Talking about quality: exploring how ‘quality’ is conceptualized in European hospitals and healthcare systems

BACKGROUND: Conceptualization of quality of care - in terms of what individuals, groups and organizations include in their meaning of quality, is an unexplored research area. It is important to understand how quality is conceptualised as a means to successfully implement improvement efforts and bridge potential disconnect in language about quality between system levels, professions, and clinical services. The aim is therefore to explore and compare conceptualization of quality among national bodies (macro level), senior hospital managers (meso level), and professional groups within clinical micro systems (micro level) in a cross-national study. METHODS: This cross-national multi-level case study combines analysis of national policy documents and regulations at the macro level with semi-structured interviews (383) and non-participant observation (803 hours) of key meetings and shadowing of staff at the meso and micro levels in ten purposively sampled European hospitals (England, the Netherlands, Portugal, Sweden, and Norway). Fieldwork at the meso and micro levels was undertaken over a 12-month period (2011-2012) and different types of micro systems were included (maternity, oncology, orthopaedics, elderly care, intensive care, and geriatrics). RESULTS: The three quality dimensions clinical effectiveness, patient safety, and patient experience were incorporated in macro level policies in all countries. Senior hospital managers adopted a similar conceptualization, but also included efficiency and costs in their conceptualization of quality. 'Quality' in the forms of measuring indicators and performance management were dominant among senior hospital managers (with clinical and non-clinical background). The differential emphasis on the three quality dimensions was strongly linked to professional roles, personal ideas, and beliefs at the micro level. Clinical effectiveness was dominant among physicians (evidence-based approach), while patient experience was dominant among nurses (patient-centered care, enough time to talk with patients). Conceptualization varied between micro systems depending on the type of services provided. CONCLUSION: The quality conceptualization differed across system levels (macro-meso-micro), among professional groups (nurses, doctors, managers), and between the studied micro systems in our ten sampled European hospitals. This entails a managerial alignment challenge translating macro level quality definitions into different local contexts.

Arbetsplatsförlagt lärande (APL) - handledares uppfattningar av vad elever ska lära sig samt vad och hur kunskapen ska bedömas

Inom ramen för gymnasieskolans yrkesprogram förläggs en del av elevens utbildning på en arbetsplats, APL. APL är betydelsefull för yrkesprogrammen eftersom hela utbildningen syftar till att knyta an till kommande yrkesroll och lära sig yrket tillsammans med redan yrkesverksamma. Bakgrunden till föreliggande studie är ett intresse för vilket lärande som pågår ute på arbetsplatserna och vad handledarna uppfattar som viktigt lärande för kommande yrkesutövning. Syftet med studien är att beskriva vad handledarna uppfattar att eleverna ska lära sig samt bedömning av elevernas kunskapsutveckling under APL. Studien är en kvalitativ studie och har omfattat intervjuer med 12 handledare med anknytning till gymnasieskolans bygg- och anläggningsprogram. Studien tar sin utgångspunkt i livsvärldsfenomenologin med fenomenografi som metodisk ansats för att beskriva handledarnas uppfattningar av APL. Resultatet av studien visar att handledarna beskriver att de inte har fått tillräckligt med kunskap och information från skolan om vad eleverna ska lära sig på APL. Detta kan innebära svårigheter att hitta passande arbetsuppgifter. Det råder vidare en brist på kunskap om vad och hur de bedömer elevernas lärande vilket leder till att eleverna bedöms på oklara grunder. Sammanfattningsvis visar således studien att det finns delar av APL som behöver förbättras och utvecklas för att nå en högre kvalitet i det arbetsplatsförlagda lärandet. Samarbetet skola och fö-retag måste förbättras, och fler handledare måste få en pedagogisk handledarutbildning.

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.