Patient involvement in quality improvement - a 'tug of war' or a dialogue in a learning process to improve healthcare?

BACKGROUND: Co-production and co-design approaches to quality improvement (QI) efforts are gaining momentum in healthcare. Yet, these approaches can be challenging, not least when it comes to patient involvement. The aim of this study was to examine what might influence QI efforts in which patients are involved, as experienced by the patients and the healthcare professionals involved. METHODS: This study involved a qualitative design inspired by the constructivist grounded theory. In one mid-sized Swedish hospital's patient process organisation, data was collected from six QI teams that involved patients in their QI efforts, addressing care paths for patients with transient, chronic and/or multiple parallel diagnoses. Field notes were collected from participant observations during 53 QI team meetings in three of the six patient processes. Individual, semi-structured interviews were conducted with 12 patients and 12 healthcare professionals in all the six QI teams. RESULTS: Patients were involved in QI efforts in different ways. In three of the QI teams, patient representatives attended team meetings regularly. One team consulted patient representatives on a single occasion, one team collected patient preferences structurally from individual interviews with patients, and one team combined interviews and a workshop with patients. The patients' and healthcare professionals' expressions of what might influence the QI efforts involving patients were similar in several ways. QI team members emphasized the importance of organisational structure and culture. Furthermore, they expressed a desire for ongoing interaction between patients and healthcare professionals in healthcare QI. CONCLUSIONS: QI team members recognised continuous dialogue and collective thinking by the sharing of experiences and preferences between patients and healthcare professionals as essential for achieving better matches between healthcare resources and patient needs in their QI efforts. Significant structural and cultural aspects of performing QI in complex hospital organisations were considered to be obstructions to progress. Therefore, to sustain learning and behaviour change through QI efforts at the team level, a deeper understanding of how structural and cultural aspects of QI promote or prevent success appears essential.

The double spiral of change--experiences of privatization in a Swedish hospital.

UNLABELLED: Privatization is a trend in countries with a public health system. It involves organizational change, a cultural transformation and changes for the employees as well as a more strictly controlled work. The objective of this study is to describe, analyse and interpret how privatization is perceived by the employees of a health care organization in Sweden. METHODOLOGY: In-depth interviews have been performed with physicians, paramedics, secretaries, nurses, assistant nurses and local managers, in all 14 respondents, after a private entrepreneur had taken over the management of a hospital. The interviews were tape-recorded and have been analysed and interpreted following a grounded theory approach. FINDINGS: The transcribed interviews show that trust is a core category and linked with emotions, commitment and security. The analysis shows that employees' experience of privatization within a health care organization differs and is full of nuances and complexities. CONCLUSION: A simultaneous virtuous and a vicious circle of experiences and reactions may describe how employees experience privatization. It can also be concluded that leadership is an important factor in the success of organizational change.

Student nurses' experiences of the clinical learning environment in relation to the organization of supervision: a questionnaire survey.

AIM: The aim was to investigate student nurses' experiences of the clinical learning environment in relation to how the supervision was organized. BACKGROUND: The clinical environment plays an essential part in student nurses' learning. Even though different models for supervision have been previously set forth, it has been stressed that there is a need both of further empirical studies on the role of preceptorship in undergraduate nursing education and of studies comparing different models. METHOD: A cross-sectional study with comparative design was carried out with a mixed method approach. Data were collected from student nurses in the final term of the nursing programme at three universities in Sweden by means of a questionnaire. RESULTS: In general the students had positive experiences of the clinical learning environment with respect to pedagogical atmosphere, leadership style of the ward manager, premises of nursing, supervisory relationship, and role of the nurse preceptor and nurse teacher. However, there were significant differences in their ratings of the supervisory relationship (p<0.001) and the pedagogical atmosphere (p 0.025) depending on how the supervision was organized. Students who had the same preceptor all the time were more satisfied with the supervisory relationship than were those who had different preceptors each day. Students' comments on the supervision confirmed the significance of the preceptor and the supervisory relationship. CONCLUSION: The organization of the supervision was of significance with regard to the pedagogical atmosphere and the students' relation to preceptors. Students with the same preceptor throughout were more positive concerning the supervisory relationship and the pedagogical atmosphere.

Nursing students' assessment of the learning environment in different clinical settings.

INTRODUCTION: Nursing students perform their clinical practice in different types of clinical settings. The clinical learning environment is important for students to be able to achieve desired learning outcomes. Knowledge is lacking about the learning environment in different clinical settings. AIM: The aim was to compare the learning environment in different clinical settings from the perspective of the nursing students. DESIGN: A cross-sectional study with comparative design was conducted. METHOD: Data was collected from 185 nursing students at three universities by means of a questionnaire involving the Clinical Learning Environment, Supervision and Nurse Teacher (CLES + T) evaluation scale. An open-ended question was added in order to ascertain reasons for dissatisfaction with the clinical placement. RESULTS: The nursing students' satisfaction with the placement did not differ between clinical settings. However, those with clinical placement in hospital departments agreed more strongly that sufficient meaningful learning situations occurred and that learning situations were multi-dimensional. Some students reported that the character of the clinical setting made it difficult to achieve the learning objectives. CONCLUSION: In the planning of the clinical placement, attention must be paid to whether the setting offers the student a meaningful learning situation where the appropriate learning outcome may be achieved.

Balancing involvement: employees' experiences of merging hospitals in Sweden.

BACKGROUND: The health care of today stands in front of demands on financial and structural changes. New technology and global economy are forces driving on the change process. AIMS: The aim of this study is to describe and broaden the understanding of the employees' experience of being involved in a merger between two health care districts in Sweden. METHODS: This study was carried out from a qualitative approach according to the grounded theory tradition. From a theme guide with specific questions, 31 interviews were carried out with employees working in the health care. FINDINGS: Five categories emerged from the body of interviews: balancing involvement, trust respect, challenge and commitment. Balancing involvement was defined as an overall core category related to the other categories. The categories trust, respect, challenge and commitment were related to subcategories and affected the core category balancing involvement. CONCLUSIONS: The overall findings point to the importance of balancing the employees' involvement in order to reach goal fulfilment change in a merger process.