Few PhD-students have a clear plan for their coming career after completion of their PhD-studies. There can be dreams of starting new enterprises, combining research with innovations in practice, or to pursue a career in academia. In health and welfare research schools there are many PhD-projects involving single PhD-students, as well as part-time PhD-students whose project is connected to their workplace. Research shows risk of low wellbeing and high levels of stress among PhD-students, together with feelings of isolation and impostor syndrome (Seeber and Horta, 2021, Schmidt and Hansson, 2018). Such negative feelings negatively impact the outcome of the PhD period and may also affect the future career of the PhD-student. To promote and sustain PhD-students health and wellbeing, there is a need to test activities that can decrease experienced negative stress during the PhD-period as well as enhancing academic competencies like academic leadership, academic writing skills and pedagogical skills. In addition, successful academics should have excellent competence in their field, collaborate with stakeholders and engage in impact activities. Thus, the PhD period needs to provide work integrated learning in academia to provide learning opportunities to develop those skills. Research concerning PhD-students’ wellbeing and progress shows that the supervisor has an extremely important role for completion of the PhD and for the wellbeing of the student (Buirski, 2022). However, there are limited resources set up for PhD supervision and mentoring, which can create stress and mismatch in needs and capacities between the supervisor and the PhD-student. During the covid-19 pandemic the risk of losing pace in PhD-projects increased, in addition to disconnectedness with academy due to digital instead of physical meetings. However, this change also provided opportunities for novel and pragmatic ways of structuring supervision and enhancing the self-efficacy of the PhD-students. The purpose is to present learnings and outcomes of work-integrated learning project in academia for PhD-students.

The focus is on two novel learning activities: online writing retreats and online monthly meetings, which were tested during the covid-19 pandemic. The aim of the learning activities was to encourage the PhD-students to be the leaders of their projects, to collaborate with others to find their role in academia, and learn the trade of being an academic, while practicing doing so, and promote wellbeing during the PhD period. The project has been performed with Plan-Do-Study-Act (PDSA) in biannual evaluation cycles. The PDSA is a quality improvement tool focusing on the translation of ideas and intentions into action (Reed and Card, 2016). The iterative structure of PDSA is well suited to promote learning of a tested change and help shape organizational culture for the better (Reed and Card, 2016). Evaluation data includes number of participants, types of spin-offs from the learning activities, and participants’ oral and written feedback on the learning activities. The collected data was analyzed from the perspective of usefulness of the learning activities related to theories of work-integrated learning.

Online structured digital writing retreats

Open to more than the PhD-students supervised by the facilitating supervisor (any PhD-student who considered themselves in need of learning better academic writing structure, master students who wanted to become PhDstudents, other supervisors who wanted to see how a digital writing retreat worked). This activity showed participants the importance and diversity of academic writing. The participants chose their own writing tasks, report on their progress, and plan for their next step – but being their own controller and thus actively practicing self-leadership. At the same time the participants shared their feelings of participating in the writing retreat when reporting their writing progress – thus creating a social, international, and interdisciplinary forum, increasing their networks and enhancing feelings of belonging. This in turn ignited cross-project collaboration, thematic discussions and sharing of scientific literature of importance. As facilitating supervisor, I participated on the same level as other participants, sharing my writing progress and feelings related to academic writing.

The 1-hour monthly meetings for PhD students supervised by the same supervisor

The meetings were co-designed by the PhD-students, where the first meeting developed from a shared practical problem concerning digital data safety. Coming meetings were then co-designed depending on experienced needs by the PhD-students. The PhD-students were in different phases of their PhD-process; thus, they could bring in varied perspectives and share learning with each other on the academic processes. They could also discuss issues that they considered important, such as being asked to review for a journal or being asked to teach at bachelor or master programs. Such collaborative working discussions across projects and disciplines are important in academia and the meetings were used to solve problems in academic practice and to test scientific ideas. As the meetings also were led in turn by the participating PhD-students, academic leadership skills were practiced in this setting. As participating supervisor, I had a more passive role than in traditional supervision meetings, and the meetings were inspirational and provided opportunities for shared learning.

Outcomes from the novel learning activities

The PhD students themselves describe how they have both acquired increased academic skills, and that the online writing retreats have been important in decreasing negative stress, creating a safe social environment which has been important for their wellbeing. The shared learning activities also presented a view of how to work together in academia, which may support the students when thinking of their future career and if this is to relate to academia. As a supervisor, I can clearly see that the activities have enhanced self-efficacy, leadership skills, cross-disciplinary collaboration, national and international networks and decreased dependency on supervisors. The additional bonus of those work-integrated learning activities has been the good progress of the participants’ projects and joy at work!

As we strive to teach our students to think critically about health and well-being in professional work, based on cooperation, life-long learning, and sustainability in working life, we need to meet the challenge of applying strategies to achieve this in academia as well. Stolle et al. (2018) underline the need to better understand CF as a research tool, to improve ourselves as self-study researchers versus teacher educators. We need to collaborate, to establish safe ways of working and negotiate shared understandings to develop and growth in professional academic achievement. Addressing sustainability challenges is most effective when coproduced by academics and non-academics in a way that provides solutions and contributions to the related scientific body of knowledge (Schneider et al., 2021). This presentation explores CF as a sustainable support function based on our experiences in a co -produced research project in a Norwegian municipality. The research question is: What characterizes CF as a sustainable support function in a follow-up research project in a Norwegian municipality?

The case

The municipality has an ongoing innovation project “The team around the teacher and the pupil (2019 –2023)”. This project has a public health- and preventive perspective based on experienced challenges in the local school setting. The focus of the project is to strengthen the pupils’ learning environment and learning outcomes, by involving the reorganization of interdisciplinary and interprofessional resources to promote coping, belonging and good mental health in all the primary and secondary schools in the municipality (Folkman et al., 2020). The research group was interdisciplinary and worked in close collaboration with the municipality´s project leaders. The project also included master students’ projects. The engagement of master students in a co -produced research project provides the students with work-integrated learning experience of research with practice.

Theory

Co-production of knowledge must explicitly recognize multiple ways of knowing and doing (Schneider et al., 2021). CF involves trusting relationships, productive tensions, and two-way learning as mechanism (Knowles et al., 2018; Stolle et al., 2018). The connection between reflection and CF (Stolle et. al, 2018), aligns with core participatory mechanisms that enable ‘dialogue and iteration’ and authentic involvement (Knowles et al., 2018; Norén & Wallin, 2018). Conflicting agendas require that parts reflect on the principles of respect and solidarity to ensure a broader collective goal and that each agenda can be met while maintaining the integrity of the overarching goal of the research (Page, 2022). Reflection is a meaning-making process highlighting relationships (Stolle et al., 2018).

Method and analysis

The research question led to an integrated analytic process (Strøm & Fagermoen, 2012), based on the project documents, reports, and articles from the project. The deductive analysis involved the interpretation of the data to explore characteristics of CF as sustainable support in work integrated learning. Two themes emerged through the analysis process: CF and knowledge production in the project and CF: mandate and role.

Results

CF and knowledge production in the project There was a period of initial negotiations between the project leader and the research group, as the project leader wanted to develop a research design suitable to support the objectives and aims of the project. Therefore, work as critical friends, started by critical questions from the research group about the operationalization of research objectives in the project and the pre-planned measures of intended results. There were negotiations of understanding in the processes of developing a contract and research plan and considering knowledge from both parties. This time-consuming process was ongoing through the follow-up research, as new perspectives and results emerged. However, this also led to a closer collaboration with more school staff and leaders in the municipality, which was beneficial for understanding the results from the project.

CF: mandate and role

Co-production in the research process took place in a field of tension, where the project leaders and the researchers acted as critical friends to each other. The underlying tension, based on the project leader`s mandate, role and knowledge of the context, and the research groups roles and competence in research methodology, proved to enhance the learning for both parties and encompassed continuous need for dialogue. However, through CF the research of the project was also used to inform and improve the project, and then provide additional collaborative research topics. The controverses advanced a dynamic co-creative learning process, linked to knowledge of practice-based evaluation research in this context, but also a nearer friendship that obliged.

Discussion

Our results show, that that CF in co-production between practice and research can contribute to promoting the legitimacy of the research contribution in the field of practice the project deals with, supported by Schneider et al., (2021). For researchers’ objectivity and integrity in the research process is essential, but this can be experienced as conflicting with project leaders’ views and need for measurable outcomes. Reflecting rooted in a scientific inquiry, can serve as generating new meaning and learning opportunity for both parties (Stolle et al., 2018). The results underpin the importance of understanding one’s language and respecting each other’s knowledge when coproducing together with academia and practice (Schneider et al., 2021). To push our thinking and learning asking critical questions, can be limited by being “best friends” (Stolle et al., 2018), thus hav ing different views are an asset. Agreement must be reached about different roles, responsibilities and knowledge, and how the objectives of each stakeholder can be achieved (Page, 2022). The participating students could have been even more involved in the CF dialogues. They were invited to result presentation meetings, but work-integrated learning would have been enhanced if they had been able to participate on more equal terms.

Conclusion

This paper presents joint learning from a mainly online CF experience, formed by mutual respect and leading to increased learning and increased value of research outcomes. The value of research collaboration and support with CF is increased. This is important in academia and for a sustainable work situation for research ers. The project also provided work-integrated learning for students, but this could have been further enhanced.

According to the current Biobanking Act in Sweden, processing of patients' biobanking consent must occur immediately without unnecessary time delay. From a patient safety perspective, it’s important to have updated consents in laboratory information systems because correctly updated consents are critical to the delivery of safe care. Previously, biobank organization where study was conducted needed an average of 77 working days to process an incoming biobanking consent, which was overly long.

The aim of improvement work is to make the process for biobanking consent more time-efficient in one biobank organization in the Region of Stockholm. Nolan’s improvement model, Service Blueprint, 5 P's analysis and the PDSA-cycles were used as methods for this improvement work. With the help of five improvement interventions the number of processing days for biobanking consents was reduced from 77 to 42 working days which is a reduction of 35 days. This improvement work resulted in a more time-efficient process and a new recommendation regarding the number of processing days for biobanking consent. 

The study of the improvement work aimed to increase the understanding of the staff's experiences regarding improvement work with the process for biobanking consent. The study was conducted as qualitative case study with an inductive approach. Qualitative data collection was carried out in the form of eight interviews. The study showed that the following factors led to increased team effectiveness and time efficiency of the process: systematization of the biobank consent process and motivational factors. Changed work methods, increased personnel resources, and developed communication channels contributed to the creation of the systematic process, which facilitated the implementation of the improvement work and made the process time efficient. Motivational factors that influenced team effectiveness under improvement work were group support, agile working methods and visual evaluation of improvement work.

Research question: Autoethnographic critical scrutiny as a step towards more inclusive research practices in participatory research?

In this presentation we would like to discuss a paper draft. The paper examines the autoethnographic accounts of four researchers to highlight and critically explore our experiences within the participatory action research (PAR) (Schubotz, 2020). PAR is based on the principles of close co-operation between researchers and participants with experience-based knowledge, in this case people with disabilities. Hancock et al. (2012) define three justifications for the participation of people with experience-based competence in research: the ethical, the qualitative and the "therapeutic". The recipients of health and welfare services should have a voice in research in areas that will have a direct impact on their life situation. The qualitative aspect concerns that people with experience -based knowledge can strengthen the quality of the research with new approaches by asking relevant questions or by recruiting participants. This can strengthen the research's relevance, validity and focus on the development of knowledge relevant to those concerned. The third rationale is the therapeutic or empowerment rationale, i.e., that the research can have a positive impact on people who receive services and who are involved in the research (Askheim et al., 2019; Hancock et al., 2012). PAR is connected to democratic values, co-creation of knowledge and the believe that this form of co-operation can influence practice. Participatory action research creates space to develop new research communities where the researcher and the researcher's agenda are pushed aside to create space for the research community that develops as a result of interaction between researchers and participants with different backgrounds (experiences) (Nind, 2014 a; Northway, 2010). PAR is a context-bound research that is most often based on dialogue-based collaboration, and which aims to develop new knowledge or insight that can primarily be recognized in the context in which it takes place (Levin, 2017). It should also be based on local challenges that participants in the research encounter in their everyday lives (Lawson et al., 2015). Collaboration with people with experience-based knowledge in research can be the key to creating opportunities to co -create an inclusive democratic society. All the authors have been doing PAR in different research projects. In various academic meetings, we often discussed methodological approaches, our research role, things not working as expected, or when we felt unsure of whether or what we were doing was right or wrong. This paper will try to bring to light and exemplify some of the tensions and challenges we have met in our research practice with PAR. Based on four autoethnographic accounts and theory on autoethnography as a background, the article will reflect upon, critically analyze, and discuss researchers' roles, power, and epistemic privileges in PAR. The autoethnographic approach is based on the researcher's reflections and critical examination of their identities, roles, power, or penalties within one or several cultural contexts (Hughes & Pennington, 2016). It is a critical reflexive action research in which the researcher takes an active, scientific, and systematic view of personal experience concerning cultural groups identified by the researcher as similar to the self (i.e., us) or as others who differ from the self (i.e., them) (Hughes & Pennington, 2016, s.8).

Establishing data:

Four of us wrote two reflections each containing autoethnographic thoughts that reflected tensions in our research practice, for example challenging privileged academic discourses or traditional researcher roles. The logs had roughly the following structure: describe the setting (where, when, why) and your reflections/tensions. Then we read all the logs and wrote down our reactions, keywords, and reflections based on our own research experience. We wrote whether the examples sounded familiar or whether they were unfamiliar or differed from our experiences. All researchers presented the reflections they had written based on the logs, and we summarized central themes based on all the logs.By reading the other authors reflections and at the same time reflecting on their texts using our own experience and taking notes, writing keywords to their texts, started the analysis process in familiarizing with the data (Braun & Clarke, 2014). The analysis was conducted by summarizing the material through the active process of identifying similar themes in the texts, using all the keywords and reflections (Braun & Clarke, 2014). The main themes identified so far were power and power (in)balance, researcher’s role, and epistemic privileges in PAR. Next, we discussed these themes, scrutinizing structures and processes that can influence the research or unconscious processes and power relations tipping the research in one particular direction (Alvesson & Sköldberg, 1994, 2017).

Reflections so far

The autoethnographic texts touch upon power and power balance in relationships between researchers and participants with experience-based knowledge. The power connects to decision-making for example who is making decisions, what kind of cooperation and co-production of knowledge is happening, and how deadlines sets premises for collaboration. The topic of power may be described on a micro level, what the researchers intend to do in the meetings but may also be connected to the framework of the research projects such as projects goals and progression within the project. Projects depend on a certain pace and effectiveness to fulfil the goals. This has to do with financing and funds that can run out. This effectiveness might be challenging when we do research with people with experience-based knowledge, especially if there is a gap between researchers' starting position, theoretical background and expectations, and co-researchers' needs, interests, or expectations. Although researchers are aware of their power and try to adapt the process so that co-researchers can experience a real contribution, it might seem that the researchers have the final word in the end, and we should discuss whether and how we should address that. Co-researchers must usually adjust to the academic world rather than vice versa.

An improved working model at the daily activity center. An improvement work and a qualitative study on the perception of professionals on motivating participants with high-functioning autism to attend daily activities.

Despite daily activities efforts to contribute to personal development, through offering meaningful activities, attendance among participants with high-functioning autism is low as those who have been granted the decision do not fully attend. This increases the likelihood of social isolation.

In the absence of evidence-based working methods, the improvement team tested whether modifying the ordinary model would increase participants' attendance. This was through incorporating a model called Step Out. Step Out’s five components focused on increasing participants' motivation, by the professionals seeing the big picture, actively creating trust, working with solution-focused methods, and using motivational interviews. Four participants with low attendance were selected to take part in the intervention.

The improvement work was conducted at a daily activity center in a small city in Sothern Sweden. The improvement work aimed to understand why the attendance of participants was low and to increase participant attendance through Step Out. The study aimed to gain an understanding of the professionals' perception of working with Step Out in the improvement work. The study was conducted through a qualitative study with five individual interviews and where the self-determination theory formed the basis for the analysis of professionals' perceptions.

The results indicate that the smart goal to double the average attendance of the participants during the intervention was achieved in two participants but was not achieved in the other two participants. In addition, six reasons were shared by the participants on why they did not attend their daily activities. The professionals perceived that Step Out had given them new tools to strengthen the participant's autonomy, competence, and sense of belonging. Structural barriers were perceived as the greatest hindrance to the implementation of Step Out.

In conclusion, participants are individuals with unique skills and interests, and professionals at the daily activity center must use an individualized approach. 

Keywords: low-attendance, motivation, self-determination theory, Step Out

This paper presents a study on inhabited silence among unaccompanied female minors in Sweden. Silence among unaccompanied minors has often been explained by experienced trauma. Conversely, research also explains silence as a natural way of establishing autonomy during adolescence. By analyzing the narratives of 11 unaccompanied female minors, we aim to problematize and broaden the understanding of silence as a lack of communication. By using Bourdieu’s concept of linguistic capital, we analyze how hegemonic narratives on migration and integration influence how the girls in this study use silence in their everyday interactions. Our findings suggest that silence can be understood as both a rejection of these narratives and a strategy to preserve the girls’ integrity. We also demonstrate how these girls negotiate their linguistic capital in relation to embodiment and othering, thereby pushing boundaries of identity and what it means to be seen as Swedish. The paper concludes that silence itself speaks and shows that what is often perceived as a lack of communication can also be understood as a failure to listen.

The Occupational Health Service (OHS) mostly work with aftercare for the individual. There are general demands for every employer to work with the occupational environment in a planned and systematic way. The competence in OHS is rarely used in the proactive work environment management. The Swedish Work Environment Act tells us to involve the OHS if knowledge and capabilities in your organization is not sufficient. At Arbetsmiljöenheten, which is Region Jönköping County built in OHS, has a tool developed to be used in the OHS involvement in proactive work environment management. It is called SMET (Structured Multidisciplinary Work Evaluation Tool). It depends on close cooperation with the employer and the employees and is the basis for work environment management and evaluation of interventions done to improve the work environment. SMET has been tested with good experiences in a small scale and the aim of the improvement work was to scale up the use and let it be possible for more of the coworkers at Arbetsmiljöenheten to use the tool. The idea to test in the improvement work was to construct an educational program for the coworker at the OHS and then together identify possibilities and obstacles for future work. A multi perspective approach was used to study the effect for the coworkers. There was no increase in the usage of SMET, neither were more coworkers involved during the project. However, coworkers thought SMET was usable both for them as individuals and for the OHS. The possibilities and the obstacles identified after the education became the base for the future work. The result from the study tells that the improvement work has strengthen the cooperation at the occupational health service and there is an enthusiasm for the future codevelopment of the way to work with SMET in preventive and proactive work environment management. The result from the study also says that even if the initiative for an extended way of working initially come from the management, the improvement work has led to a foundation on which to build on where the coworkers are central, which is important for successful improvement work. 

Preventive and health-promoting systematic collaboration in schools: Educational and Psychological Counselling Service (PPT) and public health nurses (HS) perspectives

The article examines preventive and health-promoting systems collaboration in a project in schools, focusing on Educational and Psychological Counselling Service (PPT) and public health nurses (HS). The study has a mixed methods design with a questionnaire and follow-up interviews with employees and managers at PPT and HS. The results showed changes in interdisciplinary collaboration, importance of management and project anchoring. The study discusses the learning from the project, illuminated through room for change in the organization and management of working methods in the school. The learning from the project gives implications for the further development of preventive and health-promoting systems work for the national project: A team around the teacher. The local project reveals unused potential in collaboration, due to project design and different understanding of the project’s purpose. Considering the national intention for preventive and health-promoting system work in schools in Norway, the municipal project has transferable value.

OBJECTIVE: The decline in suicide rates has leveled off in many countries during the last decade, suggesting that new interventions are needed in the work with suicide prevention. Learnings from investigations of suicide should contribute to the development of these new interventions. However, reviews of investigations have indicated that few new lessons have been learned. To be an effective tool, revisions of the current investigation methods are required. This review aimed to describe the problems with the current approaches to investigations of suicide as patient harm and to propose ways to move forward.

METHODS: Narrative literature review.

RESULTS: Several weaknesses in the current approaches to investigations were identified. These include failures in embracing patient and system perspectives, not addressing relevant factors, and insufficient competence of the investigation teams. Investigation methods need to encompass the progress of knowledge about suicidal behavior, suicide prevention, and patient safety.

CONCLUSIONS: There is a need for a paradigm shift in the approaches to investigations of suicide as potential patient harm to enable learning and insights valuable for healthcare improvement. Actions to support this paradigm shift include involvement of patients and families, education for investigators, multidisciplinary analysis teams with competence in and access to relevant parts across organizations, and triage of cases for extensive analyses. A new model for the investigation of suicide that support these actions should facilitate this paradigm shift.

HIGHLIGHTS

• There are weaknesses in the current approaches to investigations of suicide.
• A paradigm shift in investigations is needed to contribute to a better understanding of suicide.
• New knowledge of suicidal behavior, prevention, and patient safety must be applied.

Patienter och professionella vårdaktörer är i en gemensam förändrings- och lärandeprocess, där vården parallellt med medborgarna och samhället lär sig hantera digitalisering. Under senare år, bl.a. pådrivet av covid-pandemin, har digitaliseringen och införande av nya arbetssätt gått så fort att utvärdering och forskning inte hunnit med i samma takt. Syftet med rapporten ”Hur klickar vi med vården?” är att bidra med aktuell kunskap om patienters användarmönster och erfarenheter av digitala och fysiska kontakter med primärvården. Resultaten är tänkt att användas som faktaunderlag och stöd för vårdens utvecklingsarbete.

Sveriges Kommuner och Regioner (SKR) tog hösten 2022 initiativet till forskningsprojektet ”Hur klickar vi med vården?”. Uppdraget genomfördes under 2023 av en oberoende forskargrupp på Hälsohögskolan vid Jönköping University. Resultaten är presenterade i två delstudier baserade på registerdata från primärvården och intervjuer med patienter. All registrerad data från den regionala primärvården i Region Jönköpings län och Region Sörmland under perioden januari 2020 – december 2022 har ingått i undersökningen. Data från Region Jönköpings län omfattar ca 352.000 personer vilka sammanlagt hade haft kontakt med primärvården ca 4,2 miljoner gånger, motsvarande för Region Sörmland var ca 245.000 personer som hade haft ca 3,2 miljoner kontakter. I dessa data ingår kontakter med privata helt digitala vårdgivare och för Region Jönköpings län data från 1177 Sjukvårdsrådgivning. I rapporten ingår även 35 kvalitativa intervjuer med ett nationellt urval av patienter. Resultatet av den kvalitativa studien är presenterat som sex teman som beskriver patienters erfarenheter av kontakt med vården.

Policy PointsThe concept of value complexity (complexity arising from differences in people's worldviews, interests, and values, leading to mistrust, misunderstanding, and conflict among stakeholders) is introduced and explained.Relevant literature from multiple disciplines is reviewed.Key theoretical themes, including power, conflict, language and framing, meaning-making, and collective deliberation, are identified.Simple rules derived from these theoretical themes are proposed.

The purpose of the improvement work was to standardize the preparations for robotic surgery for patients with pancreatic cancer for improved patient safety in the operating room. As it was a surgical procedure (Whipples operation) with new technology, the study highlights the importance of the team's previous experience of other robotic surgery and open surgery for pancreatic cancer, as well as the challenges the team was exposed to and the opportunities and lessons they received during the improvement work.

The improvement work was based on LEAN value flow analysis, Nolan's improvement model and observational study, as well as on the structure of the improvement ramp. Based on the SEIPS model, balancing measures for work systems, processes and performance measures have been developed to measure created value for patients and the team’s employees. The study was conducted using a qualitative method using semi-structured individual interviews, with thematic analysis.

The improvement work resulted in three identified activities: surgery report, instruments and materials as well as the patient's positioning on the operating table. These are crucial for how long the preparation time will be and how they affect the team's stress before the meeting with the patient, as well as the team's focus before the start of the operation. The improvement work reduced the non-value-creating time and increased the opportunity for both patients and employees to be more involved. This is because the standardization of a manual reduced the non-value-adding time.

The study showed that acting for increased patient safety when standardizing the preparation process for a new surgical method takes time. Standardizing the preparation process and introducing new technology in healthcare provides the conditions for good and safe surgery. Standardization was seen by the team as yet another task to be performed, a view not always shared with colleagues nor management, which in turn added more burden on the team. It was of great importance that the operations team was dedicated and small in the improvement work, in order to ensure the safety of the employees and to optimize the process.

Region Stockholm has a goal to use digitalized strategic tools to make the health care system more effective, accessible and increase patient participance. This goes hand in hand with governmental, Swedish Association of Local Authorities and Regions’s vision for eHealth 2025 that aim for Sweden to be world leader in digitalization. Results of several studies have shown positive effects on reduced no-shows with using web-based appointment system.

The purpose of this improvement work was to increase patient participance and availability through efficient use of resources in the radiology department. The goal was to reduce no-shows from 3,1 percent to <2 percent until 1 of April 2022 within conventional X-ray, computed tomography, and ultrasound atDanderyds hospital. Web-based appointment system was introduced using Nolan’s model for improvement that started with a small test and then scaled up. The results showed that most patients prefer web-based appointment system over traditional booking system. With web-based appointment system patient’s participation increased. On the other hand, the no-shows didn’t reduce.

The purpose of the study was then to describe employee’s perception when introducing a web-based appointment system. A qualitative focus group interview study with phenomenographic approach was conducted and analyzed with the same approach. Four describing categories was identified: (A) Webbased appointment system as a complementary tool for healthcare professionals (B) Web-based appointment system as a complement to higher service for specific target groups (C) Web-based appointment system as a common tool for patients and healthcare professionals (D) Web-based appointment system as part of sustainable healthcare system in the future. These categories can be seen as four steps to achieve full-scale web-based appointment system.

The conclusion is that the no-shows didn’t reduce but staff labor decreased, and patient participance increased. 

BACKGROUND: Individuals undergoing radiation therapy for breast cancer frequently request information before, throughout and after the treatment as a means to reduce distress. Nevertheless, the provision of information to meet individuals needs from their level of health literacy is often overlooked. Thus, individuals information needs are often unmet, leading to reports of discontent. Internet and digital information technology has significantly augmented the available information and changed the way in which persons accesses and comprehends information. As health information is no longer explicitly obtained from healthcare professionals, it is essential to examine the sequences of the health information process in general, and in relation to health literacy. This paper reports on qualitative interviews, targeting women diagnosed with breast cancer who were given access to a health information technology tool, Digi-Do, before commencing radiation therapy, during, and after treatment. METHODS: A qualitative research design, inspired by the integrated health literacy model, was chosen to enable critical reflection by the participating women. Semi-structured interviews were conducted with 15 women with access to a digital information tool, named Digi-Do, in addition to receiving standard information (oral and written) before commencing radiation therapy, during, and after treatment. A deductive thematic analysis process was conducted. RESULTS: The results demonstrate how knowledge, competence, and motivation influence women's experience of the health information process. Three main themes were found: Meeting interactive and personal needs by engaging with health information; Critical recognition of sources of information; and Capability to communicate comprehended health information. The findings reflect the women's experience of the four competencies: to access, understand, appraise, and apply, essential elements of the health information process. CONCLUSIONS: We can conclude that there is a need for tailored digital information tools, such as the Digi-Do, to enable iterative access and use of reliable health information before, during and after the radiation therapy process. The Digi-Do can be seen as a valuable complement to the interpersonal communication with health care professionals, facilitating a better understanding, and enabling iterative access and use of reliable health information before, during and after the radiotherapy treatment. This enhances a sense of preparedness before treatment starts.

The improvement work was carried out in a nursing home and home care in municipal elderly care where the experience was that the work environment had shortcomings and that the work for the individual's participation needed to be developed. The purpose of the improvement work and the study was that through the introduction of a systematic way of working for increased participation for the individual, the individual's needs in the center (IBIC), that the care staff's work environment would be better while the individual's participation would be improved.The improvement work was based on Nolan's improvement model and through SWOT analysis, Ishikawa diagrams and an impact analysis, the understanding of the challenges that existed was developed. The improvement work meant training and increased knowledge within IBIC for the care staff. Work is underway to establish personal care plans with the participation of the individual and the individual's goals for their need of support. No positive results, this far, have been visible regarding this improvement work.The study was conducted as a case study with an abductive approach. By following the care staff´s perception of their work environment via focus group interviews and questionnaires, it can be concluded that there are tendencies towards an improved work environment by working with the older person´s participation and to perform a work that can be partially followed systematically.

BACKGROUND: Expressing a desire for surgery before participating in first-line osteoarthritis (OA) interventions (patient education and exercise therapy) has been shown to contribute to poorer outcomes from the interventions, but we lack knowledge on how these patients reflect on health care and self-management of OA.

OBJECTIVES: To explore and describe patients' perspectives of health care and self-management of OA among those expressing a desire for surgery before participating in first-line OA interventions.

METHODS: Sixteen patients with hip or knee OA referred to participate in a standardized first-line OA intervention program in primary health care in Sweden were included in the study. We used individual semi-structured interviews to collect data, which were analyzed using inductive qualitative content analysis.

RESULTS: One theme of meaning "A multifaceted picture of needs, expectations, and individual choices" and five categories were identified as perspectives from the participants regarding health care and self-management of OA: 1) lacking control and needing support; 2) standing alone in an unsupportive environment; 3) going with the flow; 4) having expectations; and 5) taking ownership.

CONCLUSION: Patients who express a desire for surgery before participating in first-line interventions for OA are not a homogeneous group. They describe a broad range of perspectives on how they reason and reflect on health care and self-management of OA based on their own needs, expectations, and choices. Findings from this study strengthen insights on the importance of exploring the patient's perspectives and individualizing OA interventions to achieve the lifestyle changes that first-line interventions strive to accomplish.

Healthcare is in constant change with fast development in knowledge, new technology and varying needs and expectations from patients, citizens, management, and politicians. There is a challenge in balancing the involved actors´ focus, needs, preferences, and resources for healthcare improvement. Improvement of healthcare is an ongoing activity, sometimes managed and controlled, often not. A key ingredient for success is competence where the need for competence varies with perspectives of the improving actors. Actors in healthcare improvement are professionals, patients, politicians, management, citizens, researchers, research foundations and others. In this report a review of frameworks in healthcare improvement are presented together with management myths and questions around needs for healthcare improvement competence and capabilities currently on the agenda.

Most improvement initiatives of some size have substantial parts of IT and have had so for a considerable time. This rather long experience of more and less successful IT implementation and use is transparent and useful in all kinds of healthcare improvement. One important issue in this report is what has real impact is the actual understanding and use of innovations and artefacts by healthcare actors in a broad sense for healthcare improvement (e.g., new clinical evidence, clinical guidelines, process changes, information systems and more). The aim in this report is to review frameworks which can be useful in healthcare improvement as well as in the study of healthcare improvement.

Conclusions concern what is found to be important to study and understand healthcare improvement, considering the presented frameworks. Improvement of healthcare is present in all the frameworks but in different ways and what is emphasized concerning scope and focus. Improving healthcare take place in the interaction of at least two parts, one of which is healthcare professionals, and another is the patient/next-of-kin. Professionals and patient populations interact in processes of social networks and structures. Actors and context are useful concepts for understanding action (use) and its social contexts. The actual use of innovations is best understood in terms of integration into clinical activities and processes – actors’ interaction, coordination and communication activities and processes.

Theoretical implications are that there is a need for more research concerning meso and macro perspectives on methods for healthcare improvement, and the interplay of perspectives regarding the understanding of improvement in healthcare. Of course, a challenge is that the objects of improvement are complex adaptive systems of healthcare is not easily to catch in simple rules. They are genuinely difficult both to change and evaluate changes. Practical implications of the report support design and contents of education programs in improvement of healthcare, in better understanding usefulness, practice, use, and experience base. To help the understanding of the need and usefulness of integrating different perspectives for successful healthcare improvement, e.g., micro, meso, and macro perspectives, use of mixed methods and more. 

Co-supervision of doctoral theses is on the rise worldwide, but we know little of the relational dynamics of the co-supervisory team and doctoral student. These teams often must work together for several years, during which supervisors may come and go. We interviewed 19 doctoral students about their experiences of co-supervision and found a complex team climate characterised by prior relations, merit- and network-gaining activities, and 'cushioning' adopted by supervisors to support the student during stressful periods. Doctoral students viewed themselves as passive and dependent - as pawns in a bigger game - suggesting that co-supervision might uphold the traditionally strong hierarchical structure of academia. We therefore suggest that all co-supervision teams discuss the roles and structure of supervision before commencing a research project.

BACKGROUND:Scientific research has identified a lack of psychometrically well-tested methods for evaluation of the work environment in healthcare settings. The Structured Multidisciplinary Work Evaluation Tool (SMET) questionnaire has been evaluated and has shown good content validity, as well as intra-rater and test-retest reliability. There are, however, still unknowns regarding the psychometric properties. If the SMET questionnaire is to be used in practical occupational health service (OHS) work and scientific research in healthcare settings, further psychometric evaluation is needed.

OBJECTIVE:The aim of this study was to gain further understanding of the psychometric properties of the SMET questionnaire when used in research and clinical OHS practice in healthcare settings.

METHODS:The psychometric evaluation was conducted using classical test theory (Cronbach’s alpha, explorative factor analysis) and Rasch analysis (measurement targeting, category threshold order, person separation index) on data previously collected in development projects within the healthcare sector.

RESULTS:The results support the use of the SMET questionnaire as a psychometrically well-tested method for evaluation of the work environment in healthcare settings. They support the use of the initial 1–10 scale since all 10 steps are used. The results also support the trichotomization procedure since the trichotomized scale captures the construct of the work environment with good measurement targeting and good category threshold order.

CONCLUSION:The results of this study support the use of the SMET questionnaire as a psychometrically well-tested method for a broad multifactorial evaluation of the work environment in healthcare settings.

In Sweden the health system is nationally regulated and locally provided by 21 regions and 290 municipalities. To meet the shifting paradigm, where the person is viewed as a co-producer of health and care, Sweden has laws, regulations and policies which support the patient as an active partner in the communication with professionals in the system. Coproduction, person-centred care and shared decision making contribute jointly to the paradigm shift. Principles of human dignity and equity must be supported nationally and enacted in the decentralized, regional provision of care. Infrastructures exist or are under development which can support and strengthen care that is co-produced and based in a person-centred philosophy and approach, where shared decision making becomes a reality in practice. A Knowledge management system together with National Quality registries have the potential to form a co-produced, person-centred learning health system, where patients, and next of kin and professionals are included as partners. The joint integration of Shared decision making, Person-centre care and Coproduction into the Swedish healthcare system now looks like a possible way to realize the emerging paradigm.

BACKGROUND: Harm from medications is a major patient safety challenge among older persons. Adverse drug events tend to arise when prescribing or evaluating medications; therefore, interventions targeting these may promote patient safety. Guidelines highlight the value of a joint plan for continued treatment. If such a plan includes medications, a medication plan promoting patient safety is advised. There is growing evidence for the benefits of including patients and health care professionals in initiatives for improving health care products and services through co-design.

OBJECTIVE: This study aimed to identify participants' needs and requirements for a medication plan and explore their reasoning for different design choices.

METHODS: Using a case study design, we collected and analyzed qualitative and quantitative data and compared them side by side. We explored the needs and requirements for a medication plan expressed by 14 participants (older persons, nurses, and physicians) during a co-design initiative in a regional health system in Sweden. We performed a directed content analysis of qualitative data gathered from co-design sessions and interviews. Descriptive statistics were used to analyze the quantitative data from survey answers.

RESULTS: A medication plan must provide an added everyday value related to safety, effort, and engagement. The physicians addressed challenges in setting aside time to apply a medication plan, whereas the older persons raised the potential for increased patient involvement. According to the participants, a medication plan needs to support communication, continuity, and interaction. The nurses specifically addressed the need for a plan that was easy to gain an overview of. Important function requirements included providing instant access, automation, and attention. Content requirements included providing detailed information about the medication treatment. Having the plan linked to the medication list and instantly obtainable information was also requested.

CONCLUSIONS: After discussing the needs and requirements for a medication plan, the participants agreed on an iteratively developed medication plan prototype linked to the medication list within the existing electronic health record. According to the participants, the medication plan prototype may promote patient safety and enable patient engagement, but concerns were raised about its use in daily clinical practice. The last step in the co-design framework is testing the intervention to explore how it works and connects with users. Therefore, testing the medication plan prototype in clinical practice would be a future step.

Medication Without Harm is according to WHO the third Global Patient Safety Challenge and affects everyone of us. But how can we make medication management safer and what is our role in this improvement process as a person using medications, next-of-kin, physician, nurse, quality improvement leader etc.? How do we all get involved and what are our input and responsibilities?

BACKGROUND: Harm from medications is a major patient safety challenge. Most adverse drug events arise when a medication is prescribed or reevaluated. Therefore, interventions in this area may improve patient safety. A medication plan, that is, a plan for continued treatment with medications, may support patient safety. Participation of patients in the design of health care products or services may improve patient safety. Co-design, as in the Double Diamond framework from the Design Council, England, can emphasize patient involvement. As the COVID-19 pandemic brought restrictions to face-to-face co-design approaches, interest in remote approaches increased. However, it is uncertain how best to perform remote co-design. Therefore, we explored a remote approach, which brought together older persons and health care professionals to co-design a medication plan prototype in the electronic health record, aiming to support patient safety.

OBJECTIVE: This study aimed to describe how remote co-design was applied to create a medication plan prototype and to explore participants' experiences with this approach.

METHODS: Within a case study design, we explored the experiences of a remote co-design initiative with 14 participants in a regional health care system in southern Sweden. Using descriptive statistics, quantitative data from questionnaires and web-based workshop timestamps were analyzed. A thematic analysis of the qualitative data gathered from workshops, interviews, and free-text responses to the survey questions was performed. Qualitative and quantitative data were compared side by side in the discussion.

RESULTS: The analysis of the questionnaires revealed that the participants rated the experiences of the co-design initiative very high. In addition, the balance between how much involved persons expressed their wishes and were listened to was considered very good. Marked timestamps from audio recordings showed that the workshops proceeded according to the plan. The thematic analysis yielded the following main themes: Everyone's perspective matters, Learning by sharing, and Mastering a digital space. The themes encompassed what helped to establish a permissive environment that allowed the participants to be involved and share viewpoints. There was a dynamic process of learning and understanding, realizing that despite different backgrounds, there was consensus about the requirements for a medication plan. The remote co-design process seemed appealing, by balancing opportunities and challenges and building an inviting, creative, and tolerant environment.

CONCLUSIONS: Participants experienced that the remote co-design initiative was inclusive of their perspectives and facilitated learning by sharing experiences. The Double Diamond framework was applicable in a digital context and supported the co-design process of the medication plan prototype. Remote co-design is still novel, but with attentiveness to power relations between all involved, this approach may increase opportunities for older persons and health care professionals to collaboratively design products or services that can improve patient safety.

Teaching and exploring the ethical issues brought about by digitalization is an important challenge in current higher education programs. Experiential learning through games is becoming increasingly relevant as games exert an enormous influence on the imaginarium of newer generations. This paper details how a class of international graduate students engaged in a year-long exploration of ethics, gender, and sustainability issues by playing, remixing, and designing games using an original Design Games Framework. Using a qualitative approach based on participatory observations that followed the student's entire game-making process and a series of final semi-structured interviews, the paper illustrates how game-making can enable higher education students to better understand the complex interplay of ethical issues and digitalization processes, as well as confirming that the Design Games Framework is a valid instrument for the exploration of ethics through the design of tabletop games in a higher education setting.

This paper sets out to present an ongoing pedagogical project where game design is used to let students both learn and reflect upon different perspectives of ethics relevant to the master program they are enrolled in. The paper explains the underlying logic behind the pedagogical process where students develop their own game and at the same time learn about different perspectives of ethics in relation to courses that they are currently taking. With an open and iterative method, we let the students explore, discuss and design a game that can be used by future students. By letting the students decide and lead the development we democratize the learning-process and engage them in a learning experience. More so, this approach to game design as a pedagogical tool to engage and democratize the learning experience is new and increasingly relevant for both students that play games on an everyday basis, but also students that are new to games. Also, it is a constant and dynamic process for both students and teachers.

The discipline of Digital health is devoted to the accumulation of sociotechnical aspects which includes running digital care programs, healthcare technologies, sharing health related experiences, providing support for the people with chronic diseases and healthcare needs of the society to deliver the healthcare services in an effective manner. This is a special project which is focused on older persons’ health (range 65 to 79 years) in the home setting from the perspectives of design science, information ethics, systems thinking, information technology, and occupational science/therapy. Older people represent a particular community which is very focused on self-care to maintain and enhance health, prevent disease and cope with illness, as well as keep themselves social and participate in their community. However, generally, it is thought that the elderly community is reluctant to adopt new technologies and are seldomly included in the development of new technologies. Therefore, it is relevant to ask: How can emerging technologies support older person’s self-care and social participation? Implementation and use of technology at home is not only important for the older persons and their families, but it also impacts other stakeholders including care personnel, municipal health and social care managers as well as health sector policymakers. Overall, aim of the project is to establish the sustainable process of capturing and describing the self-care requirements and specifications for older people in Sweden and Japan through the development of a digital self-care tool together with older people. Following goals are set for this project:

• To establish close collaborations with the technology industry (e.g., medtech start-ups from Sweden and Japan).
• Applying ELSI framework.
• Seeking partners from researcher and practitioners’ community, industry, end-users.
• To explore the needs of community-dwelling older persons for self-care and participation in their communities and society.
• To explore available technologies to support older persons’ self-care and digital engagement in the communities and society.

Background: Mental health problems (MHP) are a major public health challenge. Conventional healthcare has shown limitation on reducing MHP and there is a call for offering methods beyond healthcare as well as improve access to healthcare.

Aims: To explore experiences among people having MHP of (i) taking part in existential conversations in groups beyond conventional healthcare and (ii) seeking and receiving conventional healthcare.

Materials and methods: Four focus group interviews were conducted after finishing existential conversations in groups. Data was analyzed following thematic analysis.

Results: The theme Access to a community for exploration and acceptance describes communication through impressions and expressions together with others. A reflective perspective on everyday life, describes re-evaluation through reflection. Within the theme Experiences of healthcare related encounters, referring to the second aim, participants recollected feelings of disconnectedness, difficulties verbalizing MHP and dealing with rigid, standardized measures.

Conclusion: Existential conversations in group may contribute to a more reflected doing in accordance with one’s own values as well as improved mental health literacy. Design and measures within healthcare need to explicitly address MHP and consider individual’s own preferences.

Significance: This study contributes to understanding of coping with MHP in everyday life from an existential perspective.

Despite previous efforts to deal with the ontological split between human subjects and reality, sensemaking has remained human-centered. We argue that human-centered sensemaking risks omitting constitutive elements of reality. To escape the ontological split, we decenter sensemaking and thus extend it in such a way that it allows seemingly unrelated and independent humans and nonhumans to become connected and interdependent with what is made sense of. Doing so allows us to demonstrate how a decentered understanding of reality can produce a radically different understanding of research phenomena. As a means to show the consequences of a decentered sensemaking, we revisit the Mann Gulch disaster and show that not all disasters can be avoided by better sensemaking or good management.

In this paper, we seek to belong to the “writing differently” turn in organization studies. We argue that writing poetry when doing field work is a way of disrupting and unsettling the objective scientific gaze, the scientific ideal of experiencing the world, and of opening for the Buberian world—the world as an encounter in itself. A tension framed by Buber as I-It and I-You. Rather than merely arguing that poetry can help us understand the world differently, we argue that poetry can help us encounter the world differently. Further, by telling two field work stories, we show that poetry can help the researcher to remain human in the field. Having hope in writing poetry when doing field work transcends the more politically and individually oriented engaged ethnography, realizing that field work as encounter—I and You—holds the possibility of not only companionship, trust, mercy, cooperation, forming of joint causes, dreams but also betrayal, plundering, exploitation, and force.

BACKGROUND: Home rehabilitation programmes are increasingly implemented in many countries to promote independent living. Home rehabilitation should include a comprehensive assessment of functioning, but the scientific knowledge about the assessment instruments used in this context is limited. The aim of this study was to explore relationships between standardised tests and a self-reported questionnaire used in a home rehabilitation programme. We specifically studied whether there were gender differences within and between assessments.

METHOD: De-identified data from 302 community-dwelling citizens that participated in a municipal home rehabilitation project in Sweden was analysed. A Mann Whitney test and an independent t-test were used to analyse differences within the following assessment instruments: the Sunnaas Activity of Daily Living Index, the General Motor Function assessment scale and the European Quality of Life Five Dimension Five Level Scale. Spearman's bivariate correlation test was used to analyse relationships between the instruments, and a Fischer's Z test was performed to compare the strengths of the correlation coefficients.

RESULT: Gender differences were found both within and between the assessment instruments. Women were more independent in instrumental activities of daily living than men. The ability to reach down and touch one's toes while performing personal activities of daily living was stronger for men. There was a difference between men's self-reported performance of usual activities that included instrumental activities of daily living and the standardised assessment in performing instrumental activities of daily living. The result also showed an overall difference between the self-reported assessment and the standardised test of motor function for the total group.

CONCLUSION: The results indicate that a comprehensive assessment with the combination of standardised tests, questionnaires and patient-specific instruments should be considered in a home rehabilitation context in order to capture different dimensions of functioning. Assessment instruments that facilitate a person-centred home rehabilitation supporting personally meaningful activities for both men and women should be applied in daily practice. Further research about gender-biased instruments is needed to facilitate agreement on which specific instruments to use at both individual and organisation levels to promote gender-neutral practice.

First-line managers (FLMs) have a vital role in developing stable output and organizational competitiveness through their ability to manage front-line operations in daily work. It is also well known that FLMs are strong determinants of good ergonomics and well-being for front-line staff. However, research focusing on how FLMs deal with their important role is lacking particularly regarding empirical studies. The focus here is how they deal with uncertainties and disruptive interruptions and develop more resilient performance in daily work – introduced in this article as resilient action strategies.

This research uses two conceptual frameworks on resilient engineering for analysis of FLM's actions in daily work in two manufacturing companies, to explore how resilient action strategies can be organizationally supported. The study combines analysis of front-line activities with multilevel organizational support based on 30 semi-structured in-depth interviews with FLMs and support functions, 21 workshops as well as policy documents of the two companies. The analysis exemplifies how resilience engineering was enabled in practice in the organizations.

The study contributes to the empirical understanding of how resilience can be organizationally supported in daily front-line work. Our results show that a developed and consistent infrastructure in companies promotes the emergence of resilient action strategies in front-line work. We propose an extended model for resilient front-line performance enhancement by including coordination as a linking aspect between the earlier suggested resilient potentials – anticipate, monitor, respond and learn. This highlights the importance of both organizational support and coordination between system levels to enable the development of resilient action strategies by FLMs.

Sammanfattning

Tillgänglighet och väntetid till såväl undersökningar som vård är två stora utmaningar inom svensk hälso-och sjukvård. Bristande tillgänglighet och onödig väntetid är faktorer som kan innebära lidande för patienter, medföra onödiga kostnader för sjukvården och påverka medarbetarnas upplevelse av sin arbetsmiljö. I såväl diagnostik som behandling inom hälso- och sjukvården har radiologi en central roll.

Detta förbättringsarbete utgår från frågan om ett förbättrat flöde i form av en förberedelseenhet kan minska väntetider för patienter som behöver genomgå en datortomografiundersökning och hur det påverkar medarbetarnas arbetsmiljö.

Förbättringsarbetet visade att en förberedelseenhet kunde startas upp och ta emot fler patienter med samma medarbetarstyrka. Studien av förbättringsarbetet påvisade att arbetsmiljön upplevdes fortsatt positiv från medarbetarnas sida. Medarbetarna förklarade att förberedelseenheten underlättade flödet att de fick en tydligare överblick om flödet vilket gjorde planeringen lättare. Medarbetarna upplevde även att det var positivt att de fick utökade möjligheter till rotation mellan förberedelseenheten och undersökningsrum. De kände att det var tillfredsställande att kunna erbjuda lediga tider till fler patienter samtidigt som de kunde erbjuda lediga tider inom en snar framtid vid eventuella avbokningar.  

Förbättringsarbetets slutsats är att produktiviteten och effektiviteten ökade genom införandet av förberedelseenheten. Studiens slutats är att medarbetarnas arbetsmiljö påverkades positivt genom ökad variation av arbetsuppgifter och att mer tid frigörs för patientens frågor och funderingar.   

The Swedish Health law obliges healthcare centers to assign case managers for patients in need. Good quality in local health care thus includes providing case managers. The case manager method presupposes that care staff adopts a person-centered manor and creates care in co-production with the patients. In contrast the nurse lacks support and knowledge to provide case management. This results in patients feeling insecure, seeking frequently for health related afflict and meeting various caregivers. To improve safety and continuity for patients in need one healthcare center in the county of Dalarna has decided to provide case management for patients assigned to the center. The specific goals were to assign twelve patients to a case manager, including health care plan within six months, and to increase knowledge for nurses. Aims of the study were to describe patients’ perception whether they consider if their needs are accommodated by the case manager, and nurses’ experiences to work as a case manager. Nolans’ improvement tool was used involving patients in their care as well as training nurses in case management skills. To study the effect of case management on patients and nurses a mixed-method design was conducted. A patient questionnaire was performed and three focus group interviews, one dyad and one individual interview with nurses were conducted. Twelve patients were assigned a case manager after six months. Ten patients had an established care plan. The patients expressed that their need of care was accommodated which is in coherence with the nurses who described that their patients were in less need for care. Case managers improve safety and continuity for patients in need under circumstances that allow nurses to develop person-centred manor. Patients expressed care improved and nurses increased work values. Yet this survey was limited to a small unit and further studies are needed. 

OBJECTIVES: The Esther Network (EN) model, a person-centred care innovation in Sweden, was adopted in Singapore to promote person-centredness and improve integration between health and social care practitioners. This realist evaluation aimed to explain its adoption and adaptation in Singapore. DESIGN: An organisational case study using a realist evaluation approach drawing on Greenhalgh et al (2004)'s Diffusion of Innovations in Service Organisations to guide data collection and analysis. Data collection included interviews with seven individuals and three focus groups (including stakeholders from the macrosystem, mesosystem and microsystem levels) about their experiences of EN in Singapore, and field notes from participant observations of EN activities. SETTING: SingHealth, a healthcare cluster serving a population of 1.37 million residents in Eastern Singapore. PARTICIPANTS: Policy makers (n=4), EN programme implementers (n=3), practitioners (n=6) and service users (n=7) participated in individual interviews or focus group discussions. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcome data from healthcare institutions (n=13) and community agencies (n=59) were included in document analysis. RESULTS: Singapore's ageing population and need to transition from a hospital-based model to a more sustainable community-based model provided an opportunity for change. The personalised nature and logic of the EN model resonated with leaders and led to collective adoption. Embedded cultural influences such as the need for order and hierarchical structures were both barriers to, and facilitators of, change. Coproduction between service users and practitioners in making care improvements deepened the relationships and commitments that held the network together. CONCLUSIONS: The enabling role of leaders (macrosystem level), the bridging role of practitioners (mesosystem level) and the unifying role of service users (microsystem level) all contributed to EN's success in Singapore. Understanding these roles helps us understand how staff at various levels can contribute to the adoption and adaptation of EN and similar complex innovations systemwide.

This work presents initial results of translation, design, development and expert testing of a digitally mediated dialogue based tool for schizophrenia care in Sweden. Dialog+ is a conversational methodology that has been shown to empower patients, promote co-produced and more cost-effective care. Dialog+ was translated and the digital application was redesigned to fit with the local context using human-centered design principles. Initial results of expert user testing, using heuristic evaluations and cognitive walkthroughs, shows promise for the method to work well also in Swedish settings. Initial testing with patients shows promising results. This work exemplifies how care patterns can be improved by considering the information layer of the interaction and creating shared and collaborative working spaces during treatment sessions can help to both empower patients and facilitate a more co-produced treatment plan.

System space is introduced as a conceptual design space and as a distinct space from that traditionally addressed by most design processes. The paper intends to address the increasing complexity deriving from the ongoing blend of physical and digital in a postdigital culture and contribute to the current understanding of the effect of “systemic” ways of thinking in design disciplines. We argue that a systemic perspective cannot simply be “added” to the design process and that addressing postdigital complexity, that is, producing solutions to contemporary design problems, requires instead its own conceptualization, in its own space, to be acknowledged, practiced, and formalized as a different way of thinking. We propose that system space lives in a dialectical relationship with design space within the space of the experience and that it provides a way to escape the cognitive traps in design space. We posit that the relationships between system space and design space can be apprehended by means of an exo-process adapted from systems thinking, and that the exo-process provides a supporting structure for the intentional and necessary movement between the different spaces, scales, and modes of thinking required by contemporary design work. We then illustrate such a dialectical relationship through the analysis of three different cases and draw final considerations.

Causal loop diagrams are used to map relationships between nodes in a system. They can either contain reinforcing loops, where an action produces a result which influences more of the same action, resulting in growth or decline or balancing loops attempting to move some current state to a desired state through some action. Service design as a practice has focused on the experience of a service journey and on improving said experiences. At the same time, service design has claimed to have systemic impact. Company X, name withheld, is a European health start–up that locates medical specialist for the treatment of serious and life-threatening conditions for patients and their individual health problems.  Company X uses a data–driven approach based on the aggregated matching of qualitative data from the healthcare system together with the company’s own analysis  of patient cases, relating diagnosis with the outcome of procedures to draw patterns that help find the most suitable medical specialists for the case at hand. In this chapter, we discuss how company X combines service design practices and causal loop diagrams in order to innovate within the health market. The process will be described within the chapter as well as the business case and the lessons learnt from applying a more systemic approach to the innovation process.

This workshop invites participatory design practitioners and researchers to explore how Ostrom's 8 principles for collaborative group working can aid designers during the design process. It is proposed that the principles could help to address questions such as how to scale up and sustain co-design approaches in equitable, inclusive, efficient, and effective ways and to normalise such ways of working in wider systems. The workshop follows previous work conducted in a co-design and quality improvement context [7] where the relationships between the principles were highlighted. This relationship will be experientially explored during the workshop. The outcome of the workshop will be a set of design tools that can be applied by designers within the community that wish to explore equity and inclusion in a participatory way, the aim is to disseminate these tools with the community.