Background: Developing and implementing home telehealth (HTH) services for patients with chronic conditions is a challenge. HTH services provide continuous and integrated care to patients, but very often pilot projects face non-adoption and abandonment issues. Change processes in healthcare are often complex and require learning to adapt to non-linear and unpredictable events. Complexity science can thus provide a complementary view to the predominant Quality Improvement (QI) approach in healthcare. In this study of two pilot projects in a Swedish hospital, we explore how a theory-driven approach can be used (a) to support the development of a self-monitoring HTH service in hospital care and (b) to evaluate staff and patients' experiences from early adoption.

Methods: To plan and evaluate the service for the recipients (i.e., patients and healthcare providers), we used the Plan-Do-Study-Act (PDSA) tool in combination with two complexity-informed frameworks: the Non-adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework, and the joint Complexity Assessment Tool (CAT). The theory-informed development process led to two pilot projects of an HTH service for patients with heart failure and COVID-19. We collected data from multiple sources (project documents, a survey on readiness for change among staff, and semi-structured interviews with patients and staff) and analyzed the data using descriptive statistics and qualitative content analysis with a deductive approach.

Results: Patients and staff perceived the services as valuable as they enabled rapid feedback, and improved communication and collaboration between patients and healthcare providers. Yet, despite the extensive development efforts, there was a perceived gap between how individuals valued the service and the capacity of adopters, the organization, and the wider system to effectively integrate these services into routine care.

Conclusions: The combined use of PDSA, NASSS, and CAT can support the development and evaluation of HTH services that are perceived as valuable by individual patients and staff. For successful adoption, the value for individuals must be supported by organizational efforts to learn how to integrate new routines and tasks into clinical practice and daily life, and how to coordinate multiple providers within and outside the hospital walls.

BACKGROUND: The demographic change of an aging population constitutes a challenge for primary care organizations worldwide. The systematic implementation of preventative and proactive care models is needed to cope with increased care demands.

OBJECTIVE: To investigate the organizational readiness in primary care to implement a new care model to prevent hospitalization among frail older adults.

METHOD: Individual qualitative interviews with health care staff investigated organizational readiness at seven primary care units in Sweden. A semi-structured interview guide was used during the interviews and included broad questions on individual and collective readiness to change. Directed content analysis and organizational readiness to change theory were used in data analysis.

RESULTS: Positive beliefs among staff such as perceived benefits and compatibility with existing values contributed to a strong commitment to implement the new care model. However, perceptions such as unclear task demands, limited resources and concerns about new collaborative structures challenged implementation.

CONCLUSIONS: The findings emphasize implementation as an inter-organizational phenomenon, especially for holistic practices that span across multiple health care providers and disciplines. Furthermore, implementing care models in healthcare may require a change of culture as much as a change of practice.

Background: Men appear less interested than women in engaging in health-promoting programs. We investigated the feasibility and proof of concept of a novel intervention program targeting male supporters of professional sports clubs. Methods: Our intervention is called ViSiT and the target population in this study was overweight male supporters aged 35 - 65 years with a body mass index ≥ 28 kg/m², recruited through one football and one ice-hockey club. The participants (n = 22) participated in a 12-week lifestyle intervention with a 52-week follow-up. Body fat was assessed using bioelectrical impedance analysis. Results: The retention rate was high with 21 participants completing the 12-week program and 17 attending at least 10 of 12 sessions. Mean (standard deviation) body weight and fat reduction after 12 weeks was 8.2 (4.6) kg and 6.6 (3.6) kg, respectively. At 52 weeks, body weight and fat reduction were maintained at 6.4 (6.7) kg and 4.5 (6.5) kg. Even after 52 weeks follow-up, the participants appreciated most components of the ViSiT program and perceived the ViSiT program to have high impact on most health-related aspects investigated. Conclusions: The ViSiT program demonstrated a successful retention rate and clinically relevant weight reduction in Swedish overweight men. The maintenance of bodyweight reduction and positive experience after 1 year indicate a long-term effect of the ViSiT concept.

Introduction

The aim of this study was to evaluate participants’ and managers’ experience of the design and content of an education programme. The Knowledge to Action (KTA) framework was applied to identify the steps of knowledge creation and action in the education programme.

Methods

Data were collected from 18 participants representing two groups: participants in the intervention and supervisors and managers. Two focus groups took place: two with participants in the intervention (4 and 3 in each) and one with eleven managers.

Results

All steps in the KTA framework were identified and discussed from several aspects. The importance of selecting projects that were relevant and added value in their clinics was mentioned by all participants. The participants also mentioned that after the education, they had further understanding and increased skills in how to be active and perform continuous improvement projects. The step in the KTA process regarding how to adapt knowledge to local context was not discussed explicitly by the participants or managers.

Discussion

Education in research methods and performing improvement projects to develop the clinic creates a more positive attitude to working with continuous improvement. The participant’s self-esteem and knowledge increased regarding how to work with improvements. It is important to have the manager’s support to perform a project. Emphasis was on knowledge inquiry and synthesis and presenting the results with or without possible solutions. The participants and managers talked about barriers and knowledge use more generally and at an organizational level. This means that the participants did not gain the last bit of nowledge needed to put the action into practice. This implies that the problem regarding lack of implementation skills in health care might remain.

Addressing the poor physical health of people with severe mental illness (SMI) occurs within a complex mix of individual requirements. People with SMI often have demanding health and illness management workloads, which they are required to perform on a daily basis. Most clinical studies lack information on how much people are affected by the side effects they experience and how to manage these problems. Mental health staff often consider that their primary target is to reduce psychotic symptoms rather than health promotion. Therefore, the objective of this qualitative study was to describe the current experience of people with SMI, with the view to exploring ways that they might be involved in managing their physical health. Thirty-two people with lived experience of mental illness within a defined geographic area in Queensland, Australia, participated in semi-structured face-to-face interviews. Data were digitally recorded, transcribed verbatim and analysed using qualitative content analysis. Four key areas in which people with SMI were able to be involved in their health were identified: care continuity within a fragmented care system; medication management; credibility and being mastered; and self-mastery and self-managing health. Shared decision making in mental health care can contribute to equality, control and recovery. Involving people with SMI in shared decision making will contribute positively to their overall health. However, substantial changes are required to shift the health system from a traditional “health professional as expert” approach to one with the patients in the centre. © 2016 Elsevier GmbH

Research developments have led to increased opportunities for the use of improved diagnostic and treatment methods in physiotherapy and other areas of health care. The emergence of the evidence-based practice (EBP) movement has led to higher expectations for a more research-informed health care practice that integrates the best available research evidence with clinical experience and patient priorities and values. Physiotherapy research has grown exponentially, contributing to an increased interest in achieving a more evidence-based physiotherapy practice. However, implementation research has identified many individual and contextual barriers to research use. Strategies to achieve a more EBP tend to narrowly target individual practitioners to influence their knowledge, skills and attitudes concerning research use. However, there is an emerging recognition that contextual conditions such as leadership and culture are critical to successfully implementing EBP.

Against this background, the overall aim of this thesis was to explore conditions at different levels, from the individual level to the organizational level and beyond, for the use of research and implementation of an evidence-based physiotherapy practice. The thesis consists of four interrelated papers that address various aspects of the aim. Individual and focus group interviews were conducted with physiotherapists and managers within physiotherapy in various county councils in Sweden between 2011 and 2014. Data were analysed using qualitative content analysis, direct content analysis and hermeneutics.

It was found that many different types of motivation underlie physiotherapists’ use of research in their clinical practice, from amotivation (i.e. a lack of intention to engage in research use) to intrinsic motivation (research use is perceived as interesting and satisfying in itself). Most physiotherapists tend to view research use in favourable terms. Physiotherapists’ participation in a research project can yield many individual learning experiences that might contribute to a more research-informed physiotherapy practice. However, organizational learning was more limited. Numerous conditions at different levels (individual, workplace and extra-organizational levels) provide support for physiotherapists’ use of research in their clinical practice. However, physiotherapy leaders appear to contribute to a modest degree to establishing a culture that is conducive to implementing EBP in physiotherapy practice. Instead, EBP issues largely seem to depend on committed individual physiotherapists who keep to up to date with research in physiotherapy and inform colleagues about the latest research findings.

Background: Research in physiotherapy has increased rapidly over the last decade, yet studies have shown that many practice decisions continue to be based on knowledge obtained during initial physiotherapy education and/or personal experience, rather than findings from research. Both barriers and facilitators to achieving a more evidence-based practice (EBP) in physiotherapy have been identified. Leadership is one facilitator that has been recognized to have an important influence on the implementation of EBP in various settings. Our aim was to explore how physiotherapy leaders in Sweden influence the culture for implementation of evidence-based physiotherapy practice.

Methods: Nine interviews with managers of physiotherapy clinics were conducted in various settings in Sweden. Data were analysed using qualitative analysis and a framework developed by Schein (Schein EH. Organizational culture and leadership. 4th ed. San Francisco, CA: Jossey-Bass; 2010) was applied.

Results: The framework identifies a number mechanisms by which leaders can influence the culture of an organization and/or groups within an organization. The mechanisms of paying attention to, measuring and controlling on a regular basis as well as deliberate role modelling, teaching and coaching did have some relevance. However, EBP issues seemed to depend on committed individuals, often younger physiotherapists, who were interested in research.

Conclusions: Overall, there was limited relevance for most of the embedding mechanisms. The findings suggest that physiotherapy leaders in Sweden contribute to a modest degree to establishing a culture conducive to implementation of an evidence-based physiotherapy practice.

The need for evidence-based practice has been recognized by physiotherapy organizations over the past decades. Earlier studies have documented facilitators and barriers that affect the use and implementation of evidence-based practice. Less is known about what kind of interventions might be useful to implement evidence-based practice. This study explores what physiotherapists learn through participation in a research project relevant to their professional development towards achieving a more evidence-based physiotherapy practice. To what extent this learning was transferred to colleagues for organizational learning is also examined. This study was set in Sweden, where health care is publicly funded. Patients do not need a referral from a physician to consult a physiotherapist. Eleven interviews were conducted with physiotherapists who had participated in a randomized, controlled, multicenter, physiotherapy intervention investigating neck-specific exercise for patients with whiplash disorder. Gadamer’s hermeneutics was used to analyze the data. The physiotherapists described a range of learning experiences from their project participation, including instrumental learning (the concrete application of knowledge to achieve changes in practice) and conceptual learning (changes in knowledge, understanding or attitudes). The research project enabled the physiotherapists to develop new treatment techniques for broader application and extend their competence in techniques already known (instrumental learning). The physiotherapists believed that project participation enhanced their overall competence as physiotherapists, increased their job motivation and strengthened their self-confidence and self-efficacy (conceptual learning). Physiotherapists’ participation in the research project yielded many individual learning experiences, fostered positive attitudes to research and was conducive to achieving a more research-informed physiotherapy practice. Participation was associated with a deeper understanding of the challenges involved in conducting research. The transfer from indi-

Physiotherapists are generally positive to evidence-based practice (EBP) and the use of research in clinical practice, yet many still base clinical decisions on knowledge obtained during their initial education and/or personal experience. Our aim was to explore motivations behind physiotherapists use of research in clinical practice. Self-Determination Theory was applied to identify the different types of motivation for use of research. This theory posits that all behaviours lie along a continuum of relative autonomy, reflecting the extent to which a person endorses their actions. Eleven focus group interviews were conducted, involving 45 physiotherapists in various settings in Sweden. Data were analysed using qualitative content analysis and the findings compared with Self-Determination Theory using a deductive approach. Motivations underlying physiotherapists use of research in clinical practice were identified. Most physiotherapists expressed autonomous forms of motivation for research use, but some exhibited more controlled motivation. Several implications about how more evidence-based physiotherapy can be achieved are discussed, including the potential to tailor educational programs on EBP to better account for differences in motivation among participants, using autonomously motivated physiotherapists as change agents and creating favourable conditions to encourage autonomous motivation by way of feelings of competence, autonomy and a sense of relatedness.

Purpose – The purpose of this paper is to contribute to knowledge about dissemination strategies for Lean thinking throughout multiple healthcare organisations.

Design/methodology/approach – The Östergötland county council, Sweden (CCÖ ) was chosenas a case study for an healthcare Lean-thinking dissemination strategies. Document analysis and interviews were used and results were compared with similar strategies employed by staff at the National Health Service Institute for Innovation (NHSI) and improvement in Great Britain and the Odense University Hospital in Denmark.

Findings – The Lean improvement programme was introduced to tackle challenges such as anageing society, rising care expectations and budgetary and economic constraints. It was designedas a long-term programme to create added value for patients and employee involvement. The dissemination strategy was: forming clear visions and objectives; piloting; training potential adopters; and formal dissemination. The CCÖ strategy was focused primarily on managers and was not meant to involve all staff until the implementation stage. Staff at the NHS attempted to address nurses’ needs during dissemination, which questioned whether the CCÖ managers’ dissemination strategy is sustainable.

Practical implications – This paper inspires healthcare managers and decision makers who aim to disseminate Lean production in their organisations.

Originality/value – There are many case studies describing Lean implementation in single healthcare organisations, but little is known about effective dissemination and implementation strategies in large healthcare systems. The authors, therefore, suggest activities for developing and implementing dissemination strategies in multiple healthcare organisations.