Mechanisms for co-designing and co-producing health and social care: a realist synthesis.

OBJECTIVES: Analyse reported processes of co-design and co-production in the context of health and social care to explore the underlying mechanisms that enable inclusive and reciprocal engagement. SEARCH STRATEGY: Peer review research was obtained from a prior scoping review searching eight databases consisting of all methodologies relevant to co-design or co-production in the context of health and social care services and involving service-users. METHODS OF SELECTION: Articles were included for synthesis if they reported a process of dialogue, with mutuality, insight and clarification in their engagement process. Ninety-three peer-review articles informed our programme theory development. ANALYSIS: Data relating to co-design and co-production processes were extracted and analysed through inductive, abductive, and deductive analysis leading to the development of an initial programme theory. MAIN RESULTS: This realist synthesis finds that co-design and co-production can occur at different times, in part or all of the research and participatory process. There is an over reliance on the term 'co-design' or 'co-production' to convey complex engagement or participatory processes. We identified six mechanisms (intention, assets, dialogue, documentation, interpretation and understanding). Interaction between these six identified mechanisms in context, even if only brief, is important for supporting meaningful engagement, alignment and agreement within a co-design or co-production process. IMPLICATIONS FOR PRACTICE: The initial programme theory presented in this article provides clarity by identifying essential mechanisms which can guide the design and implementation of a range of participatory approaches. Rather than relying on a single label to convey complex participatory methods or processes, the values and principles of co-design or co-production, in combination with this programme theory, could be applied to guide implementation and reporting of specific activities within a range of research or participatory methods. PATIENT AND PUBLIC CONTRIBUTION: The initial programme theory was presented and piloted in a series of collaborative workshops between May 2023 and March 2024 with patient and public contributors, health professionals and researchers. This engagement process is currently underway to refine the programme theory and it is anticipated that this next phase will be completed in September 2024.

Applying models of co-production in the context of health and well-being. A narrative review to guide future practice.

Recent years have seen a dramatic growth in interest in the nature and extent of co-production in the health and social care sectors. Due to the proliferation of work on co-production, there is variation in practice in how co-production is defined, understood, and used in practice. We conducted a narrative review to explore, and provide an overview of, which models of health and social care co-production have been developed, applied, and critiqued over recent decades. Seventy-three peer-reviewed articles met our inclusion criteria. In this set of articles, we identified three broad types of models: conceptual/theoretical, practice-oriented, and presenting a typology. We found that practice-oriented models, predominantly from the Health Services Research and Quality Improvement literature, had largely not drawn on conceptual/theoretical models from the disciplinary fields of Public Administration & Management and Sociology. In particular, they have largely neglected theoretical perspectives on relationships and power and agency in co-production work. The concepts of Service-Dominant Logic and Public Service-Dominant Logic as ways to think about the joint, collaborative process of producing new value, particularly in the context of the use of a service, have also been neglected. Our review has identified distinct literatures which have contributed a variety of models of health and social care co-production. Our findings highlight under-explored dimensions of co-production that merit greater attention in the health and social care contexts. The overview of models of co-production we provide aims to offer a useful platform for the integration of different perspectives on co-production in future research and practice in health and social care.

Adopting, implementing and assimilating coproduced health and social care innovations involving structurally vulnerable populations: findings from a longitudinal, multiple case study design in Canada, Scotland and Sweden.

BACKGROUND: Innovations in coproduction are shaping public service reform in diverse contexts around the world. Although many innovations are local, others have expanded and evolved over time. We know very little, however, about the process of implementation and evolution of coproduction. The purpose of this study was to explore the adoption, implementation and assimilation of three approaches to the coproduction of public services with structurally vulnerable groups. METHODS: We conducted a 4 year longitudinal multiple case study (2019-2023) of three coproduced public service innovations involving vulnerable populations: ESTHER in Jönköping Region, Sweden involving people with multiple complex needs (Case 1); Making Recovery Real in Dundee, Scotland with people who have serious mental illness (Case 2); and Learning Centres in Manitoba, Canada (Case 3), also involving people with serious mental illness. Data sources included 14 interviews with strategic decision-makers and a document analysis to understand the history and contextual factors relating to each case. Three frameworks informed the case study protocol, semi-structured interview guides, data extraction, deductive coding and analysis: the Consolidated Framework for Implementation Research, the Diffusion of Innovation model and Lozeau's Compatibility Gaps to understand assimilation. RESULTS: The adoption of coproduction involving structurally vulnerable populations was a notable evolution of existing improvement efforts in Cases 1 and 3, while impetus by an external change agency, existing collaborative efforts among community organizations, and the opportunity to inform a new municipal mental health policy sparked adoption in Case 2. In all cases, coproduced innovation centred around a central philosophy that valued lived experience on an equal basis with professional knowledge in coproduction processes. This philosophical orientation offered flexibility and adaptability to local contexts, thereby facilitating implementation when compared with more defined programming. According to the informants, efforts to avoid co-optation risks were successful, resulting in the assimilation of new mindsets and coproduction processes, with examples of how this had led to transformative change. CONCLUSIONS: In exploring innovations in coproduction with structurally vulnerable groups, our findings suggest several additional considerations when applying existing theoretical frameworks. These include the philosophical nature of the innovation, the need to study the evolution of the innovation itself as it emerges over time, greater attention to partnered processes as disruptors to existing power structures and an emphasis on driving transformational change in organizational cultures.

The complexity of leadership in coproduction practices: a guiding framework based on a systematic literature review.

BACKGROUND: As coproduction in public services increases, understanding the role of leadership in this context is essential to the tasks of establishing relational partnerships and addressing power differentials among groups. The aims of this review are to explore models of coproduction leadership and the processes involved in leading coproduction as well as, based on that exploration, to develop a guiding framework for coproduction practices. METHODS: A systematic review that synthesizes the evidence reported by 73 papers related to coproduction of health and welfare. RESULTS: Despite the fact that models of coleadership and collective leadership exhibit a better fit with the relational character of coproduction, the majority of the articles included in this review employed a leader-centric underlying theory. The practice of coproduction leadership is a complex activity pertaining to interactions among people, encompassing nine essential practices: initiating, power-sharing, training, supporting, establishing trust, communicating, networking, orchestration, and implementation. CONCLUSIONS: This paper proposes a novel framework for coproduction leadership practices based on a systematic review of the literature and a set of reflective questions. This framework aims to help coproduction leaders and participants understand the complexity, diversity, and flexibility of coproduction leadership and to challenge and enhance their capacity to collaborate effectively.

Measurement and outcomes of co-production in health and social care: a systematic review of empirical studies.

BACKGROUND: Co-production is promoted as an effective way of improving the quality of health and social care but the diversity of measures used in individual studies makes their outcomes difficult to interpret. OBJECTIVE: The objective is to explore how empirical studies in health and social care have described the outcomes of co-production projects and how those outcomes were measured. DESIGN AND METHODS: A scoping review forms the basis for this systematic review. Search terms for the concepts (co-produc* OR coproduc* OR co-design* OR codesign*) and contexts (health OR 'public service* OR "public sector") were used in: CINAHL with Full Text (EBSCOHost), Cochrane Central Register of Controlled trials (Wiley), MEDLINE (EBSCOHost), PsycINFO (ProQuest), PubMed (legacy) and Scopus (Elsevier). There was no date limit. Papers describing the process, original data and outcomes of co-production were included. Protocols, reviews and theoretical, conceptual and psychometric papers were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was followed. The Mixed Methods Appraisal Tool underpinned the quality of included papers. RESULTS: 43 empirical studies were included. They were conducted in 12 countries, with the UK representing >50% of all papers. No paper was excluded due to the Mixed Methods Quality Appraisal screening and 60% of included papers were mixed methods studies. The extensive use of self-developed study-specific measures hampered comparisons and cumulative knowledge-building. Overall, the studies reported positive outcomes. Co-production was reported to be positively experienced and provided important learning. CONCLUSIONS: The lack of common approaches to measuring co-production is more problematic than the plurality of measurements itself. Co-production should be measured from three perspectives: outputs of co-production processes, the experiences of participating in co-production processes and outcomes of co-production. Both self-developed study-specific measures and established measures should be used. The maturity of this research field would benefit from the development and use of reporting guidelines.

Treatment Patterns and Efficacy of Chemotherapy After Pembrolizumab in Advanced Urothelial Cancer-a Real-World Study in the pre-Antibody-Drug Conjugate Era.

BACKGROUND: Immune checkpoint inhibitors (ICIs) have been established as a routine treatment in patients with metastatic urothelial cancer (mUC). However, there has been no standard of care after progression on ICIs. We investigated real-world treatment patterns and efficacy of chemotherapy (CHT) after pembrolizumab, in the era before introduction of maintenance avelumab and antibody-drug conjugates (ADC). PATIENTS AND METHODS: An observational, retrospective study was conducted at twelve Nordic centers. Patients with mUC were treated according to investigator´s choice of CHT after pembrolizumab. Primary endpoint was overall response (ORR) and disease control rate (DCR); secondary endpoints were progression-free (PFS) and overall survival (OS). RESULTS: In total, 102 patients were included whereof 23 patients received CHT after pembrolizumab as second line treatment (subcohort A) and 79 patients in third line (subcohort B). Platinum-gemcitabine combinations were the most common regimens in subcohort A, and vinflunine in subcohort B. The ORR and DCR were 36% and 47%, respectively. Presence of liver metastases was independently associated with lower ORR and DCR. The PFS and OS were 3.3 months and 7.7 months, respectively. Eastern Cooperative Oncology Group Performance Status (ECOG PS) and number of previous cycles of pembrolizumab were found to be independent prognostic factors associated with OS. CONCLUSION: In a real-world setting, CHT showed clinically meaningful response rates and survival in mUC patients after progression with pembrolizumab. Clinical benefit may primarily be achieved in patients with favorable ECOG PS, in patients treated with > 6 cycles pembrolizumab as well as in patients without presence of liver metastases.

Toward a Values-Informed Approach to Complexity in Health Care: Hermeneutic Review.

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 work of first line managers - A key to resilience in manufacturing.

First-line managers (FLMs) have a vital role in developing stable output and organizational competitiveness through their ability to manage front-line operations in daily work. It is also well known that FLMs are strong determinants of good ergonomics and well-being for front-line staff. However, research focusing on how FLMs deal with their important role is lacking particularly regarding empirical studies. The focus here is how they deal with uncertainties and disruptive interruptions and develop more resilient performance in daily work - introduced in this article as resilient action strategies. This research uses two conceptual frameworks on resilient engineering for analysis of FLM's actions in daily work in two manufacturing companies, to explore how resilient action strategies can be organizationally supported. The study combines analysis of front-line activities with multilevel organizational support based on 30 semi-structured in-depth interviews with FLMs and support functions, 21 workshops as well as policy documents of the two companies. The analysis exemplifies how resilience engineering was enabled in practice in the organizations. The study contributes to the empirical understanding of how resilience can be organizationally supported in daily front-line work. Our results show that a developed and consistent infrastructure in companies promotes the emergence of resilient action strategies in front-line work. We propose an extended model for resilient front-line performance enhancement by including coordination as a linking aspect between the earlier suggested resilient potentials - anticipate, monitor, respond and learn. This highlights the importance of both organizational support and coordination between system levels to enable the development of resilient action strategies by FLMs.

Using stakeholders' experiences to redesign health services for persons living with heart failure: a case study protocol in a Swedish cardiac care setting.

INTRODUCTION: Clinical guidelines promote recognising persons with heart failure (referred to as PWHF) as coproducers of their own care. Coproduction of healthcare-involving PWHF, families and professionals in care processes-aims to promote the best possible health. Still, it is unclear how to coproduce heart failure (HF) care. This study explores whether and how Experience-Based Co-Design (EBCD) involving PWHF, family members and professionals can be undertaken online, in a Swedish cardiac care setting, to codesign improved experiences of HF care. METHODS AND ANALYSIS: In EBCD, stakeholders' experiences are solicited to redesign healthcare services. First, we will undertake a thematic analysis of field notes from consultations and filmed/audio-recorded interviews with PWHF (n=10-12). This analysis will identify 'touchpoints' (emotionally positive/negative events that shape overall service experiences), edited into a 'trigger film'. Next, a thematic analysis of family members' (n=10-12) and professionals' (n=10-12) interviews will identify key themes mirroring their experiences. Separate feedback events with each stakeholder group will confirm identified touchpoints and key themes and identify areas for HF care improvement. At a joint event, prompted by the 'trigger film', stakeholders will agree on one area for HF care improvement. A team including PWHF, family members and professionals, led by an improvement adviser, will then plan, design, implement and evaluate an improvement activity addressing the identified problem area. A deductive thematic analysis of field notes, project documentation and stakeholder focus group interviews, underpinned by MUSIQ, will identify how organisational conditions influence the process. Quantitative measurements, describing the results of the improvement activity, will be integrated with qualitative data to strengthen the case. To reduce resource intensity, we will use online tools during the process. ETHICS AND DISSEMINATION: The Swedish Ethical Review Authority approved the study in May 2021. The results will be disseminated through seminars, conference presentations and publications.

Mapping definitions of co-production and co-design in health and social care: A systematic scoping review providing lessons for the future.

OBJECTIVES: This study aimed to explore how the concepts of co-production and co-design have been defined and applied in the context of health and social care and to identify the temporal adoption of the terms. METHODS: A systematic scoping review of CINAHL with Full Text, Cochrane Central Register of Controlled Trials, MEDLINE, PsycINFO, PubMed and Scopus was conducted to identify studies exploring co-production or co-design in health and social care. Data regarding date and conceptual definitions were extracted. From the 2933 studies retrieved, 979 articles were included in this review. RESULTS: A network map of the sixty most common definitions and-through exploration of citations-eight definition clusters and a visual representation of how they interconnect and have informed each other over time are presented. Additional findings were as follows: (i) an increase in research exploring co-production and co-design in health and social care contexts; (ii) an increase in the number of new definitions during the last decade, despite just over a third of included articles providing no definition or explanation for their chosen concept; and (iii) an increase in the number of publications using the terms co-production or co-design while not involving citizens/patients/service users. CONCLUSIONS: Co-production and co-design are conceptualized in a wide range of ways. Rather than seeking universal definitions of these terms, future applied research should focus on articulating the underlying principles and values that need to be translated and explored in practice. PATIENT AND PUBLIC CONTRIBUTION: The search strategy and pilot results were presented at a workshop in May 2019 with patient and public contributors and researchers. Discussion here informed our next steps. During the analysis phase of the review, informal discussions were held once a month with a patient who has experience in patient and public involvement. As this involvement was conducted towards the end of the review, we agreed together that inclusion as an author would risk being tokenistic. Instead, acknowledgements were preferred. The next phase involves working as equal contributors to explore the values and principles of co-production reported within the most common definitions.

Swedish National Guidelines on Urothelial Carcinoma: 2021 update on non-muscle invasive bladder cancer and upper tract urothelial carcinoma.

OBJECTIVE: To overview the updated Swedish National Guidelines on Urothelial Carcinoma 2021, with emphasis on non-muscle-invasive bladder cancer (NMIBC) and upper tract urothelial carcinoma (UTUC). METHODS: A narrative review of the updated version of the Swedish National Guidelines on Urothelial Carcinoma 2021 and highlighting new treatment recommendations, with comparison to the European Association of Urology (EAU) guidelines and current literature. RESULTS: For NMIBC the new EAU 2021 risk group stratification has been introduced for non-muscle invasive bladder cancer to predict risk of progression and the web-based application has been translated to Swedish (https://nmibc.net.). For patients with non-BCG -responsive disease treatment recommendations have been pinpointed, to guide patient counselling in this clinical situation. A new recommendation in the current version of the guidelines is the introduction of four courses of adjuvant platinum-based chemotherapy to patients with advanced disease in the nephroureterectomy specimen (pT2 or higher and/or N+). Patients with papillary urothelial neoplasms with low malignant potential (PUNLMP) can be discharged from follow-up already after 3 years based on a very low subsequent risk of further recurrences. CONCLUSIONS: The current version of the Swedish national guidelines introduces a new risk-stratification model and follow-up recommendation for NMIBC and adjuvant chemotherapy after radical surgery for UTUC.

Improving Health for People Living With Heart Failure: Focus Group Study of Preconditions for Co-Production of Health and Care.

BACKGROUND: Co-production of health and care involving patients, families of patients, and professionals in care processes can create joint learning about how to meet patients' needs. Although barriers and facilitators to co-production have been examined previously in various health care contexts, the preconditions in Swedish chronic cardiac care contexts are yet to be explored. This study is set in the health system of the Swedish region of Jönköping County and is part of system-wide efforts to promote better health for persons with heart failure (HF). OBJECTIVE: The objective of this study was to test the usefulness of the Capability, Opportunity, and Motivation Behavior (COM-B) model when assessing the barriers to and facilitators of co-production of health and care perceived by patients with HF, family members of patients with HF, and professionals in a Swedish chronic cardiac care context as a guide for subsequent initiatives. METHODS: Data collection involved 1 focus group interview (FGI) with patients with HF (n=5), 1 FGI with family members of patients with HF (n=5), 1 FGI with professionals in primary care (n=7), and 1 FGI with professionals in cardiac care (n=4). In addition, patients with HF kept diaries of their thoughts regarding co-production. Using a deductive approach to content analysis, underpinned by the COM-B model, barriers and facilitators were categorized into capabilities, opportunities, and motivations to co-produce health and care. RESULTS: The participants showed limited understanding of co-production as a practice. They appeared to view it as a privilege to be offered to patients on top of traditional care and rarely as an approach for improving health care processes. The interviews revealed the limited health literacy among patients and the struggle of professionals to convey health information to these patients. Co-production was considered to be more resource-intensive than traditional care. Different expectations of stakeholders' roles were revealed: professionals expected older patients not to want to co-produce health and care, and all participants expected professionals to be in charge of health care services. The family members' position involved trying to balance their desire to support their relatives with understanding when, how, and with whom to co-produce. Presumed benefits motivated stakeholders: co-production was recognized to motivate patients to improve self-care. However, the participants recognized that motivation to get involved in health and care decisions varies over time among stakeholders. CONCLUSIONS: Co-production can be facilitated by the stakeholders' motivation. However, varying levels of understanding of co-production, patients' limited health literacy, unease with power sharing between patients and professionals, and resource constraints are barriers that need to be managed to promote co-produced care and better health for persons living with HF. Further research is warranted to explore how to co-produce health care services with patients with HF and how leaders can facilitate the inevitable cultural change it requires and represents.

Telemedicine consultations with physicians in Swedish primary care: a mixed methods study of users' experiences and care patterns.

OBJECTIVE: The study aimed to explore users' experiences and care patterns concerning telemedicine consultations with physicians in Swedish primary care from 2017 to 2019.Design and participants: A mixed methods study involving 26 qualitative interviews with users of telemedicine consultations from a national sample, complemented by a quantitative registry study of data from 10,400 users in a Swedish region. RESULTS: Users mainly described telemedicine consultations as a positive experience and perceived that the service met their current health care needs. Users also valued high accessibility, timesaving, and the contribution to ecological sustainability. Users felt competent about choosing when to use telemedicine consultations, most commonly for less severe health care concerns. This was confirmed by the quantitative results; only a few users had other care contacts within physical primary care before, or after, the telemedicine consultation, attended acute care or phoned 1177 Health Care Guidance. CONCLUSIONS: This study provides a rare account of users' experiences of telemedicine consultations. Users expressed satisfaction with this up-to-date use of health care resources for them as individuals, the health care system, and the environment. Telemedicine consultations were perceived as efficient and safe according to users. In addition, the study shows a low degree of further physical contacts in primary care or in acute care related to the telemedicine consultations.Key pointsUsers have positive experiences of telemedicine consultations with physicians and experienced that the service had meet their actual needs for health care.Users were mainly satisfied with the service and highlighted the value of high accessibility.Users experienced that telemedicine consultants provided an alternative care service for mostly minor health problems, perceiving them to save time and resources for themselves, the health care system, and the environment.Most telemedicine consultations did not result in additional contacts with 1177 Health Care Guidance, physical visits to primary care, or acute health care.Telemedicine consultations with physicians were mainly used by persons aged 0-30 years and need to be further developed to suit other age groups.

Professionals' experiences of using an improvement programme: applying quality improvement work in preschool contexts.

BACKGROUND: Improvement work can be used in preschools to enrich outdoor environment for children's better health. Effective improvement work can facilitate the necessary changes, but little is known about professionals' experiences of participation in improvement interventions. The aim was to evaluate how preschool staff experience quality improvement work, using the Breakthrough Series Collaborative improvement programme, to enhance outdoor environments. METHODS: An improvement intervention using a breakthrough collaborative was performed at 9 preschools in Sweden and examined with a longitudinal mixed method design. Staff completed questionnaires on 4 occasions (n=45 participants) and interviews took place after the intervention (n=16 participants). RESULTS: The intervention was successful in the sense that the staff were content with the learning seminars, and they had triggered physical changes in the outdoor environment. They integrated the quality improvement work with their ordinary work and increasingly involved the children. The staff tested improvement tools but did not find them entirely appropriate for their work, because they preferred existing methods for reflection. CONCLUSIONS: The challenges in quality improvement work seem to be similar across contexts. Using the Breakthrough Series Collaborative in a public health intervention is promising but needs to be integrated with preunderstandings, current reflections and quality tools and models.

Promoting a sense of security in everyday life-A case study of patients and professionals moving towards co-production in an atrial fibrillation "learning café".

BACKGROUND: An improvement initiative sought to improve care for atrial fibrillation (AF) patients; many felt insecure about how to cope with AF. OBJECTIVE: To reveal AF patients' and professionals' experiences of pilot-testing a Learning Café group education programme, aimed at increasing the patients' sense of security in everyday life. DESIGN: Using an organizational case study design, we combined quantitative data (patients' sense of security) and qualitative data (project documentation; focus group interviews with five patients and five professionals) analysed using inductive qualitative content analysis. SETTING: AF patients and a multiprofessional team at a cardiac care unit in a Swedish district hospital. IMPROVEMENT ACTIVITIES: Two registered nurses invited AF patients and partners to four 2.5-hour Learning Café sessions. In the first session, they solicited participants' questions about life with AF. A physician, a registered nurse and a physiotherapist were invited to address these questions in the remaining sessions. RESULTS: AF patients reported gaining a greater sense of security in everyday life and anticipating a future shift from emergency care to planned care. Professionals reported enhanced professional development, learning more about person-centredness and gaining greater control of their own work situation. The organization gained knowledge about patient and family involvement. CONCLUSIONS: The Learning Café pilot test-exemplifying movement towards co-production through patient-professional collaboration-generated positive outcomes for patients (sense of security), professionals (work satisfaction; learning) and the organization (better care) in line with contemporary models for quality improvement and with Self-Determination Theory. This approach merits further testing and evaluation in other contexts.

Exploring, measuring and enhancing the coproduction of health and well-being at the national, regional and local levels through comparative case studies in Sweden and England: the 'Samskapa' research programme protocol.

INTRODUCTION: Cocreation, coproduction and codesign are advocated as effective ways of involving citizens in the design, management, provision and evaluation of health and social care services. Although numerous case studies describe the nature and level of coproduction in individual projects, there remain three significant gaps in the evidence base: (1) measures of coproduction processes and their outcomes, (2) mechanisms that enable inclusivity and reciprocity and (3) management systems and styles. By focusing on these issues, we aim to explore, enhance and measure the value of coproduction for improving the health and well-being of citizens. METHODS AND ANALYSIS: Nine ongoing coproduction projects form the core of an interactive research programme ('Samskapa') during a 6-year period (2019-2024). Six of these will take place in Sweden and three will be undertaken in England to enable knowledge exchange and cross-cultural comparison. The programme has a longitudinal case study design using both qualitative and quantitative methods. Cross-case analysis and a sensemaking process will generate relevant lessons both for those participating in the projects and researchers. Based on the findings, we will develop explanatory models and other outputs to increase the sustained value (and values) of future coproduction initiatives in these sectors. ETHICS AND DISSEMINATION: All necessary ethical approvals will be obtained from the regional Ethical Board in Sweden and from relevant authorities in England. All data and personal data will be handled in accordance with General Data Protection Regulations. Given the interactive nature of the research programme, knowledge dissemination to participants and stakeholders in the nine projects will be ongoing throughout the 6 years. External workshops-facilitated in collaboration with participating case studies and citizens-both during and at the end of the programme will provide an additional dissemination mechanism and involve health and social care practitioners, policymakers and third-sector organisations.

LearnOvation: an intervention to foster exploration and exploitation behaviour in health care management in daily practice.

BACKGROUND: Innovation has been identified as an important engine for improving the quality, productivity and efficiency of health care. Little is known about how to stimulate innovation capacity in primary health care in general; even less is known about how specific interventions should be designed to support managements' work with practice-based innovations. Research has shown that if managers and teams are excellent at handling the challenges of production (exploitation) and development (exploration), they are better at innovation. The aim of the study is to develop a dynamic management support programme to increase innovation leadership skills in daily practice. METHODS: The study has an interactive approach that allows the need for empirical and theoretical knowledge to emerge and merge, and a quasi-experimental cross-over design. Eight primary health care centres will participate in the study. In the first phase, the management teams at four health care centres will participate in the intervention, and the other four centres will serve as a control group. Thereafter, the units will switch places and the control group will experience the intervention. All staff at the 8 units will answer questionnaires at four points in time (before, during, after, 6 months later) to evaluate the effects of the intervention. DISCUSSION: The study will contribute to knowledge on how to organize processes of innovation and support exploitation and exploration behaviours by co-producing and testing a tailor-made management support programme for innovation work in primary health care. An expected long-term effect is that the support system will be disseminated to other centres both within and beyond the participating organizations.

Tending to innovate in Swedish primary health care: a qualitative study.

BACKGROUND: Policymakers in many countries are involved in system reforms that aim to strengthen the primary care sector. Sweden is no exception. Evidence suggests that targeted financial micro-incentives can stimulate change in certain areas of care, but they do not result in more radical change, such as innovation. The study was performed in relation to the introduction of a national health care reform, and conducted in Jönköping County Council, as the region's handling of health care reforms has attracted significant national and international interest. This study employed success case method to explore what enables primary care innovations. METHODS: Five Primary Health Care Centres (PHCCs) were purposively selected to ensure inclusion of a variety of aspects, such as size, location, ownership and regional success criteria. 48 in-depth interviews with managers and staff at the recruited PHCCs were analysed using content analyses. The COREQ checklist for qualitative studies was used to assure quality standards. RESULTS: This study identified three types of innovations, which break with previous ways of organizing work at these PHCCs: (1) service innovation; (2) process innovation; and (3) organizational innovation. A learning-oriented culture and climate, comprising entrepreneurial leadership, cross-boundary collaboration, visible and understandable performance measurements and ability to adapt to external pressure were shown to be advantageous for innovativeness. CONCLUSIONS: This qualitative study highlights critical features in practice that support primary care innovation. Managers need to consistently transform and integrate a policy "push" with professionals' understanding and values to better support primary care innovation. Ultimately, the key to innovation is the professionals' engagement in the work, that is, their willingness, capability and opportunity to innovate.

Dual loyalties: Everyday ethical problems of registered nurses and physicians in combat zones.

BACKGROUND:: When healthcare personnel take part in military operations in combat zones, they experience ethical problems related to dual loyalties, that is, when they find themselves torn between expectations of doing caring and military tasks, respectively. AIM:: This article aims to describe how Swedish healthcare personnel reason concerning everyday ethical problems related to dual loyalties between care and military tasks when undertaking healthcare in combat zones. DESIGN:: Abductive qualitative design. PARTICIPANTS AND RESEARCH CONTEXT:: Individual interviews with 15 registered nurses and physicians assigned for a military operation in Mali. ETHICAL CONSIDERATIONS:: The participants signed up voluntarily, and requirements for informed consent and confidentiality were met. The research was approved by the Regional Ethics Review Board in Gothenburg (D no. 816-14; 24 November 2014). FINDINGS:: Three main categories emerged: reasons for not undertaking combat duties, reasons for undertaking combat duties and restricted loyalty to military duties, and 14 subcategories. Reasons for not undertaking combat duties were that it was not in their role, not according to ethical codes or humanitarian law or a breach towards patients. Reasons for undertaking combat duties were that humanitarian law does not apply or has to be treated pragmatically or that it is a case of force protection. Shortage of resources and competence were reasons for both doing and not doing military tasks. Under some circumstances, they could imagine undertaking military tasks: when under threat, if unseen or if not needed for healthcare duties. DISCUSSION/CONCLUSION:: These discrepant views suggest a lack of a common view on what is ethically acceptable or not, and therefore we suggest further normative discussion on how these everyday ethical problems should be interpreted in the light of humanitarian law and ethical codes of healthcare personnel and following this, further training in ethical reflection before going on military operations.