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Reichenpfader, U., Wickström, A., Abrandt Dahlgren, M. & Carlfjord, S. (2019). Embedding hospital-based medication review: The conflictual and developmental potential of a practice. Journal of Health Organisation & Management, 33(3), 339-352
Open this publication in new window or tab >>Embedding hospital-based medication review: The conflictual and developmental potential of a practice
2019 (English)In: Journal of Health Organisation & Management, ISSN 1477-7266, E-ISSN 1758-7247, Vol. 33, no 3, p. 339-352Article in journal (Refereed) Published
Abstract [en]

Purpose: The purpose of this paper is to explore the embedding of hospital-based medication review attending to the conflictual and developmental nature of practice. Specifically, this paper examines manifestations of contradictions and how they play out in professional practices and local embedding processes.

Design/methodology/approach: Using ethnographic methods, this paper employs the activity-theoretic notion of contradictions for analyzing the embedding of medication review. Data from participant observation (in total 290?h over 48 different workdays) and 31 semi-structured interviews with different healthcare professionals in two Swedish hospital-based settings (emergency department, department of surgery) are utilized.

Findings: The conflictual and developmental potential related to three interrelated characteristics (contested, fragmented and distributed) of the activity object is shown. The contested nature is illustrated showing different conceptualizations, interests and positions both within and across different professional groups. The fragmented character of medication review is shown by tensions related to the appraisal of the utility of the newly introduced practice. Finally, the distributed character is exemplified through tensions between individual and collective responsibility when engaging in multi-site work. Overall, the need for ongoing ᅵrepairᅵ work is demonstrated.

Originality/value: By using a practice-theoretical approach and ethnographic methods, this paper presents a novel perspective for studying local embedding processes. Following the day-to-day work of frontline clinicians captures the ongoing processes of embedding medication review and highlights the opportunities to learn from contradictions inherent in routine work practices.

Place, publisher, year, edition, pages
Emerald Group Publishing Limited, 2019
Keywords
Patient safety, Qualitative research, Implementation, Medical professions, Ethnographic methods, Medical practice
National Category
Public Health, Global Health, Social Medicine and Epidemiology Nursing
Identifiers
urn:nbn:se:liu:diva-156644 (URN)10.1108/JHOM-09-2018-0268 (DOI)2-s2.0-85064750614 (Scopus ID)
Available from: 2019-05-02 Created: 2019-05-02 Last updated: 2019-06-04Bibliographically approved
Tigerstrand Grevnerts, H., Fältström, A., Sonesson, S., Gauffin, H., Carlfjord, S. & Kvist, J. (2018). Activity demands and instability are the most important factors for recommending to treat ACL injuries with reconstruction. Knee Surgery, Sports Traumatology, Arthroscopy, 26(8), 2401-2409
Open this publication in new window or tab >>Activity demands and instability are the most important factors for recommending to treat ACL injuries with reconstruction
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2018 (English)In: Knee Surgery, Sports Traumatology, Arthroscopy, ISSN 0942-2056, E-ISSN 1433-7347, Vol. 26, no 8, p. 2401-2409Article in journal (Refereed) Published
Abstract [en]

The purpose of the study was to (1) study and compare the factors that Swedish orthopaedic surgeons and physical therapists consider important for recommending ACL reconstruction and, (2) to assess how orthopaedic surgeons and physical therapists consider their own and each others, as well as patients, roles are in the treatment decision. A web-based survey assessing the relevance of 21 predetermined factors, in the choice to recommend ACL reconstruction, was sent to orthopaedic surgeons and physical therapists. Respondents were also asked to rate the importance of the assessment made by themselves, the other clinician (physical therapists rated the importance of surgeons, surgeons rated the importance of physical therapists), and the patients preferences. Orthopaedic surgeons agreed of eight, and physical therapists of seven factors as important in the choice to recommend ACL reconstruction. The factors both groups reported as important were; "patients wishes to return to contact/pivoting sports", "instability in physical activity", "instability in activities of daily living despite adequate rehabilitation", "physically demanding occupation", and "young age". Both professions rated their own and each others assessments as well as patients wishes as important for the decision to recommend ACL reconstruction. Orthopaedic surgeons and physical therapists agree about factors that are important for their decision to recommend ACL reconstruction, showing that both professions share a common ground in perceptions of factors that are important in recommending ACL reconstruction. Diagnostic study: Level III.

Place, publisher, year, edition, pages
SPRINGER, 2018
Keywords
Knee; Anterior cruciate ligament injury; Treatment decision; ACL reconstruction
National Category
Physiotherapy
Identifiers
urn:nbn:se:liu:diva-150231 (URN)10.1007/s00167-018-4846-1 (DOI)000439446600026 ()29411079 (PubMedID)
Available from: 2018-08-22 Created: 2018-08-22 Last updated: 2019-04-09
Lindblom, H., Carlfjord, S. & Hägglund, M. (2018). Adoption and use of an injury prevention exercise program in female football: A qualitative study among coaches. Scandinavian Journal of Medicine and Science in Sports, 28(3), 1295-1303
Open this publication in new window or tab >>Adoption and use of an injury prevention exercise program in female football: A qualitative study among coaches
2018 (English)In: Scandinavian Journal of Medicine and Science in Sports, ISSN 0905-7188, E-ISSN 1600-0838, Vol. 28, no 3, p. 1295-1303Article in journal (Refereed) Published
Abstract [en]

This study focuses on an injury prevention exercise program (IPEP), Knee Control, which has been shown to reduce the incidence of acute knee injury in female adolescent football players. The aim was to explore the factors influencing coaches adoption and use of Knee Control within female football in Sweden. This was a qualitative study involving interviews with 20 strategically selected coaches for female football teams, predominantly adolescent teams. The semi-structured interview guide was influenced by the Health Belief Model, and an ecological perspective was adopted during the interviews. Interviews were analyzed with qualitative content analysis. The results illustrate the different influences that interact on adoption and use of Knee Control by coaches. The coaches described themselves as crucial for Knee Control adoption and use, but external facilitators and barriers such as resources for training, social support from other coaches, clubs and football associations and player buy-in were also described as important. Knee Control characteristics, such as how well the program fit the team, also influenced use of Knee Control. Many coaches modified the program to improve player buy-in and Knee Control fit. Such modifications may risk compromising the preventive effect but may increase feasibility, that is the ease of using Knee Control, and thereby long-term use. These findings may guide the design and delivery of future IPEPs, and improve use of Knee Control, for example, by expanding the program to fit different target groups and supporting coaches and players in the use of Knee Control.

Place, publisher, year, edition, pages
Wiley-VCH Verlagsgesellschaft, 2018
Keywords
dissemination; implementation; neuromuscular training; team sports; youth
National Category
Sport and Fitness Sciences
Identifiers
urn:nbn:se:liu:diva-147150 (URN)10.1111/sms.13012 (DOI)000426529300058 ()29130536 (PubMedID)
Note

Funding Agencies|Swedish Research Council for Sport Science; Region Ostergotland

Available from: 2018-04-20 Created: 2018-04-20 Last updated: 2019-04-09
Reichenpfader, U., Wickström, A., Nilsen, P., Abrandt Dahlgren, M. & Carlfjord, S. (2018). Medi(c)ation work in the emergency department: Making standardized practice work. Professions & Professionalism, 8(2), Article ID e2298.
Open this publication in new window or tab >>Medi(c)ation work in the emergency department: Making standardized practice work
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2018 (English)In: Professions & Professionalism, ISSN 1893-1049, E-ISSN 1893-1049, Vol. 8, no 2, article id e2298Article in journal (Refereed) Published
Abstract [en]

Medication review, the systematic examination of an individual patient’s medicines in order to improve medication therapy, has been advocated as an important patient safety measure. Despite widespread use, little is known about how medication review is conducted when implemented in routine health care. Drawing from an ethnographic case study in a Swedish emergency department and using a practice-based approach, we examine how medication review is practically accomplished and how knowledge is mobilized in everyday practice. We show how physicians construct and negotiate medication safety through situated practices and thereby generate knowledge through mundane activities. We illustrate the centrality of practitioners’ collective reflexive work when co-constructing meaning and argue here that practitioners’ local adaptations can serve as important prerequisites to make “standardized” practice function in everyday work. Organizations need to build a practical capacity to support practitioners’ work-based learning in messy and time-pressured  health care  settings.

Keywords
practice-based study, ethnography, practical knowledge, professional practice, medication review, implementation, patient safety
National Category
Other Health Sciences
Identifiers
urn:nbn:se:liu:diva-151815 (URN)10.7577/pp.2298 (DOI)
Available from: 2018-10-04 Created: 2018-10-04 Last updated: 2019-05-01
Reichenpfader, U., Wickström, A., Abrandt Dahlgren, M., Nilsen, P. & Carlfjord, S. (2018). Our surgeons want this to be short and simple: practices of in-hospital medication review as coordinated sociomaterial actions. Studies in Continuing Education, 40(3), 323-336
Open this publication in new window or tab >>Our surgeons want this to be short and simple: practices of in-hospital medication review as coordinated sociomaterial actions
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2018 (English)In: Studies in Continuing Education, ISSN 0158-037X, E-ISSN 1470-126X, Vol. 40, no 3, p. 323-336Article in journal (Refereed) Published
Abstract [en]

Medication review, a systematic assessment of a patients medicines by a health care professional, is intended to prevent medication-related harms. A critical element of medication review concerns whether medication review is conducted in a coordinated way. This article draws from a case example of implementing medication review in two surgical wards of a Swedish regional hospital and aims to analyse how medication review is being accomplished with respect to the coordination of its actions. Using a practice-based ethnographic approach, we present several coordination mechanisms by illustrating how practices are connected to materials involved in medication review. Also, we show how common orientations, ends, and understandings expressed in different medication review practices contribute to the coordination of the practices. In conclusion, this article highlights the complexity of establishing and sustaining medication review as a coordinated practice in routine health care. By closely examining sociomaterial connections, this article sheds new light on the neglected issue of artefacts and arrangements in constituting and transforming a highly complex medication practice.

Place, publisher, year, edition, pages
ROUTLEDGE JOURNALS, TAYLOR & FRANCIS LTD, 2018
Keywords
Ethnography; practice theory; sociomateriality; coordination; medication safety; implementation
National Category
Pedagogy
Identifiers
urn:nbn:se:liu:diva-151230 (URN)10.1080/0158037X.2018.1458710 (DOI)000442433800007 ()
Note

Funding Agencies|Swedish Research Council for Health, Working Life and Welfare (Forte) [2014-4657]; Medical Research Council of Southeast Sweden (FORSS) [FORSS-476971, FORSS-568651]; County Council of Ostergotlands patient safety research fund (Region Ostergotlands Medel for Patientsakerhetsforskning) [LIO-533151, LIO-626451]

Available from: 2018-09-13 Created: 2018-09-13 Last updated: 2019-04-10
Carlfjord, S., Nilsing-Strid, E., Johansson, K., Holmgren, T. & Öberg, B. (2018). Practitioner experiences from the structured implementation of evidence-based practice in primary care physiotherapy: A qualitative study. Journal of Evaluation In Clinical Practice
Open this publication in new window or tab >>Practitioner experiences from the structured implementation of evidence-based practice in primary care physiotherapy: A qualitative study
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2018 (English)In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753Article in journal (Refereed) Epub ahead of print
Abstract [en]

Rationale, Aims, and Objectives

To provide best available care, the practitioners in primary health care (PHC) must have adequate knowledge about effective interventions. The implementation of such interventions is challenging. A structured implementation strategy developed by researchers at Linköping University, Sweden, was used for the implementation of an evidence‐based assessment and treatment programme for patients with subacromial pain among physiotherapists in PHC. To further develop strategies for implementation of evidence‐based practices, it was deemed important to study the implementation from the practitioners' perspective. The aim of this study was to explore the practitioners' experiences from the implementation.

Methods

A qualitative design with focus group discussions was applied. The implementation in terms of perceptions of process and outcome was evaluated by focus group discussions with, in total, 16 physiotherapists in the target group. Data were analysed using the method qualitative content analysis.

Results

The components of the strategy were viewed positively, and the applicability and evidence base behind the programme were appreciated. The programme was perceived to be adopted, and the practitioners described a changed behaviour and increased confidence in handling patients with subacromial pain. Both patient‐ and provider‐related challenges to the implementation were mentioned.

Conclusions

The practitioners' experiences from the implementation were mainly positive. A strategy with collaboration between academy and practice, and with education and implementation teams as facilitators, resulted in changes in practice. Critical voices concerned interprofessional collaboration and that the programme was focused explicitly on the shoulder, not including other components of physical function.

Place, publisher, year, edition, pages
Wiley-Blackwell Publishing Inc., 2018
Keywords
exercise; implementation; physiotherapy; primary health care; qualitative study; shoulder pain
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-155031 (URN)10.1111/jep.13034 (DOI)30246293 (PubMedID)2-s2.0-85053702144 (Scopus ID)
Available from: 2019-03-11 Created: 2019-03-11 Last updated: 2019-05-02Bibliographically approved
Danielsson, M., Nilsen, P., Rutberg, H. & Carlfjord, S. (2018). The professional culture among physicians in Sweden: potential implications for patient safety. BMC Health Services Research, 18(1), Article ID 543.
Open this publication in new window or tab >>The professional culture among physicians in Sweden: potential implications for patient safety
2018 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, no 1, article id 543Article in journal (Refereed) Published
Abstract [en]

Background

Patient safety culture, i.e. a subset of an organization’s culture, has become an important focus of patient safety research. An organization’s culture consists of many cultures, underscoring the importance of studying subcultures. Professional subcultures in health care are potentially important from a patient safety point of view. Physicians have an important role to play in the effort to improve patient safety. The aim was to explore physicians’ shared values and norms of potential relevance for patient safety in Swedish health care.

Methods

Data were collected through group and individual interviews with 28 physicians in 16 semi-structured interviews, which were recorded and transcribed verbatim before being analysed with an inductive approach.

Results

Two overarching themes, “the competent physician” and “the integrated yet independent physician”, emerged from the interview data. The former theme consists of the categories Infallible and Responsible, while the latter theme consists of the categories Autonomous and Team player. The two themes and four categories express physicians’ values and norms that create expectations for the physicians’ behaviours that might have relevance for patient safety.

Conclusions

Physicians represent a distinct professional subculture in Swedish health care. Several aspects of physicians’ professional culture may have relevance for patient safety. Expectations of being infallible reduce their willingness to talk about errors they make, thus limiting opportunities for learning from errors. The autonomy of physicians is associated with expectations to act independently, and they use their decisional latitude to determine the extent to which they engage in patient safety. The physicians perceived that organizational barriers make it difficult to live up to expectations to assume responsibility for patient safety. Similarly, expectations to be part of multi-professional teams were deemed difficult to fulfil. It is important to recognize the implications of a multi-faceted perspective on the culture of health care organizations, including physicians’ professional culture, in efforts to improve patient safety.

Place, publisher, year, edition, pages
BioMed Central, 2018
Keywords
Physicians, Patient safety, Safety culture, Qualitative research
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-149792 (URN)10.1186/s12913-018-3328-y (DOI)000438433700009 ()29996832 (PubMedID)2-s2.0-85049780334 (Scopus ID)
Available from: 2018-07-23 Created: 2018-07-23 Last updated: 2019-04-09Bibliographically approved
Peterson, A., Carlfjord, S., Schaller, A., Gerdle, B. & Larsson, B. (2017). Using education and support strategies to improve the way nurses assess regular and transient pain: A quality improvement study of three hospitals. Scandinavian Journal of Pain, 16(1), 15-21
Open this publication in new window or tab >>Using education and support strategies to improve the way nurses assess regular and transient pain: A quality improvement study of three hospitals
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2017 (English)In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 16, no 1, p. 15-21Article in journal (Refereed) Published
Abstract [en]

Background and aims

Systematic and regular pain assessment has been shown to improve pain management. Well-functioning pain assessments require using strategies informed by well-established theory. This study evaluates documented pain assessments reported in medical records and by patients, including reassessment using a Numeric Rating Scale (NRS) after patients receive rescue medication.

Methods

Documentation surveys (DS) and patient surveys (PS) were performed at baseline (BL), after six months, and after 12 months in 44 in-patient wards at the three hospitals in Östergötland County, Sweden. Nurses and nurse assistants received training on pain assessment and support. The Knowledge to Action Framework guided the implementation of new routines.

Results

According to DS pain assessment using NRS, pain assessment increased significantly: from 7% at baseline to 36% at 12 months (p < 0.001). For PS, corresponding numbers were 33% and 50% (p < 0.001). According to the PS, the proportion of patients who received rescue medication and who had been reassessed increased from 73% to 86% (p = 0.003). The use of NRS to document pain assessment after patients received rescue medication increased significantly (4% vs. 17%; p < 0.001).

Conclusions

After implementing education and support strategies, systematic pain assessment increased, an encouraging finding considering the complex contexts of in-patient facilities. However, the achieved assessment levels and especially reassessments related to rescue medication were clinically unsatisfactory. Future studies should include nursing staff and physicians and increase interactivity such as providing online education support. A discrepancy between documented and reported reassessment in association with given rescue medication might indicate that nurses need better ways to provide pain relief.

Implications

The fairly low level of patient-reported pain via NRS and documented use of NRS before and 12 months after the educational programme stresses the need for education on pain management in nursing education. Implementations differing from traditional educational attempts such as interactive implementations might complement educational programmes given at the work place. Standardized routines for pain management that include the possibility for nurses to deliver pain medication within well-defined margins might improve pain management and increase the use of pain assessments. Further research is needed that examines the large discrepancy between patient-reported pain management and documentation in the medical recording system of transient pain.

Place, publisher, year, edition, pages
Elsevier, 2017
Keywords
Assessment; Documentation; Implementation; Observation; Pain
National Category
Nursing
Identifiers
urn:nbn:se:liu:diva-145287 (URN)10.1016/j.sjpain.2017.01.013 (DOI)28850394 (PubMedID)2-s2.0-85013638729 (Scopus ID)
Available from: 2018-02-23 Created: 2018-02-23 Last updated: 2018-03-01Bibliographically approved
Ridelberg, M., Roback, K., Nilsen, P. & Carlfjord, S. (2016). Patient safety work in Sweden: quantitative and qualitative analysis of annual patient safety reports.. BMC Health Services Research, 16(98), 1-9
Open this publication in new window or tab >>Patient safety work in Sweden: quantitative and qualitative analysis of annual patient safety reports.
2016 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 16, no 98, p. 1-9Article in journal (Refereed) Published
Abstract [en]

Background

There is widespread recognition of the problem of unsafe care and extensive efforts have been made over the last 15 years to improve patient safety. In Sweden, a new patient safety law obliges the 21 county councils to assemble a yearly patient safety report (PSR). The aim of this study was to describe the patient safety work carried out in Sweden by analysing the PSRs with regard to the structure, process and result elements reported, and to investigate the perceived usefulness of the PSRs as a tool to achieve improved patient safety.

Methods

The study was based on two sources of data: patient safety reports obtained from county councils in Sweden published in 2014 and a survey of health care practitioners with strategic positions in patient safety work, acting as key informants for their county councils. Answers to open-ended questions were analysed using conventional content analysis.

Results

A total of 14 structure elements, 31 process elements and 23 outcome elements were identified. The most frequently reported structure elements were groups devoted to working with antibiotics issues and electronic incident reporting systems. The PSRs were perceived to provide a structure for patient safety work, enhance the focus on patient safety and contribute to learning about patient safety.

Conclusion

Patient safety work carried out in Sweden, as described in annual PSRs, features a wide range of structure, process and result elements. According to health care practitioners with strategic positions in the county councils’ patient safety work, the PSRs are perceived as useful at various system levels.

Place, publisher, year, edition, pages
BioMed Central, 2016
Keywords
Healthcare, Patient safety, Patient safety reports
National Category
Social and Clinical Pharmacy Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-127298 (URN)10.1186/s12913-016-1350-5 (DOI)000372864800001 ()27001079 (PubMedID)
Note

Funding agencies:  Swedish National Board of Health and Welfare

Available from: 2016-04-19 Created: 2016-04-19 Last updated: 2018-01-10Bibliographically approved
Carlfjord, S. & Festin, K. (2015). Association between organizational climate and perceptions and use of an innovation in Swedish primary health care: a prospective study of an implementation. BMC Health Services Research, 15(364)
Open this publication in new window or tab >>Association between organizational climate and perceptions and use of an innovation in Swedish primary health care: a prospective study of an implementation
2015 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 15, no 364Article in journal (Refereed) Published
Abstract [en]

Background: There is a need for new knowledge regarding determinants of a successful implementation of new methods in health care. The role of a receptive context for change to support effective diffusion has been underlined, and could be studied by assessing the organizational climate. The aim of this study was to assess the association between organizational climate when a computer-based lifestyle intervention tool (CLT) was introduced in primary health care (PHC) and the implementation outcome in terms of how the tool was perceived and used after 2 years. Methods: The CLT was offered to 32 PHC units in Sweden, of which 22 units agreed to participate in the study. Before the introduction of the CLT, the creative climate at each participating unit was assessed. After 24 months, a follow-up questionnaire was distributed to the staff to assess how the CLT was perceived and how it was used. A question on the perceived need for the CLT was also included. Results: The units were divided into three groups according to the creative climate: high, medium and low. The main finding was that the units identified as having a positive creative climate demonstrated more frequent use and more positive perceptions regarding the new tool than those with the least positive creative climate. More positive perceptions were seen at both individual and unit levels. Conclusions: According to the results from this study there is an association between organizational climate at baseline and implementation outcome after 2 years when a tool for lifestyle intervention is introduced in PHC in Sweden. Further studies are needed before measurement of organizational climate at baseline can be recommended in order to predict implementation outcome.

Place, publisher, year, edition, pages
BIOMED CENTRAL LTD, 2015
National Category
Other Social Sciences
Identifiers
urn:nbn:se:liu:diva-121896 (URN)10.1186/s12913-015-1038-2 (DOI)000361290500001 ()26358045 (PubMedID)
Note

Funding Agencies|Swedish Council for Working Life and Social Research (FAS)

Available from: 2015-10-13 Created: 2015-10-12 Last updated: 2017-12-01
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0001-9116-8156

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