Background. In line with patient-centered health care, it is necessary to understand patients’ perceptions of health. How stroke survivors perceive their health at different time points after stroke and which factors are associated with these feelings provide important information about relevant rehabilitation targets. Objective. This study aimed to identify the independent factors of health-related quality of life (HRQoL) from a biopsychosocial perspective using the methods of multivariate regression at 3 different time points poststroke. Methods. Included in the study were 99 patients from stroke units with diagnosed first-ever stroke. At admission and at 6 weeks, 3 months, and 1 year poststroke, HRQoL was assessed using the EuroQoL-5D Visual Analogue Scale (EQ-5D VAS). Consequences in Body Functions and Activities and Participation, and Environmental Factors were documented using 155 categories of the International Classification of Functioning, Disability and Health (ICF) Core Set for Stroke. Results. For a period of 1 year, problems with recreation and leisure, personality functions, energy and drive functions, and gait pattern functions were repeatedly associated with worse HRQoL. Whereas Body Functions and Activities and Participation explained more than three-fourths of the variances of HRQoL at 6 weeks and 3 months (R ² = 0.80-0.93), the variation at 1 year was best explained by either Body Functions or Environmental Factors (R ² = 0.51). Conclusions. The results indicate the importance of Body Functions and Activities and Participation (mainly personality functions and recreation and leisure) on HRQoL within 3 months poststroke, but increased impact of Environmental Factors on HRQoL at 1 year.

KRY helps people who need healthcare through digital meetings. After the appointment patients can give instant feedback about their experience. There was no system to do follow-ups when patients have left a bad review after a meeting.

The overall aim of the improvement work was to develop a better service and to offer better meetings in the future.

The purpose of the study was to investigate employees' experiences of a system for monitoring dissatisfied patients who have used digital care.

The improvement work was carried out according to Nolan's improvement model. The study was a qualitative interview study with an inductive approach. 

Reasons for complaints in digital care have not differed significantly in comparison with physical care. Employees feel that the work of calling bad reviews gave satisfied patients and a feeling of doing a good job. There was an experience of gains both for the patients as well as for the company. 

This study has shown that follow-up of patients who left a bad review is perceived as something positive for both patients and those who will perform the follow-ups. Reports of suggestions from patients for improvement of the service/product has been done and got results.

Background: From a management point of view, there are many different approaches from which to choose to engage staff members in initiatives to improve performance.

Objective: The present study evaluated how two different types of improvement strategies facilitate and encourage involvement of different professional groups in health-care organizations.

Methods/Design: Empirical data of two different types of strategies were collected within an improvement project in a County Council in Sweden. The data analysis was carried out through classifying the participants' profession, position, gender, and the organizational administration of which they were a part, in relation to their participation.

Setting: An improvement project in a County Council in Sweden.

Participants: Designed Improvement Processes consisted of n=105 teams and Intrapreneurship Projects of n=202 projects.

Intervention: Two different types of improvement strategies, Designed Improvement Processes and Intrapreneurship Projects.

Main Outcome Measures: How two different types of improvement strategies facilitate and encourage involvement of different professional groups in healthcare organizations.

Results: Nurses were the largest group participating in both improvement initiatives. Physicians were also well represented, although they seemed to prefer the less structured Intrapreneurship Projects approach. Assistant nurses, being the second largest staff group, were poorly represented in both initiatives. This indicates that the benefits and support for one group may push another group aside.

Conclusions: Managers need to give prerequisites and incentives for staff who do not participate in improvements to do so. Comparisons of different types of improvement initiatives are an underused research strategy that yields interesting and thoughtful results.

Read More: http://www.gahmj.com/doi/abs/10.7453/gahmj.2014.040

The follow-up of the Health Care Agreement in Västra Götaland proved that it was poorly known among healthcare professionals. The patients thus risked of being without necessary care. An overview and development of the Healthcare Agreement was conducted. One of the sub processes was to develop an application manual aimed at concretizing the healthcare agreement.

The improvement work consisted of developing patient cases aimed at guiding the interaction between patients in need of care both from Västra Götaland region and the municipality. The purpose of the study is to describe and analyze the professional experiences of collaboration in the health care sector in Västra Götaland.

The improvement model with the four-phase PGSA wheel was used as a structure for improvement work. As methods, focus groups in combination with surveys have been used. Qualitative content analysis of the focus group interviews was conducted with a deductive approach from collaborative frameworks.

The indicative patient cases are perceived by the participants as relevant, reality-based and that they provide guidance for collaboration. Hospitals and primary care cooperate more with the municipality's health care than with each other, despite common main organization. Collaboration occurs mainly because of Employee motivation to facilitate, assist or support a patient. However, when the partner does not meet expectations, they rely on treaties and agreements.

Background Malnutrition is associated with decreased quality of life, depression, prolonged hospitalization and shortened lifetime. This master thesis describes the study of improvement through involving an improvement team working in two medical departments that treat patients with hematological, oncological and lung diseases.

Purpose The purpose of the quality improvement is to support better health by improving the nutrition process. The purpose of the study is to describe how the improvement team through its work creates commitment int the department.

Method Nolan’s model with PDSA-cycles and description of microsystem with 5P-model are used for the improvement. A case study that included semi-structured interviews was performed with content analysis. An employee questionnaire regarding nutrition knowledge was also performed which provided quantitative data.

Results The result of the improvement shows a greater number of cost registrations but not jet higher daily intakes of energy. The result of the study describes how the improvement team has affected the improvement work based on the following themes: existence and dynamics, individualized guide and shared understanding of the goal.

Conclusion The study of the improvement work shows that the improvement work has contributed to an increased level of knowledge in nutrition both in the improvement team and in the department. The study also shows that a dynamic improvement team can influence the culture of the department by increasing commitment

Aim: The aim of this study was to describe first-line managers’ experiences of alternative modes of funding elderly care in two communities in western Sweden.

 Background: A growing elderly population demands alternative modes of funding elderly care for better outcomes for patients and better efficiency as it is publicly funded through taxation.

 Methods: The study comprised a total of eight semi-structured interviews with first-line managers working within elderly care. The interviews were analysed using manifest qualitative content analysis. Respect for the individuals was a main concern in the study.

 Results: One category, quality improvement, and four subcategories freedom of choice, organisational structure, quality awareness and market forces effects were identified to describe first-line managers’ experiences of the operation of elderly care.

 Conclusions: Quality improvement was an important factor to deal with when elderly care was operated in different organisational perspectives, either private or public. The first-line manager is a key person for developing a learning organisation that encourages both staff, clients and their relatives to improve the organisation. Moreover, person-centred care strengthens the client’s role in the organisation, which is in line with the government’s goal for the quality improvement of elderly care. However, further research is needed on how quality improvement could be developed when different caregivers operate in the same market in order to improve care from the elderly perspective.

Implications for nursing management: This study highlights alternative modes of funding elderly care. The economical perspectives should not dominate without taking care of quality improvement when the operation of elderly care is planned and implemented. Strategies such as a learning organisational structure built on person-centred care could create quality improvement in elderly care.

Background: Complex organizations need to be patient centred, focus on processes, have holistic view and promote organizational learning to secure quality. Operation and intensive care unit, Ryhov, has potential to develop its Process Management (PM) and there is room for improved patient participation.

Purpose: The purpose of the quality improvement project (QIP) was to identify and reduce quality gaps affecting patients, by develop PM and organizational learning. The purpose of the study was to describe co-workers’ understanding of the connection between PM and quality of care and describe their experiences from QIP.

Methods: The QIP has developed organizational learning concerning two pilot processes by using Nolan’s model for improvement. The study of the QIP is qualitative, based on six focus group interviews. Qualitative content analysis was used to analyse the interviews.

Results: PM demands access to improvement and professional knowledge. The organization need to create conditions for sustainability, make benefits obvious and ensure enough resources. Quality of care increases when the organization works structured and patient centred.

Conclusions: PM creates conditions for continual improvements with focus on organizational learning and increased quality of care. The organization need to actively make PM an integral and living part.

Drug-related problems are a common underlying cause of healthcare injuries, in addition to suffering mistakes are costly for health care. To prevent this patient should be familiar with their drug therapy and understand what any side effects they should. At the context, a renal medical ward the result of the National Patient Survey 2018 showed that 43 % of the patients were well-informed about their drug-therapy.

Aim

The purpose of the improvement work was to reduce the risk of drug-related problems by increasing the proportion of patients who, before discharge from a renal medical ward, were well informed about their drug therapy.

Aims  of the study was to investigate whether the improvement work affected the professional development of the employees by contributing to learning about pharmaceuticals, health literacy and person centered care.

Method

The improvement ramp was used together with Nolan’s Improvement model. A case study with mixed methods with surveys and interview was performed.

Result

An interconnection of PDSA-cycles met the complexity of the issue, which resulted in 90 % of the patients were satisfied with the drug-therapy information.

Conclusion

Complex issues require complex solutions. The employees' attitude to the question of responsibility regarding pharmaceuticals proved to be important.

Effektiv kommunikation mellan vårdens medarbetare är väsentlig för patientsäker vård. Bristfällig kommunikation är kopplad till vårdskador. På den slutenvårdsavdelning i södra Sverige, där både aktuellt förbättringsarbete och studie genomfördes, saknades ett strukturerat arbetssätt för utbyte av viktig information kring barn och ungdomars vård inom ett team av nattarbetare. Därför startades ett förbättringsarbete vilket sedan undersöktes genom en intervjustudie.

Genom att införa samling av berörda medarbetare vid varje ny patientinläggning, och tidsbestämda avstämningar som gjordes med ett kommunikationsverktyg, TEAMUP-modellen (T-trust, E-explore, A-ambition, M-model, U-undertake, P-praise) syftade förbättringsarbetet till at etablera en arbetsstruktur som möjliggör effektiv kommunikation i teamet för att minska förekomst av vårdskador samt förbättra arbetsklimatet. Förbättringsarbetet genomfördes med stöd av Nolans modell tillsammans med PDSA- cyklar (P-Plan, D-Do, S-Study, A-Act), fiskbendiagram, förbättringsramen samt värdekompass. I förbättringsarbetet deltog cirka arton nattpersonal och tio vårdnadshavare/barn >15 år. Data samlades in genom enkäter och visualiserades med figurer. Enkätsvaren visade att de nya arbetssätten har möjliggjort strukturerad kommunikation för inforamtionsbyte i teamet kring barn och ungdomars vård och behandlingar. Bland vårdnadshavare/ barn >15 år visade enkätsvaren 100% nöjdhet beträffande kommunikation i teamet kring patienters vård och behandlingar. Av personalen angav 87% att arbetsklimatet förbättrades till föjld av de nya arbetssätten. 

En kvalitativ intervjustudie gjordes när förbättringsarbetet avslutades med syfte till att undersöka hur personalen uppfattar att TEAMUP -modellen och samling vid patientinläggning har påverkat deras interna samarbete med avseende på kommunikation i teamet. En semistrukturerad intervjuguide anvvändes. Åtta medarbetare i nattpersonalgruppen medverkade i intervjuer. Data analyserades genom kvalitativ innehållsanalys. De intervjude medarbetarna beskrev att kommunikation och samarbete i teamet förbättrades. Med hjälp av de nya arbetssätten kunde personalen skapa en kultur som innebar att hjälpa varandra mer då de informerade varandra om viktiga förhållanden gällande patienter, avdelningsresurser, diagnoser och missnöje. 

Background: Scientific articles has shown that patients that have had a stroke during their hospitalization receive lesser degree of care, than patients that has been admitted with a stroke. Literature has shown we need more knowledge how to improve stroke care to get a secure, knowledge based and effective stroke care in hospitals. Aim: The study aims to identify the events that have been critical in the management of hospitalized patients who suffer a stroke. Method: CIT has been used as a data collection method to bring in information, it has been used in the airforce and more recently has been used more widely in national healthcare. Qualitative contents analysis, according to Burnard (1996), gives basis for analyzing the material. The analysis was based on 10 interviews with nurses who have experience of patients diagnosed with stroke during hospitalization. Interviews were conducted at 5 (five) different departments within the Sahlgrenska Hospital in spring 2016. Result: Critical events occur in connection with care in all parts of the care of in-hospital patients who suffer a stroke. Overall categories: unexpected event, the safety of patients affected by department resources and the backside of specialist care. The categories identified in the micro, meso and macro systems are interacting between the different systems. Conclusion: Access to current measurements is important to get an overview of the current state of in-hospital stroke patients in the form of numbers and where they occur. The study shows that there is a great need for a well-functioning stroke chain for in-hospital stroke patients and that there are implemented projects in the US that could be helpful for future improvements in stroke care. It is also important to focus on communication and information to relatives.

Background: The sickness absence in Sweden 2004 was highest inWestern Europe and the country's main economic problem. The government gave incentives to make the sick-leave process included in healthcare management system, partly because of changing requirements and deficiencies in the quality of medical-certificates quality. A local study at an orthopedic clinic showed that 23% of patients were dissatisfied with sick-leave.

Purpose: Through Six Sigma's DMAIC problem-solving model in combination with micro-systems perspective, improving the quality of medical certificates, create goals and routines in the sick-leave process and increase patient satisfaction

Method: Interviews of project participants were carried out using a micro-systems perspective. Through Six Sigma problem-solving model areas of improvement were focused on information exchange to patients and physicians as well as formulating goals and written routines. Fifty-eight patients were interviewed about their sick-leave satisfaction. Measurements of "unnecessary" actions were performed and the quality of medical certificates was followed with control-charts. The improvement project was evaluated by reflection in the group continuously.

Results: Improvements with Six Sigma and micro-systems perspective has contributed to improving the quality of medical certificates significantly p<0.001. Routines and goals for sick-leave process have been implemented in the management system. 100% of the patients at the orthopedic clinic are satisfied. Phone calls about deficiencies and incorrect cases have decreased. This methodology has contributed to a broadened understanding of patients´ experiences and between different staff-categories. The actions have had impact because the improving proposals came from and were carried out by its own staff.

Discussion: The Six Sigma and the micro-systems perspective has patient focus which can affect the values and willingness to change. The result from this study supports other studies and the approach in this study resulted in significantly improved results. Improvement actions are not generalizable, but the approach can be usefully applied in improvement efforts. Further studies of the approach and its sustainability over time are needed to strengthen the evidence.

Background: Recent focus on quality and patient safety has underlined the need to involve patients in improving healthcare. “Experience-based Co-design” (EBCD) is an approach to capture and understand patient and staff (i. e. users) experiences, identifying so called “touch points” and then working together equally in improvement efforts.

Purpose: This article elucidates patient (defined as the mother-newborn couple with next of kin) and staff experiences following improvement work carried out according to EBCD in a maternity ward and neonatal intensive care unit (NICU) in a small, acute hospital in Sweden.

Method: An experience questionnaire, derived from the EBCD approach tool set, was used for continuously evaluating each event of the EBCD improvement project. Furthermore, a focus group interview with staff and in-depth interviews with mother-father couples were held in order to collect and understand the experiences of working together according to EBCD. The analysis and interpretation of the interview data was carried through using qualitative, problem-driven content analysis. Themes, categories and sub-categories presented in this study constitute the manifest and latent content of the participants’ experiences of Experience-based Co-design.

Results: The analysis of the experience questionnaires, prior to the interviews, revealed mostly positive experiences of the participation. Both staff and patient participants stated generally happy, involved, safe, good and comfortable experiences following each event of the improvement project so far.

Two themes emerged during the analysis of the interviews. For staff participants the improvement project was a matter of learning within the microsystem through managing practical issues, moving beyond assumptions of improvement work and gaining a new way of thinking. For patients, taking part of the improvement project was expressed as the experience of involvement in healthcare through their participation and through a sense of improving for the future.

Discussion: This study confirms that, despite practical obstacles for participants, the EBCD approach to improvement work provided an opportunity for maternity ward /NICU care being explored respectfully at the experience level, by assuring the sincere sharing of useful information within the microsystem continuously, and by encouraging and supporting the equal involvement of both staff and patients. Staff and patients wanted and were able to contribute to the EBCD process of gathering information about their experiences, analyzing and responding to collected data, and engaging themselves in improving the same. Furthermore, the EBCD approach provided staff and patients the opportunity of learning within the microsystem. Nevertheless, the responsibility of the improvement work remained the responsibility of the healthcare professionals.

Keywords: Quality Improvement, Maternity Care, Neonatal Intensive Care, Experience-based Co-design

Background: Recent focus on quality and patient safety has underlined the need to involve patients in improving healthcare. “Experience-based Co-design” (EBCD) is an approach to capture and understand patient and staff (i. e. users) experiences, identifying so called “touch points” and then working together equally in improvement efforts.

Purpose:This article elucidates patient (defined as the mother-newborn couple with next of kin) and staff experiences following improvement work carried out according to EBCD in a maternity ward and neonatal intensive care unit (NICU) in a small, acute hospital in Sweden.

Method: An experience questionnaire, derived from the EBCD approach tool set, was used for continuously evaluating each event of the EBCD improvement project. Furthermore, a focus group interview with staff and in-depth interviews with mother-father couples were held in order to collect and understand the experiences of working together according to EBCD. The analysis and interpretation of the interview data was carried through using qualitative, problem-driven content analysis. Themes, categories and sub-categories presented in this study constitute the manifest and latent content of the participants’ experiences of Experience-based Co-design.

Results:The analysis of the experience questionnaires, prior to the interviews, revealed mostly positive experiences of the participation. Both staff and patient participants stated generally happy, involved, safe, good and comfortable experiences following each event of the improvement project so far.

Two themes emerged during the analysis of the interviews. For staff participants the improvement project was a matter of learning within the microsystem through managing practical issues, moving beyond assumptions of improvement work and gaining a new way of thinking. For patients, taking part of the improvement project was expressed as the experience of involvement in healthcare through their participation and through a sense of improving for the future.

Discussion: This study confirms that, despite practical obstacles for participants, the EBCD approach to improvement work provided an opportunity for maternity ward /NICU care being explored respectfully at the experience level, by assuring the sincere sharing of useful information within the microsystem continuously, and by encouraging and supporting the equal involvement of both staff and patients. Staff and patients wanted and were able to contribute to the EBCD process of gathering information about their experiences, analyzing and responding to collected data, and engaging themselves in improving the same. Furthermore, the EBCD approach provided staff and patients the opportunity of learning within the microsystem. Nevertheless, the responsibility of the improvement work remained the responsibility of the healthcare professionals.

The overall aim of this thesis was to describe patients’ experience and reconstruction regarding the onset of, and events surrounding being struck by a Subarachnoid Haemorrhage (SAH), and to describe patients’ and relatives’ views of patients’ memory ability, emotional status and activities of living, in a long-term perspective.

Methods: Both inductive and deductive approaches were used. Nine open interviews were carried out in home settings, in average 1 year and 7 seven months after the patients’ onset, and discourse analysis was used to interpret the data. Eleven relatives and 11 patients, 11 years after the onset, and 15 relatives and 15 patients, 6 years after the onset, participated in two studies. Interviews using a questionnaire with structured questions and memory tests were used to collect data. Fischer’s exact test and Z-scores were used for the statistical analysis.

Results: Patients with experience of a SAH were able to judge their own memory for what happened when they became ill. The reconstruction of the illness event may be interpreted as an identity creating process. The process of meaning-making is both a matter of understanding SAH as a pathological event and a social and communicative matter, where the SAH is construed into a meaningful life history, in order to make life complete (I). Memory problems, changes in emotional status and problems with activities of living were common (II-IV). There was correspondence between relatives’ and patients’ statements regarding the patients’ memory in general and long-term memory. Patients judged their own memory ability better than relatives, compared with results on memory tests. Relatives stated that some patients had meta-memory problems (II). The episodic memory seemed to be well  reserved, both concerning the onset and in the long-term perspective (I, II). There were more problems with social life than with P- and I-ADL (III), and social company habits had changed due to concentration difficulties, mental fatigue, and  patients’ sensitivity to noisy environments and uncertainty (IV). Relatives rated the patients’ ability concerning activities of living and emotional status, and in a similar manner to patients’ statements (III-IV).

Conclusions: The reconstruction of the illness event can be used as a tool in nursing for understanding the patient’s identity-construction. Relatives and patients stated the patients’ memory, emotional status and activities of living in a similar manner, and therefore both patients’ and relatives’ statements can be used as a tool in nursing care, in order to support the patient. However, the results showed: meta-memory problems (relatives’ statements) and that the patients’ judged their own memory ability better than relatives in comparison with results on memory tests. Nevertheless, there was a high degree of concordance between relatives’ and patients’ evaluations concerning patients´ memory ability, emotional status, emotional problems, social company habits and activities of living. Therefore both relatives’ and patients’ statements can be considered to be reliable. However, sometimes the patients and the relatives judge the patients’ memory differently. Consequently, memory tests and formalized dialogues between the patient, the relative and a professional might be required, in order to improve the mutual family relationship in a positive way. Professionals however, must first assume that patients can judge their own memory, emotional status and ability in daily life.

Background: There are clear signals that health care should provide person-centered care for the citizens. There is also a wish to increase the possibility for the patient to be involved in their care. The person-centered care can provide an opportunity for the patient to become co-creators and not only recipients of care.

Purpose: The purpose of the improvement work was to increase the patient's opportunity for participation by implementing patient narrative and care plan. The purpose of the study is to make visible the employees' experience of working with the patient narrative and care plan to create patient participation. 

Method: The improvement work was implemented with the support of Nolan's improvement model and 5P was used to assess the unit. The ideas tested were the introduction of a patient narrative and a documented care plan. Data collection for the study was conducted with interviews of six employees and analyzed with qualitative content analysis. 

Results: The proportion of patients who felt that they had participated in the decisions regarding their care/treatment on the ward to the extent they wanted, increased from 77% to 95%, that can be seen as a positive effect on patient participation. The qualitative content analysis of interviews with employees was identified in three categories: the patient's care, knowledge/communication and organization/working methods where both facilitators and barriers could be seen.

Conclusion: Person-centered care increases the possibility for the patient to participate in their care in an emergency surgical ward.

Background Sense of coherence is a theoretical construct which is used to measure the degree to which a person finds the world comprehensible, manageable and meaningful.

Aim The main aim of the present study was to assess the hypothesis of Antonovsky that meaningfulness is the most crucial component in sense of coherence. The second aim was to explore the importance of its components and factors at baseline on sense of coherence changes and if the findings can be used in cardiac rehabilitation.

Methods One hundred patients, who suffered a primary myocardial infarction were followed during two years. The instruments used were; sense of coherence questionnaire-13, 12-item short-form health survey questionnaire, the Seattle Angina Questionnaire and Health Curve.

Results Thirty-nine percent of the participants fulfilled Antonovsky's hypothesis. Comprehensibility and the baseline factors of smoking, alcohol use, marital status and disease perception proved to be of importance for sense of coherence changes over time.

Conclusion The hypothesis that meaningfulness is the most crucial component in sense of coherence is rejected for patients with primary myocardial infarction. Comprehensibility is more important than meaningfulness for changes in sense of coherence. Nurses therefore have an important task to increase comprehensibility and sense of coherence by providing information and knowledge about myocardial infarction and lifestyle changes at an early stage. The information should be given in an individualized and easily understandable way from a salutogenic perspective, which means to identify and work with factors that can contribute to preserving and promoting health.

Background: After being through a myocardial infarction (MI), a severe recovery period ensues for the patient. Long-term follow-ups are helpful, but what this should include differs between patients. Today there is no established approach to identify needs for support after an MI.

Aim: The aim was to describe sense of coherence (SOC) over time in relation to sex, as well as further SOC in relation to quality of life (QoL) and treatment satisfaction in patients with an MI. Methods. This study had an observational and longitudinal design and followed 18 women and 60 men with an acute MI for 49–67 months after the onset of MI. Instruments used were the SOC-13 and the Seattle Angina Questionnaire.

Results: Women scored lower SOC than men. A main effect of time was shown for comprehensibility which increased significantly from baseline to the long-term follow-up. Women increased from a lower level to an equal level as men at the long-term follow-up. The total SOC was significantly associated with QoL and treatment satisfaction.

Conclusion: High comprehensibility and high SOC give the patient a better basis to handle life after MI. Thus, healthcare professionals should keep in mind that SOC and especially comprehensibility have meaning for the patient’s ability to handle her or his recovery. Healthcare professionals need to together with the patient identify and work with lifestyle factors that contribute to increased comprehensibility about the disease, which gives the patient the foundation to preserve and promote her or his health both in the short and long term.

Summary

Background: Lymphedema is a chronic diagnosis that requires lifelong treatment where self-care is an important part. Lack of self-care leads to impaired lymphedema and greater tendency for erysipelas infections. The problem is that patients feel insecure about self-care of lymphedema and doubt its effect. 

Purpose: The purpose of the improvement work was to create better compliance to the patients self-care treatment. The purpose of the study was to describe patients 'experiences of the lymphatic care service and living with lymphedema and also the patients' improvement suggestions for improving self-care.

Method: With inspiration from service design and the improvement models 5P, Nolan's improvement model and PGSA.

The study with thematic analysis method was described from parts of the Kano model by Noriaki Kano; basic-, expected- and  unexpected needs.

Results: Patients become more confident in self-care if they have a self-care plan and the Lymphatic Therapists become clearer in their communication by a checklist and in collaboration with the patient. Results from the study show that the lymphatic therapists need to better communicate self-care and adapt the information individually. 

Conclusions: By sharing patients' experiences and suggestions for improvement, we can create learning and more patient involvement in development work.

The caregiver is obliged to constantly work to develop and ensure the quality of care. Research shows that reflection helps the employee to learn from their experiences. Reflection broadens perspective and develops knowledge. 

The purpose of the improvement work was to develop and ensure the quality of patients care. This by using a structured reflection model with which the teams around the patient undergoing surgery can analyse current events and identify possible risks and areas for improvement. During the improvement work a reflection model was developed, the Alingsåsmodel. It is a combination of Gibbs reflection model that gives a deeper reflection  and the Green cross model that identify risks and areas for improvement.  The purpose of the study was to describe the employees' experiences of reflecting in the team according to the Alingsås model.

The method for the improvement work was to create an interprofessional working group that used Nolan's improvement model as a structure in the work.                                  As a method in the study, a qualitative interview study was chosen. 

The goal is achieved when it comes to  increasing identified areas of improvement and risks of care injury. However, not as many reflections are carried out as desired.        The study shows that the reflection sessions are good forums that contribute to the learning and development of care, by identifying areas for improvement and identifying risks of care injuries.

The conclusion is that  the Alingsås model is a good method for constantly working on developing the quality of care we provide. 

Objectives: To investigate, in a population-based cohort of patients with juvenile chronic arthritis (JCA), onset characteristics, progression, outcome, and prognostic factors longitudinally for 5 years. Methods: This cohort consisted of 132 incidence cases identified between 1984 and 1986 in southwestern Sweden followed for 5 years with annual reports of subgroup, joint assessment, disease activity, eye examinations, laboratory measurements, and medication. At the 5-year follow-up, the Childhood Health Assessment Questionnaire (Child-HAQ) was evaluated. European League Against Rheumatism (EULAR) criteria for diagnosis and disease activity were used. Results: During the 5 years only four patients were lost to follow-up, 34% changed subgroup and 8% developed uveitis. At the 5-year follow-up the disease was active in 12% of the patients, stable in 28%, inactive in 25%, and in remission in 34%. Among those examined, 24% had radiological changes, of whom half had advanced changes. The Child-HAQ median score at the 5-year follow-up was 0.13 (range 0.0-1.9). The number of involved joints at inclusion correlated positively with active disease at the 5-year follow-up. Age at disease onset, the number of involved joints, and the number of joints with arthritis correlated positively with continuous disease and Child-HAQ score. Conclusion. Our study shows a diverse disease course during the first 5 years of JCA where one-third changed subgroup and two-thirds did not reach remission. Age of disease onset, the number of involved joints, and the number of joints with arthritis at inclusion were associated with poor outcome at the 5-year follow-up.

OBJECTIVE: To investigate disease course, outcome, and predictors of outcome in an unselected population-based cohort of individuals diagnosed with juvenile chronic arthritis (JCA) followed for 17 years. METHODS: The cohort consisted of 132 incidence JCA cases identified 1984-1986 according to EULAR criteria. At 5-year followup, 129 individuals underwent joint assessment, laboratory measurements, radiographic examination, and medication and functional assessment. At 17-year followup, 86 were examined with joint assessment, laboratory measurements, medication assessment, Health Assessment Questionnaire (HAQ), Keitel functional test (KFT), and Medical Outcomes Study Short Form-36 (SF-36). RESULTS: At 17-year followup, 40% were in remission, 44% changed subgroups, median HAQ score was 0.0 (range 0.0-1.5), and median KFT was 100 (range 54-100). SF-36 scores were significantly lower compared to a reference group. Thirty-nine percent of those in remission at 5-year followup were not in remission at 17-year followup. In multivariate analyses of variables from the 17-year followup: remission was predicted by remission at 5-year followup (OR 4.8); HAQ > 0 by rheumatoid factor (RF)-positivity at 5-year followup (OR 3.6); KFT < 100 by nonremission (OR 11.3); and RF-positivity (OR 5.6) at 5-year followup; and the SF-36 physical component summary score above average of the reference group by remission at 5-year followup (OR 5.8). CONCLUSION: This longterm study of 86 individuals with JCA showed large variability of disease courses and of impaired health-related quality of life. Sixty percent were not in remission at 17-year followup. Longterm outcome was best predicted by and associated with characteristics at 5-year followup rather than those at onset.

Background

Enhancement for people with elevated HbA1c. Improvement area was described differently from the patient and the coworkers perspective and perceived the experience of participation and the need of standardized working methods.

Purpose

Improve patients diabetic related health and their experience of participation and decrease the average of HbA1c > 9%.

Study if coproduction contributes to better diabetes care and outcomes by introducing a new working method based on PROM/PREM.

Method

Nolan's Improvement Model

Qualitative case study with content analysis

Results

Total average of HbA1c fell by 15,2%.

13 out of 14 patients lowered their HbA1c.

PROM; two out of three quliaty parameters had a positive shift.

PREM; one out of three had a positive shift.

The study indicated that a new working method enhanced both the interaction and the relationship between patient and health care providers and simultaneously created a more valuable balance between shared knowledge and experience of the disease.

Discussion

The results of this thesis indicates that coproduction creates a better environment for quality and an opportunity for a mutual relationship. Patients' answers to PROM / PREM identified areas that enabled the healthcare provider to respond to patient needs, which strengthened the role of the patient in the meeting.

Conclusion

Coproduction provides opportunities for a qualitative relationship that creates an enhanced environment for knowledge exchange and development for patients and healthcare providers.

Presently, there is a range of support programs aimed to help patients in the decision making process, in regards to their health and care. The purposes of these programs are to give the patient a reliable source of information, and allowing the patient to make their own decisions based on their personal values. However, there are no Swedish support programs for patients who suffer from rotator cuff tears. The purpose of this study was to develop the decision aid program from the United States, "Treatment Options for Rotator Cuff Tears: A Guide for Adults" from 2010, in order to function in a Swedish context. A further aim was to examine the similarities and differences between Swedish practice concerning rotator cuff tears in comparison to the version from 2010, and to describe how the decision support were perceived by patients. A co-production design with a deductive qualitative content analysis was used. The process included translation of the rotator cuff tear decisions aid program from 2010 to Swedish. Interviews with experienced physiotherapists, orthopedic surgeons and patients who have had experienced a rotator cuff tear were performed.

The main similarities presented by the comparison of providers and patient perceptions were the patient’s active role in the treatment process, descriptions of relevant treatment options, and the patient understanding of the injury. Main differences were that the physician's role was more prominent compared to the physiotherapist in the decision aid program. Also, details in regard to the conservative and postoperative treatments were missing. Physiotherapists and orthopedic physicians described a lack of support systems for decision-making in current clinical practice. Patients found the decision aid to be simple and easy to understand with regard to the content and layout, as well as being a good start for the dialogue and interaction between the patient and the provider. Overall, patients were positively inclined to the decision aid program and felt that such could be an aid in the selection of treatment and decision making process. Physiotherapists and orthopedic physicians were also optimistic about decision aid, and it could act as a catalyst for the establishment of clinical consensus. The patients felt that the decision aid provided a feeling of safety and reassurance, as well as a platform for dialogue between themselves and physiotherapists and orthopedic physicians.

Further research is needed in order to determine whether the patient experiences any benefits of decision aid in the actual decision making process. In order to improve the content of the program, it is also imperative to determine the level of detail, as well as the impact of overall cost and healthcare effectiveness regarding treatment of rotator cuff tears. 

Syfte:Förbättringsarbetet syftade till att utveckla processer och arbetssätt för kvalitetsförbättringarna utifrån patientsynpunkter. Syftet med studien var att undersöka och beskriva medarbetarnas uppfattning om och erfarenheter av delaktighet vid digitala möten när patienters synpunkter utgör grunden för kvalitetsförbättringar i mikrosystemen. 

Metod: Lösningsfokuserad coachning avsåg att engagera mikrosystemens engagemang för kvalitetsförbättringar utifrån patientsynpunkter. Telefonintervjuer med deltagare från mikrosystemen analyserades genom en kvalitativ innehållsanalys med en induktiv ansats.

Resultat: Både positiva och negativa patientsynpunkter inkom och bidrog till ökad kunskap och blev vägledande för att identifiera förbättringsområden. Att se varandra via digitala möten för kvalitetsförbättringar bidrog till samhörighet och starkare teamkänsla. Att få ta del av patientsynpunkter skapade ett engagemang för gemensamma kvalitetsförbättringar. Att få feedback av patienter på arbetet som utförs inom Enica framhävds som en faktor som gjorde det roligare att gå till jobbet. 

Konklusion: Att samla geografiskt utspridda medarbetare inom samma mikrosystem i ett digitalt möte har skapat en känsla av sammanhang. Genom förbättringsarbetet har processer och arbetssätt implementerats så att kvalitetsförbättringar utgår från patientsynpunkter.

This dissertation is about how knowledge is constructed in interactions and what knowledge entails in practical social work. It is about how a collective can provide a foundation for the construction and development of knowledge through the interactions contextualized in this study on Swedish elder care, organized by the municipality. This study follows a research tradition that recognizes knowledge as socially constructed, and focuses on the practice of knowledge within an organizational context of care.

This is an ethnographic study. The empirical material consists primarily of field notes from participant observations at two elder care units in a midsized city in Sweden. Moreover, the collected materials include national and municipal policy documents, local policy documents and guidelines, and notes from observations in staff meetings and interviews with care workers and managers. This thesis uses Institutional Ethnography as a departure point for analyzing the contextual factors for workers in elder care, mainly women, and the situational factors for acquiring knowledge.

The overall aim of this dissertation was to explore knowledge in elder care practice by analyzing the construction and application of knowledge for and by staff in elder care. This sheds light to the Mystery of Knowledge in Elder Care Practice: Locally Enabled and Disabled.

In order to pursue this aim, two questions were addressed in the study:

1. How and what kind of knowledge is expressed and made visible in daily elder care practice?

2. How is knowledge shared interactively in the context of elder care?

The findings shed light to the situation for care workers in elder care and the conditions for using and gaining knowledge. This situation is problematic as the local conditions both enables and disables knowledge use and sharing of knowledge. Contributing challenging factors are lack of recognition and equal valuing of various forms of knowledge; the organizational cultures and a limiting reflective work to the individual.

The main findings in this thesis are presented in three areas:

- a way of understanding tacit knowledge, which refers to knowledge gained by care workers through working in elder care;

- the connection between an organizational culture and the knowledge shared within the organizational culture;

- reflective practice in elder care work and the imbalance between individual and collective reflectivity.

These findings have implications for specific knowledge in social work practice and the need for education linked to this knowledge. Formal knowledge alone is insufficient for effective elder care practice; however, informal knowledge is also insufficient alone. Both are needed, and they should be linked to create synergy between the two types of knowledge.

This article explores participant observation as a research method and more specifically addresses the intriguing situation of the researcher's role in interacting with participants in the setting. The materials used in the analysis are field notes from participant observations focused on staff at two eldercare units in a mid-sized city in Sweden. Because limitations when referring to Raymond Gold's roles of participant observations are known but sparsely described and discussed, this text attempts to provide that description and discussion. The specific question posed in the article is, (How) do roles for the researcher in participant observations change during the course of fieldwork? Randall Collins' theory on interaction ritual chains is used as an analytical tool to identify symbols in the two staff groups. The examples chosen from the field are symbols displayed at the units, which moreover illustrate that the researcher’s roles in participant observations not only change once or twice during the course of fieldwork but also change continuously. Consequently, fieldworkers shift roles in different situations when observing a variety of people and settings. Observations are developed in the interaction between the researcher and the participants; therefore, referring observations to a number of roles is restrictive and limiting.

This paper addresses the issue of reflective practice, as suggested by Schon. The aim is to analyze instances of reflective practice in elder care, in order to depict individual and collective work. Reflective practice is prevailing as a way of emphasizing the value of practical knowledge and enhancing its status. Reflexivity is thinking about what and why we do something. Moreover, reflexivity is a way of incorporating knowledge with our own personal selves, making it a very personal matter. Using reflective practice in elder care enables learning, leading to improved quality of care. However, individual reflection must be accompanied by collective reflection; this is crucial to improve quality of care.

BACKGROUND: Despite the low prevalence of daily smokers in Sweden, children are still being exposed to environmental tobacco smoke (ETS), primarily by their smoking parents. A prospective intervention study using methods from Quality Improvement was performed in Child Health Care (CHC). The aim was to provide nurses with new methods for motivating and supporting parents in their efforts to protect children from ETS exposure. METHOD: Collaborative learning was used to implement and test an intervention bundle. Twenty-two CHC nurses recruited 86 families with small children which had at least one smoking parent. Using a bundle of interventions, nurses met and had dialogues with the parents over a one-year period. A detailed questionnaire on cigarette consumption and smoking policies in the home was answered by the parents at the beginning and at the end of the intervention, when children also took urine tests to determine cotinine levels. RESULTS: Seventy-two families completed the study. Ten parents (11%) quit smoking. Thirty-two families (44%) decreased their cigarette consumption. Forty-five families (63%) were outdoor smokers at follow up. The proportion of children with urinary cotinine values of >6 ng/ml had decreased. CONCLUSION: The intensified tobacco prevention in CHC improved smoking parents' ability to protect their children from ETS exposure.

Background: Living with a chronic disease such as atrial fibrillation (AF) not only affects the patient but also has implications for the partner. There is a lack of research on couples living with AF and, in particular, how they experience and deal with the disease.

Objective: The aim of this study was to explore couples’ main concerns when one of the spouses is afflicted with AF and how they continually handle it within their partner relationship.

Methods: Classical grounded theory was used throughout the study for data collection and analysis. Interviews were conducted with 12 couples (patient and partner together). There were follow-up interviews with 2 patients and 2 partners separately.

Results: Couples living with AF experience uncertainty as a common main concern. This uncertainty was fundamentally rooted in not knowing the cause of AF and apprehension about AF episodes. Couples managed this uncertainty by either explicitly sharing concerns related to AF or through implicitly sharing their concerns. Explicit sharing incorporated strategies of mutual collaboration and finding resemblance, whereas implicit sharing incorporated strategies of keeping distance and tacit understanding. Time since diagnosis and time being symptom-free were factors influencing afflicted couples’ shifting between implicit and explicit sharing.

Conclusions: Atrial fibrillation affects the partner relationship by bringing uncertainty into couples’ daily lives. Even though this study shares similarities with previous studies on couples living with chronic disease, it contributes to the existing knowledge by presenting a set of strategies used by couples in managing uncertainty when living with AF.

In order to achieve high quality in healthcare, patients and the public should be involved in quality improvement processes and designing of care. Previous studies show that it can be challenging to involve patients and relatives in research projects in palliative care, however, in Sweden few studies on this topic have been conducted. A project aiming to improve patient and public involvement was initiated at a research and development unit where a structured guide for such involvement was lacking. The project was practically carried out through a merger of another improvement work aimed for creating a basis for a digital web education by co-production. An improvement team of patient and relative representatives and healthcare professionals were monitored as they collaborated on the web training. The results show that it ́s possible to achieve high levels of participation even digitally, but there is a need for robust preparation focusing on the building of egalitarian relationships. The improvement team has highlighted six themes that web training should include. 

A qualitative design with an inductive approach was chosen for the study. The purpose was to investigate hindrances and possibilities for patient and public involvement. Seven semi-structured interviews were conducted with the improvement team participants. Data was analyzed through thematic analysis and the results highlight four key themes: Participating in a process of co-production, broadening perspective and understanding, not being able to meet in “real life”, and leadership in co-production. 

This study concludes that co-production is an essential part of quality improvement of care, but guidance is needed on how it should be implemented in practice. Co-production can be achieved digitally but can be a hindrance to building relationships. Leadership consisting of professionalism and empathy is also perceived as a strength in co-production. 

Background: Patient involvement and patient participation within health care has been more and more important the last years. One method for patient involvement that has been tested (mostly in somatic care) is Experience-Based Co-Design (EBCD). 

Local problem: The organization has structures to gather experiences from patients, but there is no structure to gather experiences from dependants or staff. There is no forum for patients, dependants and staff to meet and together work with improvement.

Aim: For the Quality Improvement project (QIP) try methods from EBCD in the context of psychiatric in-patient care. For the study of the QIP describe participant’s experiences of being part of a QIP based on EBCD, and highlight what makes it difficult to engage patients in QIP.

Method: The main structure for the QIP is Nolan’s model of change and PDSA. The study consists of a qualitative content analysis based on two semi-structured focus group interviews.

Interventions: Methods from EBCD has been adjusted according to the context and then tested.

Result: To participate in a QIP based on EBCD has been appreciated and developing. Difficulties have above all been the recruiting of patients.

Conclusions: EBCD is possible to use in psychiatric in-patient care, modifications are necessary. Which modifications and how needs to be examined further. EBCD affects both the individual and the organization. To achieve asked goals and to engage patients there are some conditions that need to be fulfilled according to structures and equalisation of power between patients, dependants and staff.

BACKGROUND: The well-being of relatives of patients having chronic heart diseases (CHD) has been found to be negatively affected by the patient's condition. Studies examining relatives of patients with atrial fibrillation (AF) indicate that their well-being may be affected in a similar manner, but further research is needed.

AIM: To explore and describe critical incidents in which relatives of patients experience how AF affects their well-being and what actions they take to handle these situations.

DESIGN AND METHOD: An explorative, descriptive design based on the critical incident technique (CIT) was used. Interviews were conducted with 19 relatives (14 women and five men) of patients hospitalised in southern Sweden due to acute symptoms of the AF.

RESULTS: The well-being of relatives was found to be affected by their worries (patient-related health), as well as the sacri-ficing of their own needs (self-related health). In handling their own well-being, these relatives adjusted to and supported the patient (practical involvement), along with adjusting their own feelings and responding to the mood of the patients (emotional involvement).

CONCLUSION: The well-being of relatives of patients with AF was affected depending on the patients' well-being. In their attempt to handle their own well-being, the relatives adjusted to and supported the patients. Further research is needed in order to evaluate the effects of support to relatives and patients respectively and together.

Background: Atrial fibrillation (AF) influences the lives of patients in the form of worsened well-being. Patients’ own experience of and how to handle AF is rarely investigated. These are important aspects for healthcare services to understand in order to support the well-being of patients with AF.

Aim: To explore and describe critical incidents in which patients experience how AF affects their well-being and what actions they take to prevent and handle it.

Design and methods: An explorative, descriptive design based on the critical incident technique (CIT) was used. Interviews were conducted with 25 patients (16 men and 9 women) with AF in a healthcare area in southern Sweden.

Results: Patients experienced discomfort and limitations in daily life. The actions they took were self-care related actions and healthcare related actions.

Conclusion: AF affects well-being when it is uncomfortable and leads to pronounced limitations in daily life with the patients trying to maintain or restore well-being through adapting and developing strategies for self-care. Patients base the handling of AF on their personal experience.

Bakgrund: Enligt lagstiftning skall vården säkra brukarens rätt till delaktighet. Vinsterna med att delaktiggöra brukaren är väl studerad. Trots såväl krav som  fördelar med delaktighet visar uppföljningar att delaktigheten brister, så även i den verksamhet studien handlar om.  För att omsätta delaktighet i praktisk handling för brukare behöver personal ha ett mera agilt förhållningssätt.  Syften: Den här studien handlar om ett förbättringsprojekt med syfte att öka brukardelaktighet på ett korttidsboende inom äldreomsorg i en liten mellansvensk kommun. Studiens syfte var att undersöka om och hur förbättringsprojektet stärkt brukardelaktighet. Metod: Verktyg och modeller från förbättringskunskap använts i förbättringsprojektet. I studien har intervjuer med deltagare från förbättringsprojektet genomförts. En induktiv ansats har använts där data har bearbetats och analyserats med innehållsanalys. Resultat: Genomförandeplaner upprättades snabbare. Arbetssättet att planera aktiviteter tillsammans med brukaren har lett till högre tillvaratagande av brukarens önskemål. Aktiviteter i förbättringsprojektet har lett till ökad reflektion bland projektdeltagarna vilket i sin tur förflyttat fokus på personalfrågor till engagemang för brukarens intressen. Slutsats: Förbättringskunskap kan leda till ökad  reflektion, kunskap och nya förhållningssätt i vård- och omsorgsarbetet bland personal, vilket i förlängningen  kan skapa ökat värde för dem vården är till för.

Improve patient participation in eating disorder care

An improvement work regarding increased participation in care of patients diagnosed with anorexia nervosa and autism spectrum disorders together with a qualitative study on patient participation

In the national patient survey, patients in the care ward for adults within the Stockholm Center for Eating Disorders estimate participation as low. Healthcare professionals also experience that patients with anorexia nervosa and autism spectrum disorders have greater challenges in meeting the eating disorder treatment offered to them. 

The purpose of this improvement work was to increase patient participation through individualized eating disorder treatment for patients with anorexia nervosa and autism spectrum disorders. The study aimed to identify patients 'and healthcare professionals' experiences and understandings of participation to be able to further develop eating disorder care.

The improvement work was carried out according to Nolan´s improvement model. The study was performed with semi-structured patient interviews with a qualitative approach based on the method Critical incident technique and focus group interviews with care staff.

The performed improvement work shows a very good result, completed activities increase patients´ experience of participation from 43% t0 83%. In addition, patients gain weight faster and the care period is shortened by about half the care period. The study shows that patients and healthcare professionals have split feelings about an excessive patient participation as they are aware of the disease´s complexity and the patient’s ambivalence for recovery. 

The results of the improvement work show that patients with anorexia nervosa and autism spectrum disorders benefits from individualized eating disorders care. On the other hand, the study shows that patients and healthcare professionals are hesitant to adept the eating disorder care individually for other patients as it may jeopardize the treatment outcome.  

Keywords: anorexia nervosa, autism spectrum disorders improvement knowledge, improvement science, patient participation