Factors influencing the use of evidence based practice among physiotherapists and occupational therapists in their clinical work

Background: Evidence-based practice (EBP) is a process through which research is applied in daily clinical practice. Occupational therapists (OTs) and physiotherapists (PTs) are expected to work in line with EBP in order to optimise health care resources. This expectation is too seldom fulfilled. Consequently, research findings may not be implemented in clinical practice in a timely manner, or at all. To remedy this situation, additional knowledge is needed regarding what factors influence the process of EBP among practitioners. The purpose of the present study was to identify factors that influence the use of EBP and the experienced effects of the use of EBP among PTs and OTs in their clinical work. Method: This was a qualitative interview study that consisted of six group interviews involving either OTs or PTs employed by the Jönköping County Council in the South of Sweden. Resulting data were analysed using content analysis. Results: The analysis resulted in the following categories: “definition of evidence and EBP”, “sources of evidence”, “barriers to acquiring evidence and to using evidence in clinical work”, “factors that facilitate the acquisition of evidence and the use of evidence in clinical work”, and “personal experiences of using EBP”. Basing clinical practice on scientific evidence evoked positive experiences, although an ambivalent view towards acting on clinical experience was evident. Participants reported that time for and increased knowledge about searching for, evaluating, and implementing EBP were needed. Conclusion: Because OTs are more oriented towards professional theories and models, and PTs are more focused on randomised controlled trials of interventions, different strategies appear to be needed to increase EBP in these two professions. Management support was considered vital to the implementation of EBP. However, the personal obligation to work in line with EBP must also be emphasised; the participants apparently underestimate its importance.

Quality improvement within nonprofit social service providers

As a relatively new phenomenon in 2009, Swedish nonprofit social service providers proposed quality improvement as a way to reduce mistakes, use resources more effectively and meet the needs and expectations of clients in a better way. Although similar experiences have been studied in health care, the transfer of quality improvement to nonprofit social services gives a possibility for more knowledge on what enables, and constrains, systematic quality improvement in this specific context. This thesis is based on five years of supporting quality improvement in the Swedish nonprofit welfare sector. Specifically, it builds knowledge on which active mechanisms and enabling or constraining structures exist for nonprofit social service quality improvement. By studying quality improvement projects that have been conducted in the development program Forum for Values, critical cases and broad overviews are found valuable. These cases have resulted in four papers on quality improvement in nonprofit social services. The papers include: critical cases from a nursing home for elderly and a daycare for disabled children (Paper I); a critical case from a sheltered housing (Paper II); an overview of performance measurements in 127 quality improvement projects (Paper III); and an analytical model of how improvement policy and practice are bridged by intermediaries (Paper IV). In this thesis, enabled or constrained events and activities related to Deming's system of profound knowledge are identified from the papers and elaborated upon. As a basis for transforming practice into continuous improvement, profound knowledge includes the four knowledge domains: appreciation of a system, theory of knowledge, understanding of variation and psychology of change. From a realist perspective, the identified events are seen as enabled or constrained by mechanisms and underlying regularities, or structures, in the context of nonprofit social services. The emerging mechanisms found in this thesis are: describing and reflecting upon project relations; forming and testing a theory of action; collecting and displaying measurable results over time; and engaging and participating in a development program. The structures that enable these mechanisms are: connecting projects to shared values such as client needs; local ownership of what should be measured; and translating quality improvement into a single practice. Constraining structures identified are: a lack of generalizable scientific knowledge and inappropriate or missing infrastructure for measurements. Reflecting upon the emergent structures of nonprofit social services, the role of political macro structures, reflective practice, competence in statistical methods and areas of expertise becomes important. From this discussion and the findings some hypotheses for future work can be formulated. First, the identified mechanisms and structures form a framework that helps explain why intended actions of quality improvement occur or not. This frameworkcan be part of formulating a program theory of quality improvement in nonprofit social services. With this theory, quality improvement can be evaluated, reflected upon and further developed in future interventions. Second,new quality improvement interventions can be reproduced more regularly by active work with known enablers and constraints from this program theory. This means that long-lasting interventions can be performed and studied in a second generation of improvement efforts. Third, if organizations integrate quality improvement as a part of their everyday practice they also develop context-specific knowledge about their services. This context-specific knowledge can be adopted and further developed through dedicated management and understanding of variation. Thus, if enabling structures are invoked and constraining structures handled, systematic quality improvement could be one way to integrate generalizable scientific knowledge as part of an evidence-creating practice.

Women's experiences of how their recovery process is promoted after a first myocardial infarction : Implications for cardiac rehabilitation care

Background: After a myocardial infarction and discharge from the hospital a recovery process follows for the women. In order to facilitate their recovery, both a preventive and promotive perspective should be taken into consideration. Despite this, today´s healthcare focuses more on prevention and thus research into the promotion of women’s recovery process is needed. Aim: To explore how women’s recovery processes are promoted after a first myocardial infarction Methods: The study had an explorative and descriptive design based on qualitative content analysis. Findings: The women’s recovery process was promoted through using external and internal resources as well as embracing behaviour, social and psychological dimensions. The women embraced these dimensions to a varying extent and this process led to them being able to take in a new perspective on life. Conclusions: The women’s personal recovery is a multidirectional process with a desire to develop and approach a new perspective on life. It is important for cardiac rehabilitation nurses to not only focus on lifestyle changes and social support, but also on working actively with the women’s inner strength in order to promote the personal recovery of the women. Furthermore, it would be interesting to investigate men’s experiences of how their recovery process after a first Myocardial infarction is promoted.

Erfarenheter från lärandeseminarier : Barn som anhöriga: Reflektioner från följeforskning

Under 2015 genomfördes nationella lärandeseminarier för att stärka implementeringen av den lag som ger barn rätt till information, råd och stöd när en förälder plötsligt avlider, är svårt sjuk eller skadad (HSL 2g §). Satsningen var ett förbättringsarbete som omfattade sex landsting som med hjälp av en projektledning träffades vid fyra tillfällen från januari till september. Två av träffarna skedde i Stockholm och två var digitala. Under våren 2015 knöts följeforskning till arbetet med frågeställningar om vilka resultat förbättringsarbetet gav och hur deltagarna upplevde arbetssättet. Syftet var att lyfta fram vad satsningen gav samt att lära inför framtida satsningar – är lärandeseminarier ett användbart arbetssätt för nationella implementeringssatsningar? Rapporten visar att lärandeseminarier tycks vara en användbar form. Teamen kan redovisa att de uppnått många av de mål som de föresatte sig under projekttiden. Det handlade om kartläggning av kunskapsläge och strukturer, kompetensutveckling samt utveckling av rutiner och material. Teamen uppskattade också att få delta i ett nationellt sammanhang som gav inspiration. Samtidigt framkom det önskemål om fortsatt och ännu mer handfast stöd i fortsatt implementering i klinisk verksamhet.

Agenda för samverkan eller verksamhetens agenda? Om professionellas erfarenheter av samverkan enligt samordnad individuell plan (SIP)

Agenda for collaboration or an agency agenda? Professionals’ experiences of colla­boration according to a coordinated individual plan (CIP) An increasing number of children and adolescents develop complex needs that require simultaneous action by different professionals. Several reports state that efforts for these children and adolescents have become increasingly specialized and fragmented. Since 2010, there are statutory requirements for collaboration according to a coordinated individual plan (SIP) between health care and social services. Pre-school and school can after regional agreement be involved in the co-ordination as equal partner. Collaboration in line with CIP is expected to offset the fragmentation for benefit of the service users’ ability to monitor and comprehend interventions. The aim was to investigate professionals’ experiences of CIP. The study consists of qualitative analysis of 12 focus group interviews with a total of 71 staff with different professions in health care, education and social services about their experiences of CIP. The results indicate that the participants act according to their core mission: nurturing, teaching and investigation. Two main categories with four sub-categories each appeared in the analysis. The main category, hindering factors, contains the categories: different mandates and requirements, requirements for presence initiative, questioning and censure, and timelines and prioritization. The main category of facilitating factors contains the categories: similar interpretation of common agreement, mutual respect and shared learning, common terminology and documentation, and willingness to collaborate. The analysis indicate that CIP was perceived as alternating between, on the one hand, a pro-active and service-focused tool, and on the other hand, a competing and compelling professional instrument.