categories and countries. Adapted to contextual differences, targeted interventions may address barriers, enhancing BZRA deprescribing. Plain Language Summary Physicians usually decide on deprescribing Benzodiazepine Receptor Agonists (BZRA), but nurses or other non-physician healthcare professionals (HCPs) can also help. However, their role is overlooked. We surveyed 258 HCPs across six European countries to identify barriers to their involvement. Major challenges included lack of time and staff, non-prioritising BZRA deprescribing, and perceived patient reluctance. HCPs who saw deprescribing as their job and believed in its benefits were more willing to support deprescribing. Stronger knowledge about BZRA was linked to greater involvement in deprescribing. As barriers vary by HCPs’ category and country, tailored strategies may enhance deprescribing support, improving patient safety. not-yet-known not-yet-known not-yet-known unknown Barriers to Supporting Deprescribing Benzodiazepines in Older Adults: A Survey of European Non-Physician Healthcare Professionals Running title: Deprescribing BZRA by Non-Physician HCP Vladyslav Shapoval 1 , Perrine Evrard 1 , François-Xavier Sibille 1,2,3 , María López-Toribio 1,3 , Olivia Dalleur 1,4 , Carole E. Aubert 5,6 , Lucy Bolt 5,6 , Vagioula Tsoutsi 7 , Maria Ntafouli 7 , Laura Fernández Maldonado 8 , Ramon Miralles 8,9 , Adam Wichniak 10,11 , Katarzyna Gustavsson 10,12 , Torgeir Bruun Wyller 13,14 , Enrico Callegari 13,15 , Jeremy M Grimshaw 16, 17 , Justin Presseau 16,19 , Séverine Henrard 1,3 , Anne Spinewine 1,18 Affiliations: 1. Clinical Pharmacy and Pharmacoepidemiology Research Group, Louvain Drug Research Institute, UCLouvain, Brussels, Belgium. 2. CHU UCL Namur, Department of Geriatric Medicine, Yvoir, Belgium. 3. Institute of Health and Society (IRSS), UCLouvain, Brussels, Belgium 4. Pharmacy Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium 5. Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland. 6. Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland 7. Sleep Research Unit, First Department of Psychiatry, Eginition Hospital, Medical School, National & Kapodistrian University of Athens, Athens, Greece 8. Fundació Salut i Envelliment UAB Universitat Autonoma de Barcelona, Barcelona, Spain 9. Hospital Universitari Germans Trias i Pujol, Badalona (Barcelona), Spain 10. Department of Clinical Neurophysiology, Sleep Medicine Center, Institute of Psychiatry and Neurology, Warsaw, Poland 11. Third Department of Psychiatry, Institute of Psychiatry and Neurology, Warsaw, Poland 12. Department of Science and Evaluation, Medical Research Agency, Warsaw, Poland 13. Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway 14. Institute of Clinical Medicine, University of Oslo, Oslo, Norway. 15. Department of Old Age Psychiatry, Østfold Hospital Trust, Grålum, Norway 16. Methodological and Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada 17. Department of Medicine, University of Ottawa, Ottawa, Canada 18. CHU UCL Namur, Pharmacy Department, Yvoir, Belgium 19. School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada Corresponding author: Vladyslav Shapoval, e-mail [email protected] tel. +32 27 64 72 36 Address: Louvain Drug Research Institute (LDRI), Clinical Pharmacy Research Group, Avenue Mounier 72/B1.72.02 1200 Woluwe-Saint-Lambert Keywords: benzodiazepines, deprescribing, medication safety, older adults, non-physician staff Word count: 3231/5000 words Abstract While physicians are primarily responsible for Benzodiazepine Receptor Agonist (BZRA) deprescribing, non-physician healthcare professionals (HCPs) can support deprescribing. This study explored barriers to BZRA deprescribing faced by non-physician HCPs. We surveyed 258 HCPs (63.2% nurses) across six European countries using a Theoretical Domain Framework (TDF)-based questionnaire. Logistic regression assessed associations between TDF domains and HCPs’ intention to support deprescribing and their routine support of BZRA deprescribing. Major barriers (defined as TDF items with a mean<3) were found in the Goals (competing priorities), Environmental Context and Resources (time and staff lack), and Social Influence (patient reluctance) domains. Five TDF domains were associated with a stronger intention to support deprescribing: Social/Professional Role and Identity (odds ratio [OR], 3.08; 95% confidence interval [CI], 1.77-5.46); Beliefs about Consequences (OR, 1.91; 95% CI, 1.07-3.34); Memory, Attention and Decision Processing (OR, 1.80; 95% CI, 1.16-2.82); Intention to promote alternatives (OR, 1.63; 95% CI, 1.07-2.49) and Reinforcement (OR, 1.57; 95% CI, 1.08-2.29). Knowledge was the only domain associated with routine BZRA deprescribing support (OR, 1.16; 95% CI, 1.06-1.27). Different categories of HCPs face similar major barriers, but barriers vary across HCP categories and countries. Adapted to contextual differences, targeted interventions may address barriers, enhancing BZRA deprescribing. not-yet-known not-yet-known not-yet-known unknown Introduction Benzodiazepine receptor agonists (BZRA) are often prescribed to older adults to treat sleep problems. However, they have an unfavourable benefit-risk balance, especially for older adults, leading to adverse events like falls, fractures, cognitive impairment, hospitalisation and premature death (1–6). Consequently, guidelines recommend avoiding BZRA prescribing and considering deprescribing for older adults taking them for two weeks or longer (7–9). Despite these recommendations, two recent studies revealed alarmingly high BZRA usage across European countries (10,11). While physicians are primarily responsible for BZRA deprescribing, non-physician healthcare professionals (HCPs) can support the deprescribing process. For instance, nurses working in assisted living facilities can contribute to reducing the use of harmful medications, including BZRA (12). Pharmacists’ involvement in patient education substantially increases BZRA deprescribing (13,14). A key issue is that we know little about barriers to and enablers of BZRA deprescribing in non-physician HCPs (15,16). Two systematic reviews on barriers to and enablers of BZRA deprescribing reveal a limited focus on pharmacists’ and nurses’ perspectives (16). A few studies focused on HCPs in nursing homes; only one addressed barriers in the hospital setting (15). Additionally, these reviews highlighted other limitations, such as the lack of theory-driven approaches to report barriers and enablers and its predominant focus on North American and Western European contexts, which limits the generalisability of findings to other regions. This study is part of the BE-SAFE project, funded by the European Union and Swiss government, aiming to improve patient safety by reducing BZRA use in older adults through a hospital-initiated deprescribing intervention. The project aligns with the Choosing Wisely De-implementation (CWDIF) framework that emphasises the identification of barriers and enablers as the first step of the de-implementation process (17). We recently reported barriers and enablers to BZRA deprescribing from physicians’ perspectives (18). This paper focuses on non-physician HCPs, such as nurses, pharmacists, and psychologists. The aim is to explore the barriers, enablers and factors associated with HCPs’ intention to support deprescribing and their routine support for BZRA deprescribing in older adults. Materials and Methods Study design and recruitment The study was conducted in accordance with the Basic & Clinical Pharmacology & Toxicology policy for experimental and clinical studies (19). We surveyed non-physician HCPs in six European countries: Belgium, Greece, Norway, Poland, Spain, and Switzerland. The study is reported according to the Consensus-Based Checklist for Reporting of Survey Studies (CROSS) (21), available in the Supplement. Recruitment occurred from December 2022 to May 2023. Eligible participants included non-physician HCPs (i.e., nurses, pharmacists, psychologists and, where relevant, other HCPs involved in patient care) working in acute medical wards or outpatient clinics that provide care for adults aged 65 and older. These non-physician HCPs were recruited from BE-SAFE participating hospitals (ranging from one to three hospitals per participating country). Wards and clinics with existing structured BZRA deprescribing processes were excluded. Collaborating with senior physicians from the participating wards and clinics, the research team identified and invited non-physician HCPs to complete the survey either online or on paper. The local research teams were responsible for entering the paper survey data into Qualtrics version 09.22. The study aligned with the principles of the Declaration of Helsinki and received approval from local ethics committees (20). All participants provided written informed consent, except in Switzerland, where it was not required. Sample size We aimed to recruit 40 non-physician HCPs per country, totalling 240 HCPs. This sample size was considered feasible within the project timeline and suitable for cross-country comparisons. We sought to ensure that at least half of the sample was comprised of nurses because they have the closest contact with patients. Survey Questionnaire The questionnaire was based on the Theoretical Domains Framework (TDF) version 2, which organises 84 constructs from 33 behaviour change theories into 14 domains reflecting determinants of health-related behaviour (21). The TDF is widely used to assess barriers and enablers (22). We initially developed questionnaire items for physicians, drawing on barriers identified in a TDF-based systematic review on BZRA deprescribing (15) and two validated TDF-based questionnaires (23,24). Since non-physician HCPs in participating countries do not have the legal authority to taper or stop BZRA, the physicians’ questionnaire was adapted to align with their roles. Experts in implementation and behavioural sciences, deprescribing, geriatrics, and sleep medicine reviewed and refined the items to ensure clarity and relevance. The final questionnaire consists of 44 questions: five on background characteristics, 35 TDF-based items, two yes/no questions on self-reported behaviour (i.e., whether the HCP has ever supported BZRA deprescribing and/or does so routinely), and two open questions for additional feedback on barriers and enablers. The 35 items cover 12 TDF domains: Knowledge; Skills; Memory, Attention, and Decision Processing; Social/Professional Role and Identity; Beliefs about Capabilities; Beliefs about Consequences; Reinforcement; Goals; Intentions (including the intention to support deprescribing, which ultimately serves as a dependent variable in the analysis); Emotions; Environmental Context and Resources; and Social Influence. We excluded two TDF domains—Optimism and Behavioural Regulation—due to the lack of relevant barriers in previous literature. Of the 35 items, 17 were identical to those in the physicians’ questionnaire, 14 were adapted from the physicians’ survey to reflect the non-physician role of non-physician HCPs, and four were newly developed to capture barriers specific to non-physician HCPs. All items were rated on a 5-point Likert scale, ranging from “Strongly agree” (5) to “Strongly disagree” (1). The questionnaire aimed to identify the barriers and enablers faced by non-physician HCPs in supporting patients and physicians during the BZRA deprescribing process. Deprescribing was defined as tapering and stopping medications to minimise polypharmacy and improve patient outcomes. Support was defined as any action by non-physician HCPs to assist patients or physicians in the BZRA deprescribing process. These actions vary by professional role and country but may include, for example, educating patients about BZRA-related harms or promoting non-pharmacological approaches. The questionnaire was translated from English into six languages (French, German, Greek, Norwegian, Polish, and Spanish) using the forward/backward translation methodology (25,26). Pilot testing was conducted with at least two non-physician HCPs per site to ensure clarity and comprehensiveness. The study protocol and questionnaires can be accessed on the Open Science Framework platform: https://osf.io/q5k8r/?view_only=2a527543f0d0486686e9ac47e1925c0b Analysis The respondents who provided answers only to background characteristic questions were excluded from the analysis. We conducted descriptive analyses for the entire sample, by HCP category and country (for nurses only). Most descriptive data consisted of categorical variables, reported as numbers and percentages, while means and standard deviations were also calculated for TDF-related questionnaire items. To ensure consistency in interpretation, we applied reversed scoring to negatively asked questions so that lower scores reflect higher barriers, regardless of the item wording. The items were classified as follows: items with a mean score of < 3 out of 5 were considered major barriers, those between 3 and 3.99 were deemed moderate barriers, and items scoring ≥ 4 were categorised as enablers. We used a multivariable ordinal logistic regression model to identify factors (background characteristics and TDF domains) associated with the intention to support BZRA deprescribing. Additionally, we used a dichotomous logistic regression model to examine the association between these factors and self-reported routine support of BZRA deprescribing. Scores for TDF domains were computed by averaging variables related to each domain. We performed univariate logistic regressions with each background characteristic and TDF domain to identify the variables associated with each outcome. Using a p-value <0.15, we selected the variables for further multivariable models. Then, we built multivariable logistic regression models and applied a stepwise selection to determine the best-fitting final multivariable model. All statistical analyses were performed using R software (version 4.2.1) with the packages “tidyr” and “Likert”. A two-sided p-value of < 0.05 indicated a statistically significant association. Answers to open-ended questions were analysed using a qualitative deductive approach. Two researchers (P.E. and V.S.), experienced in qualitative analysis and TDF, independently coded the citations within the TDF domains using NVivo 14.23.2 (Lumivero). After coding, we mostly focused on retrieving the statements that provided additional information and were not captured by the questionnaire’s items and on the most often stated assertions. Any disagreements were resolved during the meeting with a senior researcher (A.S.). Results Sample characteristics The final sample comprised 258 non-physician HCPs, including primarily nurses (163 [63.2%]), psychologists/psychotherapists (26 [10.1%]), physiotherapists (22 [8.5%]), pharmacists (20 [7.8%]), and others (27 [10.4%]). Most respondents were women (203 [79.9%]), were younger than 40 years (143 [55.5%]), and had less than 10 years of experience (107 [41.8%]). Participant characteristics are presented in Table 1. Detailed characteristics by professional group and country are available in eTable 1 and eTable 2. Barriers and enablers Two items from the Knowledge domain emerged from the descriptive analysis as enablers for supporting BZRA deprescribing: 79.3% and 81.6% of participants were aware of the risks associated with BZRA use in older adults and the available alternatives, respectively. Major barriers were identified from the descriptive analysis in seven items. Four barriers fell within the Environmental Context and Resources domain, highlighting a lack of time, insufficient staff, low prioritisation of BZRA deprescribing by the healthcare system, and the absence of clear deprescribing objectives at the hospital or department level. Additionally, participants reported that their patients are reluctant to stop their BZRA (Social Influence), that they prioritise other aspects of patient care over deprescribing (Goals) and that they have not been trained to support patients in deprescribing (Skills). Other items were identified as moderate barriers. For instance, less than half (45.6%) of participants found it relevant to initiate deprescribing within their department (Social/Professional Role and Identity); 44.9% were unsure whether there are tools available to support them deprescribing (Environmental Context and Resources); and almost half (46.9%) were unsure whether their colleagues support BZRA deprescribing (Social influence). Detailed data on TDF items are provided in Figure 1. In the free-text responses, most of the open-ended questions were answered by nurses and pharmacists. Their answers predominantly fell under the Environmental Context and Resources domain, highlighting a lack of resources, the absence of standardised approaches to deprescribing, and the perception that acute hospital settings may not be the most appropriate setting for initiating deprescribing. Several responses related to the Social/Professional Role and Identity domain reflect that some non-physician HCPs, mostly physiotherapists, do not consider themselves suitable for supporting deprescribing. Additionally, some responses reflect issues related to Social Influences, with non-physician HCPs perceiving a lack of communication between hospital and primary care necessary for successful deprescribing and expressing concerns about patients’ fears regarding stopping their sleeping pills. Factors associated with intention and self-reported behaviour Intention to support BZRA deprescribing was distributed as follows: ’Strongly agree’ – 12.9%; ’Agree’ – 53.2%; Neither agree nor disagree’ – 27.8%; ’Disagree’ – 4.8%; ’Strongly disagree’ - 1.3%. Five TDF domains were significantly associated with higher odds of intention to deprescribe BZRA: Memory, Attention, and Decision Processing (OR: 1.80, 95% CI: 1.16 - 2.82), Social/Professional Role and Identity (OR: 3.08, 95% CI: 1.77 - 5.46), Beliefs about Consequences (OR: 1.91, 95% CI: 1.07 - 3.34), Reinforcement (OR: 1.57, 95% CI: 1.07 - 2.29) and Intentions to promote alternative approaches (OR: 1.63, 95% CI: 1.07 - 2.49). A total of 27.5% of participants self-reported routinely supporting BZRA deprescribing. Knowledge was the only TDF domain significantly associated with higher odds of routine support for BZRA deprescribing (OR: 1.6, 95% CI: 1.06 - 1.27). More details on both regression models are available in Tables 3 and 4. Comparative analysis of responses by HCP categories When analysing the data by professional group, the major barriers cited above were consistent across groups. However, significant differences in barriers and enablers were observed between professions. Pharmacists, and to a lesser extent, psychologists/psychotherapists, consistently scored higher across questionnaire items (items with a mean of 4 and higher). Several items in the Knowledge, Beliefs about Consequences, Intention, and Social Influence (from colleagues) domains were identified as enablers for both groups. Additional enablers were found for pharmacists in the Social/Professional Role and Identity, Skills, and Beliefs about Capabilities domains. Furthermore, most pharmacists reported being aware of existing BZRA deprescribing guidelines (Environmental Context and Resources). In contrast, physiotherapists had lower scores across many items, indicating they face the most significant barriers to supporting deprescribing. Detailed data are provided in eTable 4. Cross-country comparative responses from nurses The number of nurses in the sample (N=163) allowed cross-country comparisons. Major barriers were consistent across all six countries, including a lack of staff and time (Environmental Context and Resources), the belief that patients are reluctant to deprescribe (Social Influence), and the perception that other issues take priority over BZRA deprescribing (Goals). We found more enablers in Spain and, to some extent, in Switzerland and Belgium than in other countries. In these countries, intentions were higher, as was the perception of their professional role in supporting BZRA deprescribing. They also had the highest ratings in the Beliefs about Capabilities and Beliefs about Consequences domains. Conversely, we found no enablers and more major barriers among Greek and Polish nurses. In Poland, Greece, and Belgium, nurses generally did not support deprescribing unless requested. Additionally, between 36% and 48% of nurses in Poland, Greece, and Switzerland believed that deprescribing could negatively impact patients’ health. Greek nurses reported a lack of support from colleagues as a major barrier, marking almost the entire Social Influence domain as a significant barrier. Detailed data are provided in eTable 3. Discussion In this cross-sectional, multinational survey, we found that non-physician HCPs, irrespective of their professional role and country of work, face several major barriers: low prioritisation of deprescribing (Goals), lack of staff and time for deprescribing (Environmental Context and Resources), and a strong perception that patients are reluctant to deprescribe (Social Influence). Yet, we found differences across categories of non-physician HCPs and countries in moderate barriers and enablers. In addition, five TDF domains were significantly associated with non-physician HCPs’ intention to support BZRA deprescribing (Memory, Attention, and Decision Processing, Social/Professional Role and Identity, Beliefs about Consequences, Reinforcement and Intention to promote alternatives). Main barriers and implications In our results, many major barriers appeared in the Environmental Context and Resources domain, including limited time and staff. While increasing resources may not be realistic, other approaches may reinforce capacity and indirectly enhance perceptions of available resources and time. Providing tools such as algorithms, leaflets, or videos is one approach to optimise resources and efficiency. Another opportunity is to improve interprofessional collaboration between physicians and non-physician HCPs within and across settings. Previous studies have demonstrated that interventions promoting interprofessional collaboration can effectively address these barriers, yielding promising results for BZRA deprescribing (27,28). Since most non-physician HCPs in our sample recognise their responsibility to support BZRA deprescribing, enhancing interprofessional collaboration in such a context seems relevant and valuable. Similarly to our survey of physicians (18), two-thirds of non-physician HCPs perceive that most patients are reluctant to deprescribe. However, patients’ willingness to reduce their medication is greater than physicians perceive (29,30). Additionally, studies show that patients often lack knowledge about the risks of prolonged BZRA use or hold misleading beliefs about its benefits (16,31,32). Non-physician HCPs could effectively support patients by providing clear and trustworthy information and initiating conversations about BZRA use. However, since the non-physician HCPs in the present survey reported a lack of training, educational interventions are crucial to improve non-physician HCPs’ knowledge, skills, and confidence in the benefits of BZRA deprescribing. While previous educational interventions have focused mostly on physicians (33–36), showing significant improvements in knowledge and beliefs, studies targeting non-physician HCPs are fewer but show similar potential (12). Lastly, the Goals domain suggests that non-physician HCPs prioritise other healthcare issues over BZRA deprescribing. Across all surveyed countries, BZRA deprescribing is not part of non-physician HCPs’ typical roles, which likely influences their behaviour. However, this does not mean they consider deprescribing unimportant. Future interventions should explore ways to elevate its priority and integrate it with other in-role responsibilities. Factors associated with intention Several TDF domains were associated with the intention to support BZRA deprescribing. Interestingly, these domains were similar to those identified in our survey of physicians (18). This suggests that similar implementation interventions to support increasing motivation could be used with physicians and non-physician HCPs to enhance intentions to deprescribe. Similarities and differences among non-physician HCPs’ categories and countries. Pharmacists reported fewer barriers and more enablers to support deprescribing, highlighting the highest levels of professional identification, knowledge, skills, self-efficacy, and intention. This aligns with evidence of pharmacists’ positive impact on deprescribing (37,38). However, their roles vary across countries. In this study, pharmacists were from Belgium, Spain, and Switzerland, but in other countries, they may not be involved in direct patient care, requiring different approaches to deprescribing interventions, or new developments around pharmaceutical care. Our findings suggest that psychologists and psychotherapists are willing to support deprescribing and often see themselves as suitable specialists for this role. Given that recent guidelines recommend cognitive-behavioural therapy as the first-line treatment for sleep problems (39–41), it is important to strengthen the role of psychologists in promoting BZRA alternatives. However, due to the limited data from previous research and the small sample size in our study, we could not fully evaluate their contribution, highlighting the need for further research. In contrast, physiotherapists face significant barriers, such as low perception of their role in BZRA deprescribing for older adults, making their involvement potentially resource-intensive with limited benefits. Therefore, prioritising other healthcare professionals, like pharmacists, nurses and psychologists, might be more effective, although the best approach may differ by country. In the cross-country analysis of nurses, key barriers were consistent across all countries. Yet, we also found pronounced differences. These discrepancies may stem from variations in nurse training programmes, prior experience with BZRA deprescribing, or differences in healthcare organisations. Additionally, the departments where nurses in our study worked varied across countries, which may also have influenced the barriers they faced. Some nurses’ barriers, like stronger knowledge and training on BZRA deprescribing, are easier to address. Others, such as reinforcing nurses’ roles in deprescribing or strengthening interprofessional collaboration, are more complex and may require organisational changes. Strengths and limitations Our study has several strengths. First, we used a theoretical framework to comprehensively report the barriers and enablers that non-physician HCPs face while deprescribing. This helps our findings contribute to a consistent and cumulative evidence base. Second, it is one of the few studies focusing on non-physician HCPs in the hospital setting, exploring their perspectives on BZRA deprescribing support. Third, we collected data from non-physician HCPs across six countries, with questionnaires translated into 6 languages. However, this study has several limitations. The self-reported nature of the questionnaire may lead to social desirability bias. While categorising items by means allowed us to divide them into major or moderate barriers and enablers, this method is based on the research team consensus, so the interpretation of results should be cautiously approached. Furthermore, we did not have data on the departments or wards where non-physician HCPs worked, even though differences in care objectives and work organisation across departments could be significant. Lastly, while interesting findings emerged from the open questions, this qualitative analysis was still limited to two non-mandatory open questions. A parallel study conducted on healthcare trajectories is ongoing and will complete our findings. Conclusion Non-physician HCPs face several behavioural barriers in supporting patients or physicians with BZRA deprescribing, including limited knowledge, lack of capacity, motivation, and opportunities. Major barriers were similar across professional categories and countries, suggesting that improvement approaches may share core strategies or components. Beyond nurses, pharmacists and psychologists—where available—could take a proactive role. Contextualising these barriers according to the country’s healthcare organisation can facilitate successfully implementing strategies to tackle them. Conflict of Interest Disclosures: The authors declare no conflict of interest. Ethics Committee and Informed consent: The study protocol received approval from all local ethics committees where the survey was conducted: CHU UCL Namur, site Godinne (approval number: B0392022000083, Belgium); Bioethics Committee of the Institute of Psychiatry and Neurology (approval number: 39/2022, Poland); Regional Committee for Medical and Health Research Ethics (approval number: 546244, Norway); Ethics Committee of Eginition Hospital (approval number: 900/22-11-2022, Greece); and The Commission on Ethics in Animal and Human Experimentation (CEEAH) of the Universitat Autònoma de Barcelona (approval number: CEEAH 6351, Spain). In Switzerland, ethical approval was waived by the Ethical Committee of the Canton of Bern following Swiss regulations on human research (Request number: Req-2022-01423). Informed consent was obtained from each participant, except in Switzerland, where the ethics committee does not require signed informed consent from healthcare professionals. Author Contributions: Questionnaire conception: items development Anne Spinewine, Vladyslav Shapoval, Perrine Evrard; items revision: all co-authors. Protocol development: Vladyslav Shapoval and Anne Spinewine – protocol revision: all co-authors. Authors contributing to the data collection are Vladyslav Shapoval, and Anne Spinewine in Belgium, Vagioula Tsoutsi, Maria Ntafouli in Greece, Adam Wichniak, Katarzyna Gustavsson in Poland, Torgeir Bruun Wyller, Enrico Callegari in Norway, Laura Fernández Maldonado, Ramon Miralles Basseda in Spain, and Carole E. Aubert and Lucy Bolt in Switzerland. Data analyses: Vladyslav Shapoval, Séverine Henrard, Perrine Evrard, Anne Spinewine. Writing–original draft: Vladyslav Shapoval, Anne Spinewine; review & editing: all co-authors. Funding/Support: This study received funding from the European Union’s Horizon Europe research and innovation program under grant agreement No 101057123 and the Swiss State Secretariat for Education, Research and Innovation (SERI) (contract No 22.00116). Carole E. Aubert was also supported by the Swiss National Science Foundation (grant PZ00P3_201672 / 1). François-Xavier Sibille was supported by a grant “Clinical Master Specialist Applicant for a Ph.D.” of the Fonds de la Recherche Scientifique – FNRS (Belgium). Role of the Funder/Sponsor: The funders were not involved in the study’s design, execution, data collection, management, analysis, interpretation, manuscript preparation, review, approval, or the decision to submit it for publication. Disclaimer: The views and opinions expressed are solely those of the authors and do not necessarily represent those of the European Union or the Swiss State Secretariat for Education, Research and Innovation (SERI). Data Sharing Statement: The data dictionary and de-identified data will be made available to others. The data dictionary can be accessed on the Open Science Framework (OSF) platform via the link: To obtain the data, please contact [email protected] or [email protected] . The data will be provided to anyone who requests it and specifies the purpose of their analysis. There will be no restrictions on the type of analysis or any other limitations on access. AI Use in Manuscript Preparation: We acknowledge the use of ChatGPT, version 4.0, developed by OpenAI, for language editing in various sections of this manuscript in February 2025. The authors reviewed and modified the content as needed and took full responsibility for the final published version. not-yet-known not-yet-known not-yet-known unknown References 1. Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ. 2005 Nov 19;331(7526):1169. 2. 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Background characteristics of non-physician healthcare professionals (N=258) Country Belgium 47 (18.2) Greece 47 (18.2) Norway 36 (14) Poland 50 (19.4) Spain 38 (14.7) Switzerland 40 (15.5) Age, y ≤ 30 77 (29.9) 31 – 40 66 (25.6) 41 – 50 61 (23.6) 51 – 60 48 (18.6) ≥ 61 6 (2.3) Gender Men 51 (20.1) Women 203 (79.9) HCPs ’ categories Nurse 163 (63.2) Pharmacist 20 (7.8) Psychologist/Psychotherapist 26 (10.1) Physiotherapist 22 (8.5) Others b 27 (10.4) Type of care Inpatients 147 (58.8) Outpatients (seen in clinics) 50 (20) Both (inpatients/outpatients) 53 (21.2) Experience, y Less than 5 years 64 (25) 5 – 9 years 43 (16.8) 10 – 14 years 50 (19.5) 15 – 19 years 26 (10.1) 20 years or more 73 (28.6) Supporting deprescribing before Yes 140 (57.6) No 103 (42.4) Routine deprescribing support Yes 65 (27.5) No 171 (72.5) HCP: Healthcare professional; a missing response (excluded from percentages) totalled 4 participants for Gender, 8 for Type of practice, 2 for Experience, 15 for supporting deprescribing before, and 17 for routine support of deprescribing. b “Other” includes 10 care assistants (caregivers), five occupational therapists, one radiology technician, and 11 individuals whose roles could not be identifie Table 2. Factors associated with self-reported intentions to support BZRA deprescribing in multivariable ordinal logistic regression for non-physician healthcare professionals (N = 217) a Background characteristics Country [Belgium is reference] Greece Norway Poland Spain Switzerland 0.41 0.37 0.62 0.48 1.73 0.15 - 1.09 0.12 - 1.06 0.21 - 1.83 0.16 - 1.40 0.55 - 5.45 0.08 0.07 0.39 0.18 0.35 TDF-variables c Skills 1.51 0.92 - 2.50 0.10 Memory, Attention, and Decision Processing 1.80 1.16 - 2.82 < 0.001 b Beliefs about Consequences 1.91 1.07 - 3.34 0.03 b Social/Professional Role and Identity 3.08 1.77 - 5.46 < 0.001 b Reinforcement 1.57 1.08 - 2.29 0.02 b Intention (to promote alternative approaches) 1.63 1.07 - 2.49 0.02 b Social Influence 1.58 0.96 - 2.62 0.07 OR – Odds ratio; CI – Confidence interval; TDF – Theoretical Domain Framework. a 41 individuals had missing data in some of the variables included in the model and were thus excluded. b significant result. c Scores at the TDF domain level were computed by averaging item scores for each domain. Table 3. Factors associated with self-reported routine support BZRA deprescribing, in multivariable binary logistic regression for non-physician healthcare professionals (N = 217) a Background characteristics Country [Belgium is reference] Greece Norway Poland Spain Switzerland 1.00 1.09 0.88 1.12 0.83 0.84 - 1.20 0.90- 1.33 0.72 - 1.07 0.93 - 1.35 0.67 - 1.02 0.95 0.36 0.20 0.24 0.07 TDF-variables c Knowledge 1.16 1.06 - 1.27 < 0.001 b Memory, Attention, and Decision Processing 1.07 0.99 - 1.15 0.10 Social/Professional Role and Identity 1.08 0.99 - 1.18 0.09 Environmental Context and Resources 1.07 0.97 - 1.19 0.16 OR – Odds ratio; CI – Confidence interval; TDF – Theoretical Domain Framework. a The software automatically omitted 41 individuals due to missing data in some of the variables included in the model. b significant result. c Scores at the TDF domain level were computed by averaging item scores for each domain. Figure 1: Barriers to BZRA deprescribing by TDF-based items for healthcare professionals (N=258) * Reversed scorings. SD: standard deviation; TDF: Theoretical domain Framework; BZRA: Benzodiazepine Receptor Agonist. Items are measured on a 5-point Likert scale from 1 (”Strongly disagree”) to 5 (”Strongly agree”) E indicates enabler (mean≥ 4); mB moderate barrier (mean: 3-3.99); MB major barriers (mean< 3) TDF domains: Knw. – Knowledge; Skl. – Skills; MAD – Memory, Attention, and Decision Processing; SPRaI –Social/Professional Role and Identity; BaCap. – Beliefs about Capabilities; BaCon. – Beliefs about Consequences; Ren. -Reinforcement; Gol. – Goals; In. – Intentions; Em. – Emotions; ECaR – Environmental Context and Resources; Soc.Inf. – Social Influence. Information & Authors Information Version history V1 Version 1 09 April 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Collection Basic & Clinical Pharmacology & Toxicology Authors Affiliations Vladyslav Shapoval 0009-0005-0209-1879 [email protected] Universite catholique de Louvain Louvain Drug Research Institute View all articles by this author Perrine Evrard Universite catholique de Louvain Louvain Drug Research Institute View all articles by this author François-Xavier Sibille Universite catholique de Louvain Louvain Drug Research Institute View all articles by this author María López-Toribio Universite catholique de Louvain Louvain Drug Research Institute View all articles by this author Olivia Dalleur Universite catholique de Louvain Louvain Drug Research Institute View all articles by this author Carole E. Aubert Inselspital Universitatsspital Bern View all articles by this author Lucy Bolt Inselspital Universitatsspital Bern View all articles by this author Vagioula Tsoutsi Ethniko kai Kapodistriako Panepistemio Athenon Ergasterio Anatomias - Anatomeio View all articles by this author Maria Ntafouli Ethniko kai Kapodistriako Panepistemio Athenon Ergasterio Anatomias - Anatomeio View all articles by this author Laura Fernández Maldonado Universitat Autonoma de Barcelona Fundacio Salut i Envelliment View all articles by this author Ramon Miralles Universitat Autonoma de Barcelona Fundacio Salut i Envelliment View all articles by this author Adam Wichniak Instytut Psychiatrii i Neurologii w Warszawie View all articles by this author Katarzyna Gustavsson Instytut Psychiatrii i Neurologii w Warszawie View all articles by this author Torgeir Wyller Oslo universitetssykehus Oslo sykehusservice View all articles by this author Enrico Callegari Oslo universitetssykehus Oslo sykehusservice View all articles by this author Jeremy Grimshaw M Ottawa Hospital Research Institute Centre for Implementation Research View all articles by this author Justin Presseau Ottawa Hospital Research Institute Centre for Implementation Research View all articles by this author Séverine Henrard Universite catholique de Louvain Louvain Drug Research Institute View all articles by this author Anne Spinewine Universite catholique de Louvain Louvain Drug Research Institute View all articles by this author Metrics & Citations Metrics Article Usage 453 views 195 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Vladyslav Shapoval, Perrine Evrard, François-Xavier Sibille, et al. 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