Purpose: Quality improvement has developed and spread, and today, all Swedish Regions emphasize that their strategies are based on systematic improvement. This paper aims to describe and illuminate the development of Quality Improvement (QI) in Swedish healthcare and welfare organizations by using publications in a Swedish context.

Design/methodology/approach: The overview synthesis is inspired by a scoping literature review approach of relevant literature. All publications relevant to Swedish healthcare and welfare settings between 1992 until 2020 were included.

Findings: In all, 213 papers, 29 books and chapters and 34 dissertations related to QI and research in Swedish healthcare and welfare context were identified. From 2011 to 2020, the publication rate increased rapidly. Six different focus areas emerged: systematic and value-creating improvement work; collaboration between organizations and healthcare providers; use of improvement methods and (theoretical) models; leadership and learning; measurements, quality registers and follow-up; and involvement and patient safety. Further QI development in Swedish healthcare and welfare points to an increased importance of collaboration between organizations and coproduction with beneficiaries for the healthcare and welfare services.

Originality/value: This paper is one of the first to describe and illuminate the QI development in the healthcare and welfare sector in a country. The trajectory also points to a need for coproduction to handle future challenges. 

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.

Improvement work and study of interprofessional collaboration between pediatricians and clinical pharmacist in license prescription

Pediatricians in the pediatric department at Vrinnevi Hospital experience challenges with prescribing license drugs, resulting in additional work for the doctors and delays in children receiving their medications from pharmacies. License medicine refers to the process where a physician seeks permission to choose a medication treatment not available in Sweden, involving healthcare providers, the Swedish medical product agency, and pharmacies.

The author had the opportunity to lead this project. The improvement effort involved a team consisting of seven pediatricians and two clinical pharmacists,

The aim of quality improvement project was to initiate and involve an established method where pharmacists could provide support to doctors by with the help of new work flow. The SMART goal was for 50% of the doctors in the focus group to seek support from clinical pharmacists during the measurement period. Results of the improvement work was a newly established workflow that was approved by the management and applied, along with the creation of information sheets that invite guardians to understand the licensing process.

The aim of study was evaluating the interaction through the implementation of the COM-B method and the analysis of interviews and field data. Result of the empirical findings show that collaboration took place where clinical pharmacists and pediatrists, through their extensive knowledge and communication skills, support both the care, the pharmacy, and also help patients to obtain their medicine on time.

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

In Sweden, it is estimated that 40 000 girls and women have been subjected to female genital mutilation (FGM). The care provision varies within Sweden and healthcare staff may, for example, lack the knowledge to provide adequate care. Women who have undergone FGM type 3 have labia that are sewn together and cover the vaginal opening. Defibulation therefore needs to take place during pregnancy or at birth. The Vulva clinic in Angered’s hospital is a specialist clinic that provides healthcare to women who have been subjected to FGM. Despite the advantages of defibulation during pregnancy, there have been no referrals to the Vulva clinic regarding pregnant women in recent years.  

An improvement project was initiated with the aim of designing a training course for healthcare staff at antenatal clinics. The purpose of the training course was to identify pregnant woman who have been subjected to FGM type 3 and refer them to the Vulva clinic. In connection with the improvement project a study was carried out with the aim of describing staff reactions and what they had learnt, after completing the FGM training course. 

The Kirkpatrick model was used for designing and evaluating the training course that the Vulva clinic offered. Referrals received were counted and medical records reviewed to answer the purpose of the improvement project. Data for the study was gathered using a questionnaire. The results show that the participants reacted positively to the training course and that knowledge and awareness had improved. There was an increase in referrals from antenatal clinics of pregnant women subjected to FGM type 3. Most of the women chose defibulation during pregnancy. Through the improvement project more pregnant women who have been subjected to FGM type 3 are given options before childbirth and have the opportunity to be involved in decisions about when defibulation should take place.

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. 

Leadership development (LD) plays a significant role in achieving high-quality performance and business results, but there is little research on how leadership development itself evolves as the organization develops. This study explores how a leadership development system evolved over 30 years, during a time when the organization became increasingly high performing. Through reflexive thematic analysis of organizational documents and interviews with top managers and practitioners, the study provides a rich longitudinal description of the evolvement. The results revealed three pervasive changes of the leadership development system: 1) from a system for business-specific learning to one for system-wide learning; 2) from a system for personal development to one for customer-oriented quality development; and 3) from a leadership development system consisting of leadership development programs to one that is integrated into regular meetings and uses simple rules. These changes supported the gradual transformation of the leadership development from being independent to becoming integrated in the wider system, supporting the business system. The findings offer a unique insight into how an organization transitioned from individual leader development towards promoting collective aspects of leadership development. The study provides two main theoretical contributions that support the perspective of viewing leadership development as integrated within organizational development. Firstly, we present a more multifaceted way of understanding leadership development, wherein managers and employees, customer outcomes, and business advancement are seen as mutually developing. Secondly, we introduce two new critical points that complement previous descriptions of an advanced leadership development system: It is system wide (not only business specific) and customer oriented (not only leader/participant oriented).

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.

Health care in Sweden is heavily subsidized and costs for the user are small, both for physical consultation and telemedicine, and for public and private health care. It has been argued that telemedicine consultations will increase care consumption, lead to higher costs, and create inequalities. As older people often are less skilled in digital technology, increased digitalization of care might increase inequalities. Telehealth is mainly conducted by private companies. This study is based on all private telemedicine consultations in two regions in southern Sweden 2020-2022, with approx. 656,000 inhabitants. 106,000 persons had 343,000 telemedicine consultations, 3.2 consultations p/p. The number of consultations differed neglectable between age groups, for women median was 2.0 for the age groups (< 65/65-79/80+), and for men it was 1.0. The proportion of people WITH telemedicine consultations differed heavily between the age group as well as months. Total number of telemedicine consultations per month varied 4-8.5 thousand among women, and 2-4 thousand among men. The months with most consultations were March-June 2021. Proportion of telehealth consultations was low in the age group 65-79, and even lower among 80+. The proportion of consultations by people 65-79 years increased steadily and reached its peak July-September 2021 with >20%. After that, it increased rapidly down to < 3% among women and < 4% among men. The pattern was similar among people 80+ with peaks at approx. 2% among women and close to 2% among men. The conclusion is that there is still a huge age difference in the use of telehealth consultations.

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 Points

• The 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. 

Pressure ulcers (PU) cause physical, psychological, social, and economic suffering. The complex microsystem is a Swedish thoracic critical care unit (TCCU) where patients are cared for after heart surgery and/or severe organ failure. These patients are especially at risk of developing PU due to surgical, treatment related, and intrinsic factors. Different patients’ needs need to be constantly balanced. 

The improvement effort focused on patients with a length of stay of at least three days at TCCU and aimed to improve patients’ skin status by translating PU evidence to the local context and thereby improving PU processes. The specific aim to increase the proportion of patients without PU from 60 percent to 80 percent was surpassed during the last two months of the seven months improvement period. Other PU measures improved earlier.  The other specific aim improving the monthly average number of repositionings per day per patient from 6 to 7,8 was surpassed twice. The improvements were achieved by combining Nolan’s model of improvement and the SHIFT-Evidence framework. 

A single case case-study was conducted to describe the healthcare professionals’ experience of the impact the improvement effort focusing on PU had on the complex microsystem TCCU. Data from two focus group discussions, one survey and two meeting protocols were triangulated and resulted in three themes and one subtheme: increased awareness and ability to act, the meaningfulness of pressure ulcer activities including the subtheme varied patient benefits related to conflicting needs, and change in work method evokes emotions.

Key aspects of the improvement effort’s success were vast preparations, engaged nursing staff, knowledge of the local context and adaptation. Even though positive behavioural changes related to PU activities were achieved there was a prize to be paid, in form of some degree of displacement effects and ethical stress. 

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: Disordered eating refers to unhealthy, sometimes excessive eating including so-called compensatory behaviours such as extreme dieting or voluntary vomiting. Between 24% and 30% of adolescent boys are suggested to engage in disordered eating, making it a significant public health issue. However, current instruments for assessing disordered eating among adolescents have been primarily developed and validated for girls and women, which may make for flawed assessment of boys. The aim of this study is to shed light on adolescent boys' perceptions of eating, weight, and food intake to better understand their perspectives in service of disordered eating research.

METHODS: This exploratory study was conducted from May to November 2022 using focus groups with a total of 39 adolescent boys (aged 12-19 years) who attended 7th to 12th grade in one of four schools in Southern Sweden. In addition, participants completed a form with questions on background demographics and eating habits. The transcripts of the focus group discussions were analysed using thematic analysis.

RESULTS: The quantitative data showed that around one third of the adolescent boys were overweight or obese. They ate at least one meal per day with the family and ate healthy food about five days per week and unhealthy food about three. Analysis of the qualitative data yielded six themes: The intertwined relationship between food and one's health, "Don't worry, food makes you happy," "To be hungry or not. That is the question," Boys DO care about appearances, Dieting and weight gain, and Disordered eating is a tricky matter.

CONCLUSION: Adolescent boys appeared to have a good understanding of food and healthy eating. They also experienced body positivity and seemed to have only minor issues regarding their weight. The primarily pathological perspective used to measure disordered eating among girls seems in need of revision to adhere to boys' thoughts and ideas regarding eating and weight.

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.

An increasing number of older people with severe mental illness (SMI) poses additional challenges to healthcare and social services. This scoping review aimed to investigate the life situation of older people living with severe mental illness and identify the research gaps in the existing literature. The current review followed the methodological framework for conducting scoping reviews by Arksey and O'Malley, consisting of five main stages: (1) identifying the research question (2) identifying relevant studies, (3) selecting the studies, (4) charting the data, and (5) collating, summarising, and reporting the results. An optional sixth stage, a consultation exercise, has also been used in this study: The scoping review was conducted in accordance with the PRISMA extension for scoping reviews PRISMA-ScR, and the databases PsychINFO Scopus, Cinahl, Web of Science and PubMed were used. A total of 24 studies were included in the review. The thematic analysis focused on: (1) the perspective of older people with SMI, (2) the perspective of healthcare professionals supporting older people with SMI, and (3) the perspective of informal carers supporting older people with SMI. The results describe the life situation of older people living with SMI, especially in relation to the older peoples' experiences of suffering and well-being. The staff and the informal carers need adequate knowledge to provide support to the older people with SMI. To gain greater knowledge about the life situation and support needed by older people with SMI, we strongly advocate additional research focusing on their own experiences.

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.

Aim: To study Swedish pediatric oncologists’ practical and emotional experiences of referring, including and/or treating children in early-phase clinical trials.

Methods: A nationwide study was conducted using a mixed-method approach. Structured interviews based on a study-specific questionnaire and participants’ personal reflections were utilized. Survey responses were analyzed using descriptive statistics, while participants’ comments were analyzed using thematic analysis. All interviews were recorded and transcribed verbatim.

Results: In total, 29 physicians with 4 to 32 years of experience in pediatric oncology participated, with 19 (66%) having > 10 years of experience. Three themes appeared: 1) Optimization-based approach focused on finding the most suitable treatment and care for every child with a refractory/relapsed cancer eligible for an early-phase clinical trial; 2) Team-based approach aimed at establishing local and national consensus in decision-making for treatment options, including early-phase clinical trials and palliative care; 3) Family-based approach in which the physicians provided families with actionable information, listened to their desires, and endeavored to maintain hope in challenging circumstances. Several participants (40% with ≤ 10 years of experience and 58% with > 10 years of experience) viewed the early-phase clinical trial as a potential “chance of cure”. A majority (80%) of physicians with ≤ 10 years of experience, reported that they often or always felt personally and emotionally affected by communication regarding early-phase clinical trials. Delivering difficult news in cases of uncertain prognosis was identified as the major challenge. None of the study participants felt adequately prepared in terms of sufficient knowledge and experience regarding early-phase clinical trials. The physicians expressed a need for guidance and training in communication to address these challenges.

Conclusions: Working with early-phase clinical trials highlight a field where physicians cannot solely rely on their expertise or past experiences, and where they are likely to be deeply emotionally involved. Physicians who care for children eligible for such studies require targeted educational initiatives and supervision.

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.