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  • 1.
    Asaye, Mengstu Melkamu
    et al.
    University of Gondar, Gondar, Ethiopia.
    Gelaye, Kassahun Alemu
    University of Gondar, Gondar, Ethiopia.
    Matebe, Yohannes Hailu
    University of Gondar, Gondar, Ethiopia.
    Lindgren, Helena
    Karolinska Institutet, Solna; Sofiahemmet University, Stockholm.
    Erlandsson, Kerstin
    Dalarna University, School of Health and Welfare, Sexual Reproductive Perinatal Health. Karolinska Institutet, Solna.
    Experience and perceptions of healthcare providers on clinical management and care of near-miss infants: a qualitative content analysis2023In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 23, no 1, article id 1403Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Neonatal Near Miss (NNM) refers to neonates with severe complications who almost died but survived immediately after birth. In Ethiopia, the prevalence of NNM has been assessed using a validated Neonatal Near-Miss Assessment Scale. However, understanding the experiences and perceptions of healthcare providers in the clinical management and care of NNM infants remains unexplored. The aim was to investigate the determinants contributing to the survival of neonatal near-miss babies and to identify any barriers encountered, as reported by the experiences of healthcare providers in public hospitals of Amhara Regional State, northwest Ethiopia.

    METHODS: Semi structured interviews were used to collect data from 25 midwives, nurses, and pediatricians with at least six months of prior experience in one of the labor wards or neonatal intensive care units at one of the four public health hospitals in the Amhara Regional state of northwest Ethiopia included in a large intervention study assessing a NNM scale. Purposeful sampling was used, selecting participants based on their experiences related to the aim of this study. The participants had a varying level of education and years of experience to care for NNM infants. The average age of the healthcare providers was 31 years, with 7 years of work experience. The transcripts of the interviews with the healthcare providers were analyzed using qualitative content analysis.

    RESULTS: The experience and perceptions of healthcare providers was described in the main category "A sense of hopelessness when caring for the baby" capturing a broader emotional and professional aspect, while the subcategories "Unclear responsibilities discharging one's mission", "Provision of kangaroo mother care" and "Quick action required at birth" are more specific and practical. Healthcare providers perceived a sense of hopelessness when caring for the NNM infant, particularly providing Kangaroo Mother Care (KMC) and quick actions when required at birth to save the life of the infant.

    CONCLUSION: Unclear responsibilities and a sense of hopelessness could have acted as barriers, hindering the ability of healthcare providers to fulfill their mission of taking swift actions and providing KMC to NNM infants, thus impacting their ability to save the lives of these infants. Healthcare providers' and parents' attitudes must be changed towards hope rather than hopelessness when caring for NNM infants.

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  • 2.
    Bogren, Malin
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Erlandsson, Kerstin
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Byrskog, Ulrika
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    What prevents midwifery quality care in Bangladesh? A focus group enquiry with midwifery students2018In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 18, no 1, article id 639Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: With professional midwives being introduced in Bangladesh in 2013, the aim of this study was to describe midwifery students perceptions on midwives' realities in Bangladesh, based on their own experiences.

    METHOD: Data were collected through 14 focus group discussions that included a total of 67 third-year diploma midwifery students at public nursing institutes/colleges in different parts of Bangladesh. Data were analyzed deductively using an analytical framework identifying social, professional and economical barriers to the provision of quality care by midwifery personnel.

    RESULTS: The social barriers preventing midwifery quality care falls outside the parameters of Bangladeshi cultural norms that have been shaped by beliefs associated with religion, society, and gender norms. This puts midwives in a vulnerable position due to cultural prejudice. Professional barriers include heavy workloads with a shortage of staff who were not utilized to their full capacity within the health system. The reason for this was a lack of recognition in the medical hierarchy, leaving midwives with low levels of autonomy. Economical barriers were reflected by lack of supplies and hospital beds, midwives earning only low and/or irregular salaries, a lack of opportunities for recreation, and personal insecurity related to lack of housing and transportation.

    CONCLUSION: Without adequate support for midwives, to strengthen their self-confidence through education and through continuous professional and economic development, little can be achieved in terms of improving quality care of women during the period around early and late pregnancy including childbirth.The findings can be used for discussions aimed to mobilize a midwifery workforce across the continuum of care to deliver quality reproductive health care services. No matter how much adequate support is provided to midwives, to strengthen their self-confidence through education, continuous professional and economic development, addressing the social barriers is a prerequisite for provision of quality care.

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  • 3.
    Borg, Johan
    et al.
    Lunds universitet.
    Larsson, Stig
    Östergren, Per-Olof
    Rahman, A. S. M. Atiqur
    Bari, Nazmul
    Khan, A. H. M. Noman
    User involvement in service delivery predicts outcomes of assistive technology use: A cross-sectional study in Bangladesh2012In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 12, article id 330Article in journal (Refereed)
    Abstract [en]

    Background: Knowledge about the relation between user involvement in the provision of assistive technology and outcomes of assistive technology use is a prerequisite for the development of efficient service delivery strategies. However, current knowledge is limited, particularly from low-income countries where affordability is an issue. The objective was therefore to explore the relation between outcomes of assistive technology use and user involvement in the service delivery process in Bangladesh. Methods: Using structured interviews, data from 136 users of hearing aids and 149 users of manual wheelchairs were collected. Outcomes were measured using the International Outcome Inventory for Hearing Aids (IOI-HA), which was adapted for wheelchair users. Predictors of user involvement included preference, measurement and training. Results: Users reported outcomes comparable to those found in other high- and low-income countries. User involvement increased the likelihood for reporting better outcomes except for measurement among hearing aid users. Conclusions: The findings support the provision of assistive technology as a strategy to improve the participation of people with disabilities in society. They also support current policies and guidelines for user-involvement in the service delivery process. Simplified strategies for provision of hearing aids may be explored.

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  • 4. Bostrom, Anne-Marie
    et al.
    Rudman, Ann
    Karolinska Institutet.
    Ehrenberg, Anna
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Gustavsson, Jens Petter
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska Inst, Dept Neurobiol Care Sci & Soc, Div Nursing, Huddinge, Sweden.
    Factors associated with evidence-based practice among registered nurses in Sweden: a national cross-sectional study2013In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 13, article id 165Article in journal (Refereed)
    Abstract [en]

    Background: Evidence-based practice (EBP) is emphasized to increase the quality of care and patient safety. EBP is often described as a process consisting of distinct activities including, formulating questions, searching for information, compiling the appraised information, implementing evidence, and evaluating the resulting practice. To increase registered nurses' (RNs') practice of EBP, variables associated with such activities need to be explored. The aim of the study was to examine individual and organizational factors associated with EBP activities among RNs 2 years post graduation.

    Methods: A cross-sectional design based on a national sample of RNs was used. Data were collected in 2007 from a cohort of RNs, included in the Swedish Longitudinal Analyses of Nursing Education/Employment study. The sample consisted of 1256 RNs (response rate 76%). Of these 987 RNs worked in healthcare at the time of the data collection. Data was self-reported and collected through annual postal surveys. EBP activities were measured using six single items along with instruments measuring individual and work-related variables. Data were analyzed using logistic regression models.

    Results: Associated factors were identified for all six EBP activities. Capability beliefs regarding EBP was a significant factor for all six activities (OR = 2.6 - 7.3). Working in the care of older people was associated with a high extent of practicing four activities (OR = 1.7 - 2.2). Supportive leadership and high collective efficacy were associated with practicing three activities (OR = 1.4 - 2.0).

    Conclusions: To be successful in enhancing EBP among newly graduated RNs, strategies need to incorporate both individually and organizationally directed factors.

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  • 5.
    Crilly, Julia
    et al.
    Gold Coast Health, Southport, QLD, Australia; Griffith University, Southport, QLD, Australia.
    Sweeny, Amy
    Gold Coast Health, Southport, QLD, Australia; Griffith University, Southport, QLD, Australia.
    Muntlin, Åsa
    Uppsala University, Uppsala.
    Green, David
    Gold Coast Health, Southport, QLD, Australia.
    Malyon, Lorelle
    Queensland Children's Hospital, Children's Health Queensland, Brisbane, QLD, Australia.
    Christofis, Luke
    Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia.
    Higgins, Malcolm
    Women's and Children's Hospital, North Adelaide, South Australia, Australia.
    Källberg, Ann-Sofie
    Dalarna University, School of Health and Welfare, Caring Science/Nursing. Falun Hospital, Falun.
    Dellner, Sara
    Region Stockholm, Stockholm.
    Myrelid, Åsa
    Uppsala University Children's Hospital, Uppsala.
    Djärv, Therese
    Karolinska University Hospital, Stockholm; Karolinska Institutet, Solna, Stockholm.
    Göransson, Katarina
    Dalarna University, School of Health and Welfare, Caring Science/Nursing. Karolinska Institutet, Solna, Stockholm.
    Factors predictive of hospital admission for children via emergency departments in Australia and Sweden: an observational cross-sectional study2024In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 24, no 1, article id 235Article in journal (Refereed)
    Abstract [en]

    Background: Identifying factors predictive of hospital admission can be useful to prospectively inform bed management and patient flow strategies and decrease emergency department (ED) crowding. It is largely unknown if admission rate or factors predictive of admission vary based on the population to which the ED served (i.e., children only, or both adults and children). This study aimed to describe the profile and identify factors predictive of hospital admission for children who presented to four EDs in Australia and one ED in Sweden.

    Methods: A multi-site observational cross-sectional study using routinely collected data pertaining to ED presentations made by children < 18 years of age between July 1, 2011 and October 31, 2012. Univariate and multivariate analysis were undertaken to determine factors predictive of hospital admission.

    Results: Of the 151,647 ED presentations made during the study period, 22% resulted in hospital admission. Admission rate varied by site; the children's EDs in Australia had higher admission rates (South Australia: 26%, Queensland: 23%) than the mixed (adult and children's) EDs (South Australia: 13%, Queensland: 17%, Sweden: 18%). Factors most predictive of hospital admission for children, after controlling for triage category, included hospital type (children's only) adjusted odds ratio (aOR):2.3 (95%CI: 2.2-2.4), arrival by ambulance aOR:2.8 (95%CI: 2.7-2.9), referral from primary health aOR:1.5 (95%CI: 1.4-1.6) and presentation with a respiratory or gastrointestinal condition (aOR:2.6, 95%CI: 2.5-2.8 and aOR:1.5, 95%CI: 1.4-1.6, respectively). Predictors were similar when each site was considered separately.

    Conclusions: Although the characteristics of children varied by site, factors predictive of hospital admission were mostly similar. The awareness of these factors predicting the need for hospital admission can support the development of clinical pathways.

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  • 6. Ekman, Björn
    et al.
    McKee, Kevin
    Dalarna University, School of Health and Welfare, Social Work.
    Vicente, Joana
    Magnusson, Lennart
    Hanson, Elizabeth
    Cost analysis of informal care: estimates from a national cross-sectional survey in Sweden.2021In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 21, no 1, article id 1236Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Over the past decades, informal care has increased in most OECD-countries. Informal care is costly to caregivers and to society in the form of lost income and direct costs of providing care. Existing evidence suggests that providing informal care affects caregivers' overall health. However, estimates of the social costs of informal care based on national data on individuals are currently scarce.

    OBJECTIVE: This study contributes to the existing evidence on the costs of informal care by estimating the direct and indirect costs to caregivers using a purposive national household survey from Sweden.

    METHODS: Adopting a bottom-up, prevalence approach, the direct and indirect costs are estimated using the survey data and the value of working time and leisure time from existing sources.

    RESULTS: The results suggest that around 15% of the adult population of Sweden provide informal care and that such care costs around SEK 152 billion per year (around 3% of GDP; USD 16,3 billion; EUR 14,5 billion), or SEK 128000 per caregiver. Around 55% of costs are in the form of income loss to caregivers. The largest cost items are reduced work hours and direct costs of providing informal care. Replacing informal caregivers with professional care providers would be costly at around SEK 193,6 billion per year.

    CONCLUSIONS: Findings indicate that, even in a country with a relatively generous welfare system, significant resources are allocated toward providing informal care. The costing analysis suggests that effective support initiatives to ease the burden of informal caregivers may be cost-effective.

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  • 7.
    Eldh, Ann Catrine
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Almost, Joan
    DeCorby-Watson, Kara
    Gifford, Wendy
    University of Ottawa.
    Harvey, Gill
    University of Adelaide.
    Hasson, Henna
    Karolinska Institutet.
    Kenny, Deborah
    Moodie, S
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Yost, J
    Clinical interventions, implementation interventions, and the potential greyness in between - a discussion paper2017In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 17, no 1, article id 16Article in journal (Refereed)
    Abstract [en]

    Background: There is increasing awareness that regardless of the proven value of clinical interventions, the use of effective strategies to implement such interventions into clinical practice is necessary to ensure that patients receive the benefits. However, there is often confusion between what is the clinical intervention and what is the implementation intervention. This may be caused by a lack of conceptual clarity between 'intervention' and 'implementation', yet at other times by ambiguity in application. We suggest that both the scientific and the clinical communities would benefit from greater clarity; therefore, in this paper, we address the concepts of intervention and implementation, primarily as in clinical interventions and implementation interventions, and explore the grey area in between. Discussion: To begin, we consider the similarities, differences and potential greyness between clinical interventions and implementation interventions through an overview of concepts. This is illustrated with reference to two examples of clinical interventions and implementation intervention studies, including the potential ambiguity in between. We then discuss strategies to explore the hybridity of clinical-implementation intervention studies, including the role of theories, frameworks, models, and reporting guidelines that can be applied to help clarify the clinical and implementation intervention, respectively. Conclusion: Semantics provide opportunities for improved precision in depicting what is 'intervention' and what is 'implementation' in health care research. Further, attention to study design, the use of theory, and adoption of reporting guidelines can assist in distinguishing between the clinical intervention and the implementation intervention. However, certain aspects may remain unclear in analyses of hybrid studies of clinical and implementation interventions. Recognizing this potential greyness can inform further discourse.

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  • 8.
    Eldh, Ann Catrine
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet.
    Ehrenberg, Anna
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Squires, J.A.
    Estabrooks, C.E.
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Translating and testing the Alberta Context Tool for use among nurses in Swedish elder care2013In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 13, article id 68Article in journal (Refereed)
    Abstract [en]

    Background. There is emerging evidence that context is important for successful transfer of research knowledge into health care practice. The Alberta Context Tool (ACT) is a Canadian developed research-based instrument that assesses 10 modifiable concepts of organizational context considered important for health care professionals’ use of evidence. Swedish and Canadian health care have similarities in terms of organisational and professional aspects, suggesting that the ACT could be used for measuring context in Sweden. This paper reports on the translation of the ACT to Swedish and a testing of preliminary aspects of its validity, acceptability and reliability in Swedish elder care.

    Methods. The ACT was translated into Swedish and back-translated into English before being pilot tested in ten elder care facilities for response processes validity, acceptability and reliability (Cronbach’s alpha). Subsequently, further modification was performed.

    Results. In the pilot test, the nurses found the questions easy to respond to (52%) and relevant (65%), yet the questions’ clarity were mainly considered ‘neither clear nor unclear’ (52%). Missing data varied between 0 (0%) and 19 (12%) per item, the most common being 1 missing case per item (15 items). Internal consistency (Cronbach’s Alpha > .70) was reached for 5 out of 8 contextual concepts. Translation and back translation identified 21 linguistic- and semantic related issues and 3 context related deviations, resolved by developers and translators.

    Conclusion. Modifying an instrument is a detailed process, requiring time and consideration of the linguistic and semantic aspects of the instrument, and understanding of the context where the instrument was developed and where it is to be applied. A team, including the instrument’s developers, translators, and researchers is necessary to ensure a valid translation. This study suggests preliminary validity, reliability and acceptability evidence for the ACT when used with nurses in Swedish elder care.

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  • 9.
    Eldh, Ann Catrine
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Uppsala universitet.
    Fredriksson, Mio
    Uppsala universitet.
    Halford, Christina
    Uppsala universitet.
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Dahlström, Tobias
    Uppsala universitet.
    Vengberg, Sofie
    Uppsala universitet.
    Winblad, Ulrika
    Uppsala universitet.
    Facilitators and barriers to applying a national quality registry for quality improvement in stroke care2014In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 14, article id 354Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: National quality registries (NQRs) purportedly facilitate quality improvement, while neither the extent nor the mechanisms of such a relationship are fully known. The aim of this case study is to describe the experiences of local stakeholders to determine those elements that facilitate and hinder clinical quality improvement in relation to participation in a well-known and established NQR on stroke in Sweden.

    METHODS: A strategic sample was drawn of 8 hospitals in 4 county councils, representing a variety of settings and outcomes according to the NQR's criteria. Semi-structured telephone interviews were conducted with 25 managers, physicians in charge of the Riks-Stroke, and registered nurses registering local data at the hospitals. Interviews, including aspects of barriers and facilitators within the NQR and the local context, were analysed with content analysis.

    RESULTS: An NQR can provide vital aspects for facilitating evidence-based practice, for example, local data drawn from national guidelines which can be used for comparisons over time within the organisation or with other hospitals. Major effort is required to ensure that data entries are accurate and valid, and thus the trustworthiness of local data output competes with resources needed for everyday clinical stroke care and quality improvement initiatives. Local stakeholders with knowledge of and interest in both the medical area (in this case stroke) and quality improvement can apply the NQR data to effectively initiate, carry out, and evaluate quality improvement, if supported by managers and co-workers, a common stroke care process and an operational management system that embraces and engages with the NQR data.

    CONCLUSION: While quality registries are assumed to support adherence to evidence-based guidelines around the world, this study proposes that a NQR can facilitate improvement of care but neither the registry itself nor the reporting of data initiates quality improvement. Rather, the local and general evidence provided by the NQR must be considered relevant and must be applied in the local context. Further, the quality improvement process needs to be facilitated by stakeholders collaborating within and outside the context, who know how to initiate, perform, and evaluate quality improvement, and who have the resources to do so.

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  • 10.
    Eldh, Ann Catrine
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Uppsala universitet.
    Fredriksson, Mio
    Uppsala universitet.
    Vengberg, Sofie
    Uppsala universitet.
    Halford, Christina
    Uppsala universitet.
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet.
    Dahlström, Tobias
    Uppsala universitet.
    Winblad, Ulrika
    Uppsala universitet.
    Depicting the interplay between organisational tiers in the use of a national quality registry to develop quality of care in Sweden2015In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 15, no 1, article id 519Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: With a pending need to identify potential means to improved quality of care, national quality registries (NQRs) are identified as a promising route. Yet, there is limited evidence with regards to what hinders and facilitates the NQR innovation, what signifies the contexts in which NQRs are applied and drive quality improvement. Supposedly, barriers and facilitators to NQR-driven quality improvement may be found in the healthcare context, in the politico-administrative context, as well as with an NQR itself. In this study, we investigated the potential variation with regards to if and how an NQR was applied by decision-makers and users in regions and clinical settings. The aim was to depict the interplay between the clinical and the politico-administrative tiers in the use of NQRs to develop quality of care, examining an established registry on stroke care as a case study.

    METHODS: We interviewed 44 individuals representing the clinical and the politico-administrative settings of 4 out of 21 regions strategically chosen for including stroke units representing a variety of outcomes in the NQR on stroke (Riksstroke) and a variety of settings. The transcribed interviews were analysed by applying The Consolidated Framework for Implementation Research (CFIR).

    RESULTS: In two regions, decision-makers and/or administrators had initiated healthcare process projects for stroke, engaging the health professionals in the local stroke units who contributed with, for example, local data from Riksstroke. The Riksstroke data was used for identifying improvement issues, for setting goals, and asserting that the stroke units achieved an equivalent standard of care and a certain level of quality of stroke care. Meanwhile, one region had more recently initiated such a project and the fourth region had no similar collaboration across tiers. Apart from these projects, there was limited joint communication across tiers and none that included all individuals and functions engaged in quality improvement with regards to stroke care.

    CONCLUSIONS: If NQRs are to provide for quality improvement and learning opportunities, advances must be made in the links between the structures and processes across all organisational tiers, including decision-makers, administrators and health professionals engaged in a particular healthcare process.

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  • 11.
    Elf, Marie
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Flink, Maria
    Karolinska Institutet .
    Nilsson, Marie
    Karolinska Institutet .
    Tistad, Malin
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    von Koch, Lena
    Karolinska Institutet .
    Ytterberg, Charlotte
    Karolinska Institutet .
    The case of value-based healthcare for people living with complex long-term conditions2017In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 17, no 1, p. 1-6, article id 24Article in journal (Refereed)
    Abstract [en]

    Background

    There is a trend towards value-based health service, striving to cut costs while generating value for the patient. The overall objective comprises higher-quality health services and improved patient safety and cost efficiency. The approach could align with patient-centred care, as it entails a focus on the patient’s experience of her or his entire cycle of care, including the use of well-defined outcome measurements. Challenges arise when the approach is applied to health services for people living with long-term complex conditions that require support from various healthcare services. The aim of this work is to critically discuss the value-based approach and its implications for patients with long-term complex conditions. Two cases from clinical practice and research form the foundation for our reasoning, illustrating several challenges regarding value-based health services for people living with long-term complex conditions.

    Discussion

    Achieving value-based health services that provide the health outcomes that matter to patients and providing greater patient-centredness will place increased demands on the healthcare system. Patients and their informal caregivers must be included in the development and establishment of outcome measures. The outcome measures must be standardized to allow evaluation of specific conditions at an aggregated level, but they must also be sensitive enough to capture each patient’s individual needs and goals. Healthcare systems that strive to establish value-based services must collaborate beyond the organizational boundaries to create clear patient trajectories in order to avoid fragmentation.

    Summary

    The shift towards value-based health services has the potential to align healthcare-service delivery with patient-centred care if serious efforts to take the patient’s perspective into account are made. This is especially challenging in fragmented healthcare systems and for patients with long-term- and multi-setting-care needs.

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  • 12.
    Elf, Marie
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Fröst, Peter
    Chalmers Tekniska Högskola.
    Lindahl, Göran
    Chalmers Tekniska Högskola.
    Wijk, Helle
    Shared-decision making in designing new healthcare environments: ready to take off for improved quality2015In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 15, article id 114Article in journal (Refereed)
    Abstract [en]

    Background

    Successful implementation of new methods and models of healthcare to achieve better patient outcomes and safe, person-centered care is dependent on the physical environment of the healthcare architecture in which the healthcare is provided. Thus, decisions concerning healthcare architecture are critical because it affects people and work processes for many years and requires a long-term financial commitment from society. In this paper, we describe and suggest several strategies (critical factors) to promote shared-decision making when planning and designing new healthcare environments.

    Discussion

    This paper discusses challenges and hindrances observed in the literature and from the authors extensive experiences in the field of planning and designing healthcare environments. An overview is presented of the challenges and new approaches for a process that involves the mutual exchange of knowledge among various stakeholders. Additionally, design approaches that balance the influence of specific and local requirements with general knowledge and evidence that should be encouraged are discussed.

    Summary

    We suggest a shared-decision making and collaborative planning and design process between representatives from healthcare, construction sector and architecture based on evidence and end-users’ perspectives. If carefully and systematically applied, this approach will support and develop a framework for creating high quality healthcare environments.

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  • 13.
    Elf, Marie
    et al.
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Poutilova, M
    von Koch, L
    Öhrn, Kerstin
    Dalarna University, School of Education, Health and Social Studies, Health and Caring Sciences/Oral Health Science.
    Using system dynamics for collaborative design: a case study2007In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 7, no 123Article in journal (Refereed)
    Abstract [en]

    Background 

    In order to facilitate the collaborative design, system dynamics (SD) with a group modelling approach was used in the early stages of planning a new stroke unit. During six workshops a SD model was created in a multiprofessional group.

    Aim

    To explore to which extent and how the use of system dynamics contributed to the collaborative design process.

    Method

    A case study was conducted using several data sources.

    Results

    SD supported a collaborative design, by facilitating an explicit description of stroke care process, a dialogue and a joint understanding. The construction of the model obliged the group to conceptualise the stroke care and experimentation with the model gave the opportunity to reflect on care.

    Conclusion

    SD facilitated the collaborative design process and should be integrated in the early stages of the design process as a quality improvement tool.

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  • 14.
    Elf, Marie
    et al.
    Dalarna University, School of Health and Welfare, Caring Science/Nursing.
    Rasoal, Dara
    Dalarna University, School of Health and Welfare, Caring Science/Nursing.
    Zingmark, Magnus
    Kylén, Maya
    Dalarna University, School of Health and Welfare, Caring Science/Nursing. Lund University.
    The importance of context: a qualitative study exploring healthcare practitioners’ experiences of working with patients at home after a stroke2023In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 23, no 1, article id 733Article in journal (Refereed)
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  • 15.
    Elf, Marie
    et al.
    Dalarna University, School of Health and Welfare, Caring Science/Nursing.
    Rasoal, Dara
    Lund University.
    Zingmark, Magnus
    Lund University; Health and Social Care Administration, Östersund; Umeå University.
    Kylén, Maya
    Dalarna University, School of Health and Welfare, Caring Science/Nursing. Lund University.
    The importance of context-a qualitative study exploring healthcare practitioners' experiences of working with patients at home after a stroke2023In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 23, no 1, article id 733Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Stroke significantly impacts individuals, leading to the need for long-lasting rehabilitation and adaptation to environmental demands. Rehabilitation after stroke is increasingly performed in patients' homes, and it is argued that rehabilitation in this context is more person-centred and positively impacts client outcomes. However, the role of environmental factors in this process is largely unknown. The aim of this study was to explore how multidisciplinary healthcare practitioners working with rehabilitation in the home after stroke consider possibilities and challenges in the environment and how environmental factors are documented in patients' records.

    METHODS: Eight multidisciplinary healthcare practitioners working with home-based rehabilitation after stroke participated in two semistructured focus group sessions. Thematic analysis was used to analyse the transcripts of recorded focus group discussions. Data were also collected from patient history records (N = 14) to identify interventions to increase patients' opportunities to participate in activities inside and outside the home. These records were analysed using life-space mobility as a conceptual framework.

    RESULTS: The analysis generated four overarching themes concerning possibilities and challenges in the environment: (1) the image of rehabilitation conflicts with place, (2) the person in the home reveals individual needs and capabilities, (3) environmental characteristics influence the rehabilitation practice, and (4) the person is integrated within a social context. The patient record analysis showed that most patients were discharged from hospital to home within four days. Assessments at the hospital mainly focused on basic activities of daily living, such as the patient's self-care and walking ability. Also at home, the assessments and actions primarily focused on basic activities with little focus on participation in meaningful activities performed in different life situations outside the home.

    CONCLUSIONS: Our research suggests that one way to improve practice is to include the environment in the rehabilitation and consider the person´s life space. Interventions should focus on supporting out-of-home mobility and activities as part of person-centred stroke rehabilitation. This must be supported by clear documentation in the patient records to strengthen clinical practice as well as the communication between stakeholders.

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  • 16. Erichsen Andersson, Annette
    et al.
    Frödin, Maria
    Dellenborg, Lisen
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Sahlgrenska Academy, University of Gothenburg; Karolinska Institutet.
    Hök, Jesper
    Gillespie, Brigid M
    Wikström, Ewa
    Iterative co-creation for improved hand hygiene and aseptic techniques in the operating room: experiences from the safe hands study2018In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 18, no 1, article id 2Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Hand hygiene and aseptic techniques are essential preventives in combating hospital-acquired infections. However, implementation of these strategies in the operating room remains suboptimal. There is a paucity of intervention studies providing detailed information on effective methods for change. This study aimed to evaluate the process of implementing a theory-driven knowledge translation program for improved use of hand hygiene and aseptic techniques in the operating room.

    METHODS: The study was set in an operating department of a university hospital. The intervention was underpinned by theories on organizational learning, culture and person centeredness. Qualitative process data were collected via participant observations and analyzed using a thematic approach.

    RESULTS: Doubts that hand-hygiene practices are effective in preventing hospital acquired infections, strong boundaries and distrust between professional groups and a lack of psychological safety were identified as barriers towards change. Facilitated interprofessional dialogue and learning in "safe spaces" worked as mechanisms for motivation and engagement. Allowing for the free expression of different opinions, doubts and viewing resistance as a natural part of any change was effective in engaging all professional categories in co-creation of clinical relevant solutions to improve hand hygiene.

    CONCLUSION: Enabling nurses and physicians to think and talk differently about hospital acquired infections and hand hygiene requires a shift from the concept of one-way directed compliance towards change and learning as the result of a participatory and meaning-making process. The present study is a part of the Safe Hands project, and is registered with ClinicalTrials.gov (ID: NCT02983136 ). Date of registration 2016/11/28, retrospectively registered.

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  • 17.
    Ericsson, Christoffer R
    et al.
    University of Helsinki, Helsinki, Finland; Arcada University of Applied Sciences, Helsinki, Finland.
    Lindström, Veronica
    Umeå University, Umeå, Sweden; Ambulance Service Umeå, Umeå, Sweden; Sophiahemmet University, Stockholm, Sweden.
    Rudman, Ann
    Dalarna University, School of Health and Welfare, Caring Science/Nursing. Karolinska Institutet, Stockholm, Sweden; .
    Nordquist, Hilla
    University of Helsinki, Helsinki, Finland; South-Eastern Finland University of Applied Sciences, Kotka, Finland; .
    Paramedics' perceptions of job demands and resources in Finnish emergency medical services: a qualitative study2022In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 22, no 1, article id 1469Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Paramedics' fatigue is rising. Stress factors show increased risk for burnout, fatigue, leaving the profession, decreased performance and risk for patient safety. Meanwhile, paramedics' strong community of practice, autonomy and a sense of professional respect are important factors in forming psychological resilience. We aimed to explore Finnish paramedics' perceptions of job demands and resources.

    METHODS: Our study design was descriptive, inductive with a constructivist approach. Using reflexive thematic analysis, we analyse open-ended questions, from a web-based survey and essays written by Finnish paramedic masters-degree students. The study followed the SRQR checklist.

    RESULTS: We identified paramedics' job demands as stress from a high workload, environmental factors and emotional burden. Performance expectations and a sense of inadequacy were further noted, as well as an organizational culture of hardiness, presenting lack of support and sense of inequality. Paramedics' job resources were pressure management strategies, which were expressed as positive coping mechanisms, agency to affect workload and professional self-actualization, expressed as psychologically safe work community, professional pride and internal drive to professional development.

    CONCLUSIONS: Finnish paramedics exhibit resources and demands related to uncertainty and emotional burden as well as cultural hardiness and psychological safety in communities.

    PATIENT OR PUBLIC CONTRIBUTION: This study was done based on survey data collected and analysed by the authors. No patient or public contribution was utilized for this study.

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  • 18.
    Fridberg, Helena
    et al.
    Dalarna University, School of Health and Welfare, Care Sciences. Dalarna University, School of Health and Welfare, Medical Science.
    Wallin, Lars
    Dalarna University, School of Health and Welfare, Caring Science/Nursing. University of Gothenburg.
    Tistad, Malin
    Dalarna University, School of Health and Welfare, Medical Science. Karolinska Institute, Stockholm.
    Operationalisation of person-centred care in a real-world setting: a case study with six embedded units2022In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 22, no 1, article id 1160Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Although person-centred care (PCC) is growing globally in popularity it is often vague and lacks conceptual clarity and definition. The ambiguity stretches from PCC's underlying philosophical principles and definitions of the concept to how it is operationalised and practised on the ground by health care professionals. We explore how the PCC model by the Gothenburg University Centre for Person-centred Care (GPCC) was operationalised in a real-world setting by using a set of recommendations by Fixsen and others that define and structure the core components of innovations in four distinct but interrelated components: philosophical principles and values, contextual factors, structural elements and core practices. Thus, this study aimed to increase knowledge about core practices in PCC in six health care units in real-world circumstances.

    METHODS: A case study with six embedded health care units was conducted from 2016 to 2019. We collected data from three sources: interviews (n = 12) with change agents, activity logs and written documents. Data were triangulated, and core practices were identified and deductively coded to the PCC model's structural elements: initiating, working and safeguarding the partnership with patients.

    RESULTS: We identified operationalisations of PCC in line with the three structural elements in the GPCC model at all included health care units. A range of both similarities and dissimilarities between units were identified, including the level of detail in describing PCC practices, when these practices were conducted and by whom at the workplace. The recommendations for describing the core components of PCC also helped us identify how some operationalisations of PCC seemed more driven by contextual factors, including a new regulation for planning and documenting care across health care specialities.

    CONCLUSIONS: Our findings show how PCC is operationalised in different health care units in a real-world setting based on change agents' understanding of the concept and their unique context. Increased knowledge of PCC and its philosophical principles and values, contextual factors, structural elements and core practices, is necessary to build a common understanding of the PCC-concept. Such knowledge is essential when PCC is operationalised as part of implementation efforts in health care.

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  • 19.
    Fridberg, Helena
    et al.
    Dalarna University, School of Teacher Education, Educational Work.
    Wallin, Lars
    Dalarna University, School of Health and Welfare, Caring Science/Nursing. Sahlgrenska Academy at the University of Gothenburg.
    Tistad, Malin
    Dalarna University, School of Health and Welfare, Medical Science. Karolinska Institute, Stockholm.
    The innovation characteristics of person-centred care as perceived by healthcare professionals: an interview study employing a deductive-inductive content analysis guided by the consolidated framework for implementation research.2021In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 21, no 1, article id 904Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Person-centred care (PCC) is promoted as an innovation that will improve patients' rights and increase their participation in healthcare. Experience shows that the implementation of PCC is challenging and often results in varying levels of adoption. How health care professionals (HCPs) perceive an innovation such as PCC is an important factor to consider in implementation. Yet, such studies are scarce. Thus, in a sample of healthcare units in a region in Sweden, involved in a transition to PCC, we aimed to investigate HCPs' perceptions of PCC.

    METHODS: An interview study was conducted in 2018 during the implementation of PCC with HCPs (n = 97) representing diverse vocational roles in six healthcare contexts. Data were collected via focus groups (n = 15), dyadic interviews (n = 5), and individual interviews (n = 22) and analysed using a deductive-inductive content analysis. The deductive approach was guided by the Consolidated Framework for Implementation Research (CFIR), followed by an inductive analysis to describe HCPs' in-depth perceptions of PCC in relation to each of the CFIR constructs.

    RESULTS: Eight constructs from two of the CFIR domains, Intervention characteristics and Inner setting, were used to code HCPs' perceptions of PCC. One construct, Observability, was added to the coding sheet to fully describe all the data. The constructs Relative advantage, Complexity, Compatibility, Observability, and Available resources were discussed in depth by HCPs and resulted in rich and detailed data in the inductive data analysis. This analysis showed large variations in perceptions of PCC among HCPs, based on factors such as the PCCs ethical underpinnings, its operationalisation into concrete working routines, and each HCPs' unique recognition of PCC and the value they placed on it.

    CONCLUSIONS: We identified nine CFIR constructs that seem pertinent to HCPs' perceptions of PCC. HCPs report an array of mixed perceptions of PCC, underlining its complex nature. The perceptions are shaped by a range of factors, such as their individual understandings of the concept and the operationalisation of PCC in their local context. Stakeholders in charge of implementing PCC might use the results as a guide, delineating factors that may be important to consider in a wide range of healthcare contexts.

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  • 20.
    Fridberg, Helena
    et al.
    Dalarna University, School of Health and Welfare, Care Sciences. Dalarna University, School of Health and Welfare, Medical Science.
    Wallin, Lars
    Dalarna University, School of Health and Welfare, Caring Science/Nursing. Institute of Health and Care Sciences and University of Gothenburg Centre for Person-Centred Care, Sahlgrenska Academy at the University of Gothenburg, Gothenburg.
    Tistad, Malin
    Dalarna University, School of Health and Welfare, Medical Science. Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm.
    Tracking, naming, specifying, and comparing implementation strategies for person-centred care in a real-world setting: a case study with seven embedded units2022In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 22, no 1, article id 1409Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The implementation of person-centred care (PCC) is advocated worldwide. Stakeholders in charge of implementing PCC as a broad-scale change across the health care sector face two intertwined and complex challenges. First, making sense of PCC as an intervention with complex innovation characteristics and second, staging implementation of PCC by choosing appropriate implementation strategies. We aimed to explore one of these challenges by tracking, naming, specifying, and comparing which strategies and how strategies were enacted to support the implementation of more PCC in a real-world setting represented by one health care region in Sweden.

    METHODS: A case study with seven embedded units at two organisational levels within a health care region was conducted from 2016 to 2019. Data were collected from three sources: activity logs, interviews, and written documents. Strategies were identified from all sources and triangulated deductively by name, definition, and cluster in line with the taxonomy Expert Recommendations for Implementing Change (ERIC) and specified according to recommendations by Proctor and colleagues as actor, action, action target, temporality, dose, outcome, and justification.

    RESULTS: Four hundred thirteen activities were reported in logs, representing 43 discrete strategies identified in ERIC (n = 38), elsewhere (n = 1), or as emerging strategies (n = 4). The highest reported frequencies of discrete strategies were identified as belonging to two clusters: Train and educate stakeholders (40%) and Develop stakeholder interrelationships (38%). We identified a limited number of strategies belonging to the cluster Use evaluative and iterative strategies (4.6%) and an even smaller number of strategies targeting information to patients about the change initiative (0.8%). Most of the total dose of 11,076 person-hours in the 7 units was spent on strategies targeting health care professionals who provide PCC (81.5%) while the dose of strategies targeting support functions was 18.5%.

    CONCLUSIONS: Our findings show both challenges and merits when strategies for implementation of PCC are conducted in a real-world setting. The results can be used to support and guide both scientists and practitioners in future implementation initiatives.

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  • 21.
    Fridberg, Helena
    et al.
    Dalarna University, School of Education, Health and Social Studies, Care Sciences.
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Sahlgrenska Academy at the University of Gothenburg.
    Wallengren, C.
    Kottorp, A.
    Forsman, Henrietta
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Tistad, Malin
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Karolinska Institutet.
    Development and evaluation of the measurement properties of a generic questionnaire measuring patient perceptions of person-centred care2020In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 20, no 1, article id 960Article in journal (Refereed)
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  • 22.
    Gelin, Maria
    et al.
    Dalarna University, School of Health and Welfare, Care Sciences. Dalarna University, School of Health and Welfare, Caring Science/Nursing. Center for Clinical Research Dalarna, Uppsala University, Falun.
    Gesar, Berit
    Center for Clinical Research Dalarna, Uppsala University, Falun; Uppsala University, Uppsala.
    Källberg, Ann-Sofie
    Dalarna University, School of Health and Welfare, Caring Science/Nursing. Center for Clinical Research Dalarna, Uppsala University, Falun.
    Ehrenberg, Anna
    Dalarna University, School of Health and Welfare, Caring Science/Nursing.
    Gustavsson, Catharina
    Dalarna University, School of Health and Welfare, Medical Science. Center for Clinical Research Dalarna, Uppsala University, Falun; Uppsala University, Uppsala.
    Introducing a triage and Nurse on Call model in primary health care - a focus group study of health care staff's experiences2023In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 23, no 1, article id 1299Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: With the increased demand for health care services and with simultaneous staff shortages, new work models are needed in primary health care. In November 2015, a Swedish primary health care centre introduced a work model consisting of a structured patient sorting system with triage and Nurse on Call. The aim of this study was to describe the staff's experiences of introducing the triage and Nurse on Call model at the primary health care centre.

    METHODS: Five focus group discussions with staff (n = 39) were conducted 4 years after the introduction of the work model. Groups were divided by profession: medical secretaries, nursing assistants, physicians, primary health care nurses, and registered nurses. The transcribed text from the discussions was analysed using qualitative inductive content analysis.

    RESULTS: The analysis generated one overarching theme: The introduction of triage and Nurse on Call addresses changed preconditions in primary health care, but the work culture, organization, and acquisition of new knowledge are lagging behind. The overarching theme had five categories: (1) Changed preconditions in primary health care motivate new work models; (2) The triage and Nurse on Call model improves teamwork and may increase the quality of care; (3) Unclear purpose and vague leadership make introducing the work model difficult; (4) Difficulties to adopt the work model as it challenges professional autonomy; and (5) The triage and Nurse on Call model requires more knowledge and competence from nurses in primary health care.

    CONCLUSIONS: This study contributes with knowledge about implications of a new work model in primary health care from the perspective of health care staff. The work model using triage and Nurse on Call in primary health care was perceived by participants to increase availability and optimize the use of resources. However, before introduction of new work models, it is important to identify barriers to and facilitators for successful improvements in the local health care context. Additional education for the health care staff is important if the transition is to be successful. Complementary skills and teamwork, supported by a facilitator seems important to ensure a well-prepared workforce.

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  • 23.
    Goldkuhl, Lisa
    et al.
    Sahlgrenska Academy, University of Gothenburg, Gothenburg; Sahlgrenska University Hospital, Gothenburg.
    Tistad, Malin
    Dalarna University, School of Health and Welfare, Medical Science. Karolinska Institutet, Huddinge.
    Gyllensten, Hanna
    Sahlgrenska Academy, University of Gothenburg, Gothenburg.
    Berg, Marie
    Sahlgrenska Academy, University of Gothenburg, Gothenburg; Evangelical University in Africa, Bukavu, Democratic Republic of Congo.
    Implementing a new birthing room design: a qualitative study with a care provider perspective2023In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 23, no 1, article id 1122Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Research shows that interventions to protect the sensitive physiological process of birth by improving the birthing room design may positively affect perinatal outcomes. It is, however, crucial to understand the mechanisms and contextual elements that influence the outcomes of such complex interventions. Hence, we aimed to explore care providers' experiences of the implementation of a new hospital birthing room designed to be more supportive of women's birth physiology.

    METHODS: This qualitative study reports on the implementation of the new birthing room, which was evaluated in the Room4Birth randomised controlled trial in Sweden. Individual interviews were undertaken with care providers, including assistant nurses, midwives, obstetricians, and managers (n = 21). A content analysis of interview data was conducted and mapped into the three domains of the Normalisation Process Theory coding manual: implementation context, mechanism, and outcome.

    RESULTS: The implementation of the new room challenged the prevailing biomedical paradigm within the labour ward context and raised the care providers' awareness about the complex interplay between birth physiology and the environment. This awareness had the potential to encourage care providers to be more emotionally present, rather than to focus on monitoring practices. The new room also evoked a sense of insecurity due to its unfamiliar design, which acted as a barrier to integrating the room as a well-functioning part of everyday care practice.

    CONCLUSION: Our findings highlight the disparity that existed between what care providers considered valuable for women during childbirth and their own requirements from the built environment based on their professional responsibilities. This identified disparity emphasises the importance of hospital birthing rooms (i) supporting women's emotions and birth physiology and (ii) being standardised to meet care providers' requirements for a functional work environment.

    TRIAL REGISTRATION: ClinicalTrials.gov: NCT03948815, 14/05/2019.

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  • 24. Grooten, Wilhelmus Johannes Andreas
    et al.
    Hansson, Amanda
    Forsman, Mikael
    Kjellberg, Katarina
    Toomingas, Allan
    Müller, Mira
    Svartengren, Magnus
    Äng, Björn
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Karolinska Institutet; Uppsala University.
    Non-participation in initial and repeated health risk appraisals: a drop-out analysis based on a health project2019In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 19, no 1, article id 130Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Health risk assessment (HRAs) are commonly used by occupational health services (OHS) to aid workplaces in keeping their employees healthy, but for unknown reasons, many employees choose not to participate in the HRAs. The aim of the study was to explore whether demographic, lifestyle and health-related factors in employees are associated with non-participation in initial and repeated HRAs.

    METHODS: In an OHS-based health project, 2022 municipal employees were asked to participate in three repeated HRAs. Multiple logistic regression analyses were used so as to determine associations between non-participating and demographic, lifestyle and health-related factors (e.g. biomarkers).

    RESULTS: Among the employees who were asked to participate in the health project, more than half did not participate in any HRA and among those who did, more than one third did not participate in repeated HRAs. Young age, male sex and being employed in the Technical department or Health and Social Care department in comparison with being employed in the department for Childcare and Education were factors significantly associated with non-participation in the initial HRA. These factors, together with being on sick leave and having unhealthy dietary habits, were factors associated with non-participation in repeated HRAs.

    CONCLUSIONS: Among the non-participators in initial HRAs and in repeated HRAs younger men and those already related to ill-health were overrepresented. This implicates that health care providers to a higher extent should focus on "those most needed" and that employers should be more engaged in results of repeated HRA's. Future studies should focus on modifiable variables that could make the HRAs more attractive and inclusive.

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  • 25. Gustafsson, Inga-Britt
    et al.
    Winblad, Ulrika
    Wallin, Lars
    Dalarna University, School of Health and Welfare, Caring Science/Nursing. Dalarna County Council, Falun; Centre for Clinical Research, Falun.
    Fredriksson, Mio
    Factors that shape the successful implementation of decommissioning programmes: an interview study with clinic managers2021In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 21, no 1, article id 805Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: As a response to many years of repetitive budget deficits, Region Dalarna in Sweden started a restructuring process in 2015, and implemented a decommissioning programme to achieve a balanced budget until 2019. Leading politicians and public servants took the overall decisions about the decommissioning programme, but the clinical decision-making and implementation was largely run by the clinic managers and their staff. As the decommissioning programme improved the finances, met relatively little resistance from the clinical departments, and neither patient safety nor quality of care were perceived to be negatively affected, the initial implementation could be considered successful. The aim of this study was to investigate clinic managers' experience of important factors enabling the successful implementation of a decommissioning programme in a local healthcare organization.

    METHODS: Drawing on a framework of factors and processes that shape successful implementation of decommissioning decisions, this study highlights the most important factors that enabled the clinic managers to successfully implement the decommissioning programme. During 2018, an interview study was conducted with 26 clinic managers, strategically selected to represent psychiatry, primary care, surgery and medicine. A deductive content analysis was used to analyze the interviews. By applying a framework to the data, the most important factors were illuminated.

    RESULTS: The findings highlighted factors and processes crucial to implementing the decommissioning programme: 1) create a story to get a shared image of the rationale for change, 2) secure an executive leadership team represented by clinical champions, 3) involve clinic managers at an early stage to ensure a fair decision-making process, 4) base the decommissioning decisions on evidence, without compromising quality and patient safety, 5) prepare the organisation to handle a process characterised by tensions and strong emotions, 6) communicate demonstrable benefits, 7) pay attention to the need of cultural and behavioral change and 8) transparently evaluate the outcome of the process.

    CONCLUSIONS: From these findings, we conclude that in order to successfully implement a decommissioning programme, clinic managers and healthcare professions must be given and take responsibility, for both the process and outcome.

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  • 26.
    Gustavsson, Catharina
    et al.
    Dalarna University, School of Health and Welfare, Medical Science. Uppsala universitet.
    Nordqvist, Maria
    Uppsala universitet.
    Bergman Bruhn, Åsa
    Dalarna University, School of Culture and Society, Occupational Science.
    Bröms, Kristina
    Uppsala universitet.
    Jerdén, Lars
    Dalarna University, School of Health and Welfare, Medical Science. Uppsala universitet.
    Kallings, Lena V.
    Uppsala universitet ; GIH.
    Wallin, Lars
    Dalarna University, School of Health and Welfare, Caring Science/Nursing.
    Process evaluation of an implementation intervention to facilitate the use of the Swedish Physical Activity on Prescription in primary healthcare2023In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 23, no 1, article id 996Article in journal (Refereed)
    Abstract [en]

    Background The Swedish Physical Activity on Prescription (PAP-S) is a method for healthcare to promote physical activity for prevention and treatment of health disorders. Despite scientific support and education campaigns, the use has been low. The aim of this study was to perform a process evaluation of an implementation intervention targeting the use of the PAP-S method in primary healthcare (PHC). Specifically, we wanted to evaluate feasibility of the implementation intervention, and its effect on the implementation process and the outcome (number of PAP-S prescriptions).

    Methods This was a longitudinal study using the Medical Research Council guidance for process evaluation of a 9-month implementation intervention among healthcare staff at three PHC centres in Sweden. Data was collected by: participatory observations of the implementation process; questionnaires to the staff before, after and 6 months after the implementation intervention; interviews after the implementation intervention; and number of PAP-S prescriptions.

    Results During the implementation intervention, the workplaces’ readiness-to-change and the healthcare staff’s confidence in using the PAP-S method were favourably influenced, as was the number of PAP-S prescriptions. After the implementation intervention, the number of PAP-S prescriptions decreased to about the same number as before the implementation intervention, at two out of three PHC centres. Four of the six implementation strategies appeared to impact on the implementation process: external facilitation; leadership engagement by a committed workplace management; local PAP-S coordinator taking a leading role and acting as local champion; educational outreach concerning how to use the PAP-S method.

    Conclusion The implementation intervention was not sufficient to produce sustained change of the healthcare staff’s behaviour, nor did it achieve favourable long-term outcome on the number of PAP-S prescriptions. The healthcare staffs’ sparse knowledge of the PAP-S method prior to the implementation intervention hampered the implementation. More hands-on education in how to use the PAP-S method introduced early in the implementation process is imperative for successful implementation of the PAP-S method. The findings also suggest that committed workplace management and local PAP-S coordinators, taking leading roles and acting as local champions, need to be firmly established at the PHC centres before the external facilitator withdraws.

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  • 27.
    Gustavsson, Catharina
    et al.
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Center for Clinical Research Dalarna; Mälardalens högskola; Uppsala universitet.
    Nordqvist, Maria
    Bröms, Kristina
    Jerdén, Lars
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Center for Clinical Research Dalarna, Department of Public Health and Caring Sciences, Uppsala University, Falun.
    Kallings, Lena V
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet; Göteborgs universitet.
    What is required to facilitate implementation of Swedish physical activity on prescription? - interview study with primary healthcare staff and management2018In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 18, no 1, article id 196Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: The method, Swedish Physical Activity on Prescription (SPAP), has been launched in Swedish healthcare to promote physical activity for prevention and treatment of lifestyle related health disorders. Despite scientific support for the method, and education campaigns, it is used to a limited extent by health professionals. The aim of the study was to describe the views of health professionals on perceived facilitators, barriers and requirements for successful implementation of SPAP in primary healthcare.

    METHODS: Eighteen semi-structured interviews with stakeholders in SPAP, i.e. ten people working in local or central management and eight primary healthcare professionals in two regional healthcare organisations, were analysed using qualitative content analysis.

    RESULTS: We identified an overarching theme regarding requirements for successful implementation of SPAP: Need for knowledge and organisational support, comprising four main categories: Need for increased knowledge and affirmative attitude among health professionals; Need for clear and supportive management; Need for central supporting structures; Need for local supporting structures. Knowledge of the SPAP method content and core components was limited. Confidence in the method varied among health professionals. There was a discrepancy between the central organisation policy documents declaring that disease preventive methods were prioritised and a mandatory assignment, while the health professionals asked for increased interest, support and resources from management, primarily time and supporting structures. There were somewhat conflicting views between primary healthcare professionals and managers concerning perceived barriers and requirements. In contrast to some of the management's beliefs, all primary healthcare professionals undisputedly acknowledged the importance of promoting physical activity, but they lacked time, written routines and in some cases competence for SPAP counselling.

    CONCLUSION: The study provides knowledge regarding requirements to facilitate the implementation of SPAP in healthcare. There was limited knowledge among health professionals regarding core components of SPAP and how to practise the method, which speaks for in-depth training in the SPAP method. The findings highlight the importance of forming policies and guidelines and establishing organisational supporting structures, and ensuring that these are well known and approved in all parts of the healthcare organisation.

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  • 28.
    Göras, Camilla
    et al.
    Falu Hospital; Center for Clinical Research, Falun.
    Nilsson, Ulrica
    Ekstedt, Mirjam
    Unbeck, Maria
    Karolinska Institutet.
    Ehrenberg, Anna
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Managing complexity in the operating room: a group interview study.2020In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 20, no 1, article id 440Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Clinical work in the operating room (OR) is considered challenging as it is complex, dynamic, and often time- and resource-constrained. Important characteristics for successful management of complexity include adaptations and adaptive coordination when managing expected and unexpected events. However, there is a lack of explorative research addressing what makes things go well and how OR staff describe they do when responding to challenges and compensating for constraints. The aim of this study was therefore to explore how complexity is managed as expressed by operating room nurses, registered nurse anesthetists, and surgeons, and how these professionals adapt to create safe care in the OR.

    METHOD: Data for this qualitative explorative study were collected via group interviews with three professional groups of the OR-team, including operating room nurses, registered nurse anesthetists and operating and assisting surgeons in four group interview sessions, one for each profession except for ORNs for which two separate interviews were performed. The audio-taped transcripts were transcribed verbatim and analyzed by inductive qualitative content analysis.

    RESULTS: The findings revealed three generic categories covering ways of creating safe care in the OR: preconditions and resources, planning and preparing for the expected and unexpected, and adapting to the unexpected. In each generic category, one sub-category emerged that was common to all three professions: coordinating and reaffirming information, creating a plan for the patient and undergoing mental preparation, and prioritizing and solving upcoming problems, respectively.

    CONCLUSION: Creating safe care in the OR should be understood as a process of planning and preparing in order to manage challenging and complex work processes. OR staff need preconditions and resources such as having experience and coordinating and reaffirming information, to make sense of different situations. This requires a mental model, which is created through planning and preparing in different ways. Some situations are repetitive and easier to plan for but planning for the unexpected requires anticipation from experience. The main results strengthen that abilities described in the theory of resilience are used by OR staff as a strategy to manage complexity in the OR.

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  • 29. Göras, Camilla
    et al.
    Wallentin, Fan Yang
    Nilsson, Ulrica
    Ehrenberg, Anna
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Swedish translation and psychometric testing of the safety attitudes questionnaire (operating room version)2013In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 13, article id 104Article in journal (Refereed)
    Abstract [en]

    Background: Tens of millions of patients worldwide suffer from avoidable disabling injuries and death every year. Measuring the safety climate in health care is an important step in improving patient safety. The most commonly used instrument to measure safety climate is the Safety Attitudes Questionnaire (SAQ). The aim of the present study was to establish the validity and reliability of the translated version of the SAQ.

    Methods: The SAQ was translated and adapted to the Swedish context. The survey was then carried out with 374 respondents in the operating room (OR) setting. Data was received from three hospitals, a total of 237 responses. Cronbach's alpha and confirmatory factor analysis (CFA) was used to evaluate the reliability and validity of the instrument.

    Results: The Cronbach's alpha values for each of the factors of the SAQ ranged between 0.59 and 0.83. The CFA and its goodness-of-fit indices (SRMR 0.055, RMSEA 0.043, CFI 0.98) showed good model fit. Intercorrelations between the factors safety climate, teamwork climate, job satisfaction, perceptions of management, and working conditions showed moderate to high correlation with each other. The factor stress recognition had no significant correlation with teamwork climate, perception of management, or job satisfaction.

    Conclusions: Therefore, the Swedish translation and psychometric testing of the SAQ (OR version) has good construct validity. However, the reliability analysis suggested that some of the items need further refinement to establish sound internal consistency. As suggested by previous research, the SAQ is potentially a useful tool for evaluating safety climate. However, further psychometric testing is required with larger samples to establish the psychometric properties of the instrument for use in Sweden.

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  • 30. Kardakis, T.
    et al.
    Jerdén, Lars
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Umeå University; Center for Clinical Research Dalarna, Nissers väg 3, Falun.
    Nyström, M. E.
    Weinehall, L.
    Johansson, H.
    Implementation of clinical practice guidelines on lifestyle interventions in Swedish primary healthcare - a two-year follow up2018In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 18, no 1, article id 227Article in journal (Refereed)
    Abstract [en]

    Background: Implementation of interventions concerning prevention and health promotion in health care has faced particular challenges resulting in a low frequency and quality of these services. In November 2011, the Swedish National Board of Health and Welfare released national clinical practice guidelines to counteract patients' unhealthy lifestyle habits. Drawing on the results of a previous study as a point of departure, the aim of this two-year follow up was to assess the progress of work with lifestyle interventions in primary healthcare as well as the uptake and usage of the new guidelines on lifestyle interventions in clinical practice. Methods: Longitudinal study among health professionals with survey at baseline and 2 years later. Development over time and differences between professional groups were calculated with Pearson chi-square test. Results: Eighteen percent of the physicians reported to use the clinical practice guidelines, compared to 58% of the nurses. Nurses were also more likely to consider them as a support in their work than physicians did. Over time, health professionals usage of methods to change patients' tobacco habits and hazardous use of alcohol had increased, and the nurses worked to a higher extent than before with all four lifestyles. Knowledge on methods for lifestyle change was generally high; however, there was room for improvement concerning methods on alcohol, unhealthy eating and counselling. Forty-one percent reported to possess thorough knowledge of counselling skills. Conclusions: Even if the uptake and usage of the CPGs on lifestyle interventions so far is low, the participants reported more frequent counselling on patients' lifestyle changes concerning use of tobacco and hazardous use of alcohol. However, these findings should be evaluated acknowledging the possibility of selection bias in favour of health promotion and lifestyle guidance, and the loss of one study site in the follow up. Furthermore, this study indicates important differences in physicians and nurses' attitudes to and use of the guidelines, where the nurses reported working to a higher extent with all four lifestyles compared to the first study. These findings suggest further investigations on the implementation process in clinical practice, and the physicians' uptake and use of the CPGs. © 2018 The Author(s).

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  • 31. Lindblad, Marléne
    et al.
    Unbeck, Maria
    Karolinska Institutet.
    Nilsson, Lena
    Schildmeijer, Kristina
    Ekstedt, Mirjam
    Identifying no-harm incidents in home healthcare: a cohort study using trigger tool methodology.2020In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 20, no 1, article id 289Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Patient safety in home healthcare is largely unexplored. No-harm incidents may give valuable information about risk areas and system failures as a source for proactive patient safety work. We hypothesized that it would be feasible to retrospectively identify no-harm incidents and thus aimed to explore the cumulative incidence, preventability, types, and potential contributing causes of no-harm incidents that affected adult patients admitted to home healthcare.

    METHODS: A structured retrospective record review using a trigger tool designed for home healthcare. A random sample of 600 home healthcare records from ten different organizations across Sweden was reviewed.

    RESULTS: In the study, 40,735 days were reviewed. In all, 313 no-harm incidents affected 177 (29.5%) patients; of these, 198 (63.2%) no-harm incidents, in 127 (21.2%) patients, were considered preventable. The most common no-harm incident types were "fall without harm," "deficiencies in medication management," and "moderate pain." The type "deficiencies in medication management" was deemed to have a preventability rate twice as high as those of "fall without harm" and "moderate pain." The most common potential contributing cause was "deficiencies in nursing care and treatment, i.e., delayed, erroneous, omitted or incomplete treatment or care."

    CONCLUSION: This study suggests that it is feasible to identify no-harm incidents and potential contributing causes such as omission of care using record review with a trigger tool adapted to the context. No-harm incidents and potential contributing causes are valuable sources of knowledge for improving patient safety, as they highlight system failures and indicate risks before an adverse event reach the patient.

  • 32. Lindblom, Sebastian
    et al.
    Tistad, Malin
    Dalarna University, School of Health and Welfare, Medical Science. Karolinska Institutet, Huddinge.
    Flink, Maria
    Laska, Ann Charlotte
    von Koch, Lena
    Ytterberg, Charlotte
    Referral-based transition to subsequent rehabilitation at home after stroke: one-year outcomes and use of healthcare services2022In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 22, no 1, article id 594Article in journal (Refereed)
    Abstract [en]

    Background: There is a lack of knowledge about patients’ journeys across the stroke care continuum, especially regarding the transition from inpatient to outpatient care and rehabilitation. Therefore, the aim of the present study was to explore and describe patterns of healthcare use over a one-year period, health outcomes at 3 and 12 months for patients following a referral-based transition to subsequent rehabilitation in the home, and the caregiver burden on their significant others. A further aim was to explore factors associated with the use of rehabilitation and healthcare after the referral-based transition to continued rehabilitation in the home for people recovering from a stroke. Methods: Data regarding healthcare use during the first 12 months post-stroke was collected from the Region Stockholm computerized register. Data on patient characteristics, disease-related data, and functioning were retrieved drawn from medical records and questionnaires. Descriptive statistics were used to present healthcare use, participants’ characteristics, disease-related data, and patient functioning. Multivariable regression models were created to explore associations between the total number of outpatient contacts, total visits with the neurorehabilitation team, and the independent variables. Results: The mean age for the 190 participants was 73 years for men and 78 years for women. Twenty-one participants (11%) had an acute rehospitalization within 30 days after discharge, and 41 participants (21%) were re-hospitalized within 90 days. Twenty-two (12%) of the participants had no visits with the neurorehabilitation team, 73 (39%) participants had 1–3 visits, 57 (30%) had 4–16 visits, and 38 (20%) had ≥17 visits. Female sex and length of hospital stay were associated with a higher number of visits with the neurorehabilitation team. Living alone, higher self-rated recovery, and being able to walk independently were associated with a lower number of visits with the neurorehabilitation team. Female sex, having home help services before the stroke, longer length of hospital stay, and more comorbidities were associated with a higher number of outpatient contacts. Conclusions: The findings indicate that there is no generic pattern of healthcare use during the first-year post-stroke in patients receiving referral-based transition to continued rehabilitation in the home. The different patterns of healthcare use seemed to mirror the participants’ level of functioning. However, there is a need to further investigate how follow-up and rehabilitation correspond to the needs of patients and their significant others in the short- and long-term perspective. Trial registration: ClinicalTrials.gov, registration number: NCT02925871. Date of registration: October 6, 2016. © 2022, The Author(s).

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  • 33. Lundell, S.
    et al.
    Tistad, Malin
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Rehn, B.
    Wiklund, M.
    Holmner, Å.
    Wadell, K.
    Building COPD care on shaky ground: A mixed methods study from Swedish primary care professional perspective2017In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 17, no 1, article id 467Article in journal (Refereed)
    Abstract [en]

    Background: Chronic obstructive pulmonary disease (COPD) is a public health problem. Interprofessional collaboration and health promotion interventions such as exercise training, education, and behaviour change are cost effective, have a good effect on health status, and are recommended in COPD treatment guidelines. There is a gap between the guidelines and the healthcare available to people with COPD. The aim of this study was to increase the understanding of what shapes the provision of primary care services to people with COPD and what healthcare is offered to them from the perspective of healthcare professionals and managers.

    Methods: The study was conducted in primary care in a Swedish county council during January to June 2015. A qualitatively driven mixed methods design was applied. Qualitative and quantitative findings were merged into a joint analysis. Interviews for the qualitative component were performed with healthcare professionals (n = 14) from two primary care centres and analysed with qualitative content analysis. Two questionnaires were used for the quantitative component; one was answered by senior managers or COPD nurses at primary care centres (n = 26) in the county council and the other was answered by healthcare professionals (n = 18) at two primary care centres. The questionnaire data were analysed with descriptive statistics.

    Results: The analysis gave rise to the overarching theme building COPD care on shaky ground. This represents professionals driven to build a supportive COPD care on 'shaky' organisational ground in a fragmented and non-compliant healthcare organisation. The shaky ground is further represented by uninformed patients with a complex disease, which is surrounded with shame. The professionals are autonomous and pragmatic, used to taking responsibility for their work, and with limited involvement of the management. They wish to provide high quality COPD care with interprofessional collaboration, but they lack competence and are hindered by inadequate routines and lack of resources.

    Conclusions: There is a gap between COPD treatment guidelines and the healthcare that is provided in primary care. To facilitate implementation of the guidelines several actions are needed, such as further training for professionals, additional resources, and improved organisational structure for interprofessional collaboration and patient education. 

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  • 34.
    Marmstål Hammar, Lena
    et al.
    Dalarna University, School of Health and Welfare, Caring Science/Nursing. Mälardalen University, Västerås; Karolinska Institutet, Stockholm.
    Alam, Moudud
    Dalarna University, School of Information and Engineering, Statistics.
    Eklund, Caroline
    Mälardalen University, Västerås.
    Boström, Anne-Marie
    Karolinska Institutet, Stockholm; Karolinska University Hospital, Huddinge; Stockholms Sjukhem, Stockholm.
    Lövenmark, Annica
    Mälardalen University, Västerås.
    Clarity and adaptability of instructions preventing the spread of the COVID-19 virus and its association with individual and organisational factors regarding the psychosocial work environment: a cross-sectional study2023In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 23, no 1, article id 1312Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In Sweden, older people in residential care had the highest mortality rates, followed by those who received home care, during the coronavirus disease 2019 (COVID-19) pandemic. Staff working in the care of older people assumed responsibility for preventing the spread of the virus despite lacking the prerequisites and training. This study aimed to investigate the psychosocial work environment during the COVID-19 pandemic among staff in the care of older people and examine the factors associated with staff's perceptions of the clarity of instructions and the ability to follow them.

    METHODS: A cross-sectional study design was employed using a web survey. The staff's perceptions of their psychosocial environment were analysed using descriptive statistics. The association between organisational and individual factors, as well as the degree of clarity of the instructions and the staff's ability to follow them, were assessed using multivariate (ordinal) regression analysis.

    RESULTS: The main findings show that perceptions of the clarity and adaptability of the instructions were primarily correlated with organisational factors, as higher responses (positive) for the subscales focusing on role clarity, support and encouragement in leadership at work were associated with the belief that the instructions were clear. Similarly, those indicating high job demands and high individual learning demands were less likely to report that the instructions were clear. Regarding adaptability, high scores for demands on learning and psychological demands were correlated with lower adaptability, while high scores for role clarity, encouraging leadership and social support, were associated with higher adaptability.

    CONCLUSIONS: High job demands and individual learning demands were demonstrated to decrease the staff's understanding and adoption of instructions. These findings are significant on an organisational level since the work environment must be prepared for potential future pandemics to promote quality improvement and generally increase patient safety and staff health.

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  • 35.
    Palmcrantz, Susanne
    et al.
    Karolinska institutet.
    Tistad, Malin
    Dalarna University, School of Education, Health and Social Studies, Medical Science. Karolinska institutet.
    Eldh, Ann Catrine
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet.
    Holmqvist, Lotta Widén
    Karolinska institutet.
    Ehrenberg, Anna
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Tomson, Göran
    Karolinska institutet.
    Olsson, Christina B
    Karolinska institutet; Stockholm läns landsting.
    Wallin, Lars
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet.
    Assessing feasibility and acceptability of study procedures: getting ready for implementation of national stroke guidelines in out-patient health care2015In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 15, article id 517Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Even though Swedish national guidelines for stroke care (SNGSC) have been accessible for nearly a decade access to stroke rehabilitation in out-patient health care vary considerably. In order to aid future interventions studies for implementation of SNGSC, this study assessed the feasibility and acceptability of study procedures including analysis of the context in out-patient health care settings.

    METHODS: The feasibility and acceptability of recruitment, observations and interviews with managers, staff and patients were assessed, as well as the feasibility of surveying health care records.

    RESULTS: To identify patients from the the hospitals was feasible but not from out-patient care where a need to relieve clinical staff of the recruitment process was identified. Assessing adherence to guidelines and standardized evaluations of patient outcomes through health care records was found to be feasible and suitable assessment tools to evaluate patient outcome were identified. Interviews were found to be a feasible and acceptable tool to survey the context of the health care setting.

    CONCLUSION: In this feasibility study a variety of qualitative and quantitative data collection procedures and measures were tested. The results indicate what can be used as a set of feasible and acceptable data collection procedures and suitable measures for studying implementation of stroke guidelines in an out-patient health care context.

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  • 36. Paul, Mandira
    et al.
    Gemzell-Danielsson, Kristina
    Kiggundu, Charles
    Namugenyi, Rebecka
    Klingberg-Allvin, Marie
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing. Karolinska institutet.
    Barriers and facilitators in the provision of post-abortion care at district level in central Uganda – a qualitative study focusing on task sharing between physicians and midwives2014In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 14, no 28Article in journal (Refereed)
    Abstract [en]

    Background

    Abortion is restricted in Uganda, and poor access to contraceptive methods result in unwanted pregnancies. This leaves women no other choice than unsafe abortion, thus placing a great burden on the Ugandan health system and making unsafe abortion one of the major contributors to maternal mortality and morbidity in Uganda. The existing sexual and reproductive health policy in Uganda supports the sharing of tasks in post-abortion care. This task sharing is taking place as a pragmatic response to the increased workload. This study aims to explore physicians’ and midwives’ perception of post-abortion care with regard to professional competences, methods, contraceptive counselling and task shifting/sharing in post-abortion care.

    Methods

    In-depth interviews (n = 27) with health care providers of post-abortion care were conducted in seven health facilities in the Central Region of Uganda. The data were organized using thematic analysis with an inductive approach.

    Results

    Post-abortion care was perceived as necessary, albeit controversial and sometimes difficult to provide. Together with poor conditions post-abortion care provoked frustration especially among midwives. Task sharing was generally taking place and midwives were identified as the main providers, although they would rarely have the proper training in post-abortion care. Additionally, midwives were sometimes forced to provide services outside their defined task area, due to the absence of doctors. Different uterine evacuation skills were recognized although few providers knew of misoprostol as a method for post-abortion care. An overall need for further training in post-abortion care was identified.

    Conclusions

    Task sharing is taking place, but providers lack the relevant skills for the provision of quality care. For post-abortion care to improve, task sharing needs to be scaled up and in-service training for both doctors and midwives needs to be provided. Post-abortion care should further be included in the educational curricula of nurses and midwives. Scaled-up task sharing in post-abortion care, along with misoprostol use for uterine evacuation would provide a systematic approach to improving the quality of care and accessibility of services, with the aim of reducing abortion-related mortality and morbidity in Uganda.

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  • 37. Petersson, Kerstin
    et al.
    Persson, Margareta
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Lindkvist, Marie
    Hammarstrm, Margareta
    Haglund, Ingrid
    Nilses, Carin
    Skogsdal, Yvonne
    Mogren, Ingrid
    User perspectives on the Swedish Maternal Health Care Register2014In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 14, article id 613Article in journal (Refereed)
    Abstract [en]

    Background: Established in 1999, the Swedish Maternal Health Care Register (MHCR) collects data on pregnancy, birth, and the postpartum period for most pregnant women in Sweden. Antenatal care (ANC) midwives manually enter data into the Web-application that is designed for MHCR. The aim of this study was to investigate midwives? experiences, opinions and use of the MHCR.

    Method: A national, cross-sectional, questionnaire survey, addressing all Swedish midwives working in ANC, was conducted January to March 2012. The questionnaire included demographic data, preformed statements with six response options ranging from zero to five (0 = totally disagree and 5 = totally agree), and opportunities to add information or further clarification in the form of free text comments. Parametric and non-parametric methods and logistic regression analyses were applied, and content analysis was used for free text comments.

    Results: The estimated response rate was 53.1%. Most participants were positive towards the Web-application and the included variables in the MHCR. Midwives exclusively engaged in patient-related work tasks perceived the register as burdensome (70.3%) and 44.2% questioned the benefit of the register. The corresponding figures for midwives also engaged in administrative supervision were 37.8% and 18.5%, respectively. Direct electronic transfer of data from the medical records to the MHCR was emphasised as significant future improvement. In addition, the midwives suggested that new variables of interest should be included in the MHCR ? e.g., infertility, outcomes of previous pregnancy and birth, and complications of the index pregnancy.

    Conclusions: In general, the MHCR was valued positively, although perceived as burdensome. Direct electronic transfer of data from the medical records to the MHCR is a prioritized issue to facilitate the working situation for midwives. Finally, the data suggest that the MHCR is an underused source for operational planning and quality assessment in local ANC centres.

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  • 38. Petersson, Kerstin
    et al.
    Persson, Margareta
    Dalarna University, School of Education, Health and Social Studies, Caring Science/Nursing.
    Lindkvist, Marie
    Hammarstrom, Margareta
    Nilses, Carin
    Haglund, Ingrid
    Skogsdal, Yvonne
    Mogren, Ingrid
    Internal validity of the Swedish Maternal Health Care Register2014In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 14, article id 364Article in journal (Refereed)
    Abstract [en]

    Background: The Swedish Maternal Health Care Register (MHCR) is a national quality register that has been collecting pregnancy, delivery, and postpartum data since 1999. A substantial revision of the MHCR resulted in a Web-based version of the register in 2010. Although MHCR provides data for health care services and research, the validity of the MHCR data has not been evaluated. This study investigated degree of coverage and internal validity of specific variables in the MHCR and identified possible systematic errors.

    Methods: This cross-sectional observational study compared pregnancy and delivery data in medical records with corresponding data in the MHCR. The medical record was considered the gold standard. The medical records from nine Swedish hospitals were selected for data extraction. This study compared data from 878 women registered in both medical records and in the MHCR. To evaluate the quality of the initial data extraction, a second data extraction of 150 medical records was performed. Statistical analyses were performed for degree of coverage, agreement and correlation of data, and sensitivity and specificity.

    Results: Degree of coverage of specified variables in the MHCR varied from 90.0% to 100%. Identical information in both medical records and the MHCR ranged from 71.4% to 99.7%. For more than half of the investigated variables, 95% or more of the information was identical. Sensitivity and specificity were analysed for binary variables. Probable systematic errors were identified for two variables.

    Conclusions: When comparing data from medical records and data registered in the MHCR, most variables in the MHCR demonstrated good to very good degree of coverage, agreement, and internal validity. Hence, data from the MHCR may be regarded as reliable for research as well as for evaluating, planning, and decision-making with respect to Swedish maternal health care services.

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  • 39. Rucker, Fredrik
    et al.
    Hardstedt, Maria
    Rucker, Sekai Chenai Mathabire
    Aspelin, Emma
    Smirnoff, Alexander
    Lindblom, Anders
    Gustavsson, Catharina
    Dalarna University, School of Health and Welfare, Medical Science.
    From chaos to control - experiences of healthcare workers during the early phase of the COVID-19 pandemic: a focus group study2021In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 21, no 1, article id 1219Article in journal (Refereed)
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  • 40.
    Rudman, Ann
    et al.
    Karolinska Institutet.
    Waldenström, Ulla
    Critical views on postpartum care expressed by new mothers2007In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 7, article id 178Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Women's evaluation of hospital postpartum care has consistently been more negative than their assessment of other types of maternity care. The need to further explore what is wrong with postpartum care, in order to stimulate changes and improvements, has been stressed. The principal aim of this study was to describe women's negative experiences of hospital postpartum care, expressed in their own words. Characteristics of the women who spontaneously gave negative comments about postpartum care were compared with those who did not.

    METHODS: Data were taken from a population-based prospective longitudinal study of 2783 Swedish-speaking women surveyed at three time points: in early pregnancy, at two months, and at one year postpartum. At the end of the two follow-up questionnaires, women were asked to add any comment they wished. Content analysis of their statements was performed.

    RESULTS: Altogether 150 women gave negative comments about postpartum care, and this sample was largely representative of the total population-based cohort. The women gave a diverse and detailed description of their experiences, for instance about lack of opportunity to rest and recover, difficulty in getting individualised information and breastfeeding support, and appropriate symptom management. The different statements were summarised in six categories: organisation and environment, staff attitudes and behaviour, breastfeeding support, information, the role of the father and attention to the mother.

    CONCLUSION: The findings of this study underline the need to further discuss and specify the aims of postpartum care. The challenge of providing high-quality follow-up after childbirth is discussed in the light of a development characterised by a continuous reduction in the length of hospital stay, in combination with increasing public demands for information and individualised care.

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  • 41.
    Saarijärvi, Markus
    et al.
    Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden; KU Leuven, Department of Public Health and Primary Care, Leuven, Belgium.
    Wallin, Lars
    Dalarna University, School of Health and Welfare, Caring Science/Nursing. Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden; University of Gothenburg Centre for Person-Centered Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Moons, Philip
    Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden; KU Leuven, Department of Public Health and Primary Care, Leuven, Belgium; Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa.
    Gyllensten, Hanna
    Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden; University of Gothenburg Centre for Person-Centered Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Bratt, Ewa-Lena
    Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden; Department of Pediatric Cardiology, The Queen Silvia Children's Hospital, Gothenburg, Sweden.
    Implementation fidelity of a transition program for adolescents with congenital heart disease: the STEPSTONES project2022In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 22, no 1, article id 153Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Although transition programs have been evaluated for adolescents with chronic conditions, these have rarely involved process evaluations. Indeed, outcomes of complex interventions are dependent on how the intervention is implemented in practice and evaluations of implementation process are therefore pivotal. The aim of this study was to evaluate the extent to which a transition program for adolescents with congenital heart disease was delivered as intended. Research questions were 1) to what level of fidelity was the program delivered? and 2) what potential moderating factors affected the delivery of the program and overall fidelity?

    METHODS: A mixed methods design was used, where a process evaluation was embedded in the STEPSTONES randomized controlled trial in Sweden. The implementation fidelity framework by Carrol (2007) and Hasson (2010) was used to design, collect and analyze data. Quantitative data consisted of intervention records on adherence and were analyzed with descriptive statistics. Qualitative data on moderators affecting fidelity were collected through interviews, log-books and focus group interviews with healthcare professionals implementing the intervention and participatory observations of the implementation process. Data were analyzed with deductive content analysis. Triangulation was used to integrate quantitative and qualitative data within the fidelity framework.

    RESULTS: Six out of eight components of the transition program were delivered to an extent that adhered to the program theory or achieved a high level of fidelity. However, components involving peer support had a low attendance by the participating sample (32.2%), and the joint transfer meeting was challenging to implement, despite achieving high adherence. Moderators affecting the implementation process were the adolescent's and healthcare professional's engagement in the intervention, contextual factors and a lack of standard operating procedures for all components in the program.

    CONCLUSION: Barriers and facilitators for a future implementation of transition programs have been illuminated in this study. The use of an implementation fidelity framework in the process evaluation proved successful in providing a comprehensive evaluation of factors affecting the implementation process. However, implementation fidelity must be considered in relation to adaptations to the local and personal prerequisites in order to create interventions that can achieve fit.

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  • 42. Saarijärvi, Markus
    et al.
    Wallin, Lars
    Dalarna University, School of Health and Welfare, Caring Science/Nursing. University of Gothenburg.
    Moons, Philip
    Gyllensten, Hanna
    Bratt, Ewa-Lena
    Mechanisms of impact and experiences of a person-centred transition programme for adolescents with CHD: the Stepstones project.2021In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 21, no 1, article id 573Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: During the past decade there has been some evaluation of transition programmes for adolescents with chronic conditions. However, this has rarely involved process evaluations focusing on mechanisms leading to outcomes, thus hampering implementation of these complex interventions. Our aim was to (I) describe adolescents' and parents' experiences of participating in a person-centred transition programme aiming to empower them in transition to adulthood and (II) explore the mechanisms of impact.

    METHODS: A qualitative process evaluation was performed, embedded in a randomized controlled trial evaluating the effectiveness of a transition programme for adolescents with congenital heart disease in Sweden. A purposive sample of 14 adolescents and 12 parents randomized to the intervention group were interviewed after participation in the programme. Data were analysed deductively and inductively in NVivo v12.

    RESULTS: Experiences of participation in the transition programme were generally positive. Meeting a transition coordinator trained in person-centred care and adolescent health and embarking on an educational process based on the adolescents' prerequisites in combination with peer support were considered key change mechanisms. However, support to parents were not sufficient for some participants, resulting in ambivalence about changing roles and the unmet needs of parents who required additional support.

    CONCLUSIONS: Participants experienced increased empowerment in several dimensions of this construct, thus demonstrating that the transition programme was largely implemented as intended and the evidence-based behaviour-change techniques used proved effective in reaching the outcome. These findings can inform future implementation of transition programmes and illuminate challenges associated with delivering a complex intervention for adolescents with chronic conditions.

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  • 43. Schildmeijer, Kristina
    et al.
    Unbeck, Maria
    Karolinska Institutet.
    Muren, Olav
    Perk, Joep
    Pukk Härenstam, Karin
    Nilsson, Lena
    Retrospective record review in proactive patient safety work - identification of no-harm incidents.2013In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 13, article id 282Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: In contrast to other safety critical industries, well-developed systems to monitor safety within the healthcare system remain limited. Retrospective record review is one way of identifying adverse events in healthcare. In proactive patient safety work, retrospective record review could be used to identify, analyze and gain information and knowledge about no-harm incidents and deficiencies in healthcare processes. The aim of the study was to evaluate retrospective record review for the detection and characterization of no-harm incidents, and compare findings with conventional incident-reporting systems.

    METHODS: A two-stage structured retrospective record review of no-harm incidents was performed on a random sample of 350 admissions at a Swedish orthopedic department. Results were compared with those found in one local, and four national incident-reporting systems.

    RESULTS: We identified 118 no-harm incidents in 91 (26.0%) of the 350 records by retrospective record review. Ninety-four (79.7%) no-harm incidents were classified as preventable. The five incident-reporting systems identified 16 no-harm incidents, of which ten were also found by retrospective record review. The most common no-harm incidents were related to drug therapy (n = 66), of which 87.9% were regarded as preventable.

    CONCLUSIONS: No-harm incidents are common and often preventable. Retrospective record review seems to be a valuable tool for identifying and characterizing no-harm incidents. Both harm and no-harm incidents can be identified in parallel during the same record review. By adding a retrospective record review of randomly selected records to conventional incident-reporting, health care providers can gain a clearer and broader picture of commonly occurring, no-harm incidents in order to improve patient safety.

  • 44.
    Tistad, Malin
    et al.
    Dalarna University, School of Health and Welfare, Medical Science. Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm.
    Wallin, Lars
    Dalarna University, School of Health and Welfare, Caring Science/Nursing. Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden; Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    Carlström, Eric
    Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden; Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
    A comparison of three organisational levels in one health care region in Sweden implementing person-centred care: coupled, decoupled or recoupled in a complex organisation2022In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 22, no 1, article id 196Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Establishing more substantial patient involvement in the health care has become fundamental to Western health care services. Person-centred care (PCC) has been developed as a way of working that involve the patients and family members. However, the implementation of PCC in clinical practice has proven to be challenging. The aim of this study was to explore the congruence of managers' perceptions and understanding of various aspects of PCC across three organisational levels in one health care region in Sweden in terms of coupling, decoupling and recoupling.

    METHODS: A policy on increased patient participation in health care was adopted in one health care region in Sweden. This policy was embodied in the form of PCC and a support strategy for the implementation was put in place. Participants representing three organisational levels (senders: politicians, n = 3; messengers: senior management, n = 7; and receivers: middle- and frontline managers, n = 13) were interviewed and documents collected. A deductive qualitative content analysis was performed and findings from the three organisational levels compared.

    RESULTS: Descriptions of PCC at all the three organisational levels included health care provided in partnership between provider and patient. However, messengers and receivers also included aspects of how work was organised as part of the concept. Representatives at all levels expected high-quality care while reducing health care costs as an outcome, however, messengers and receivers also anticipated improvements in the work environment and reduced staff turnover. Strategies to support implementation included continuation and enhancement of existing routines that were considered person-centred and development of new ones. A need to make PCC less 'fuzzy' and ambiguous and instead communicate a more tangible care process was described. Representatives among messengers and receivers also suggested that no actions were needed because the practice was already considered person-centred.

    CONCLUSION: The findings indicated that congruence between organisational levels existed in some aspects, suggesting coupling between policy and practice. However, also incongruences were identified that might be due to the fuzziness of definitions and the application of PCC in practice, and the difficulty in assessing the level of patient-centredness in clinical practice.

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  • 45.
    Unbeck, Maria
    et al.
    Karolinska Institutet.
    Lindemalm, Synnöve
    Nydert, Per
    Ygge, Britt-Marie
    Nylén, Urban
    Berglund, Carina
    Härenstam, Karin Pukk
    Validation of triggers and development of a pediatric trigger tool to identify adverse events.2014In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 14, article id 655Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Little is known about adverse events (AEs) in pediatric patients. Record review is a common methodology for identifying AEs, but in pediatrics the record review tools generally have limited focus. The aim of the present study was to develop a broadly applicable record review tool to identify AEs in pediatric inpatients.

    METHODS: Using a broad literature review and expert opinion with a modified Delphi process, a pediatric trigger tool with 88 triggers, definitions, and descriptions including AE preventability decision support was developed and tested in a random sample of 600 hospitalized pediatric patients admitted in 2010 to a single university children's hospital. Four registered nurse-physician teams performed complete two-stage retrospective reviews of 150 records each from either neonatal, surgical/orthopedic, medicine, or emergency medicine units.

    RESULTS: Registered nurse review identified 296 of 600 records with triggers indicating potential AEs. Records (n = 121) with only false positive triggers not indicating any potential AEs were not forwarded to the next review stage. On subsequent physician review, 204 (34.0%) of patients were found to have had 563 AEs, range 1-27 AEs/patient. A total of 442 preventable AEs were found in 161 patients (26.8%), range 1-22. Overall, triggers were found 3,598 times in 417 (69.5%) records, with a mean of 6 (median 1, range 0-176) triggers per patient. The overall positive predictive value of the triggers was 22.9%, (range 0.0-100.0%). The final pediatric trigger tool, developed with a second Delphi round, required 29 triggers.

    CONCLUSIONS: AEs are common in pediatric patients and most are preventable. The main contributions of this study are to further develop and adapt trigger definitions, including AE preventability decision support, to introduce new triggers in pediatric care, as well as to apply pediatric triggers in different clinical specialties. Our findings resulted in a national pediatric trigger tool, and might also be adapted internationally. The pediatric trigger tool can help healthcare organizations to measure and analyze the AEs occurring in hospitalized children in order to improve patient safety.

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