Conversations about alcohol in healthcare - cross-sectional surveys in the Netherlands and Sweden

Background

This study evaluated and compared the extent, duration, contents, experiences and effects of alcohol conversations in healthcare in the Netherlands and Sweden in 2017.

Methods

Survey data in the Netherlands and Sweden were collected through an online web panel. Subjects were 2996 participants (response rate: 50.8%) in Sweden and 2173 (response rate: 82.2%) in the Netherlands. Data was collected on socio-demographics, alcohol consumption, healthcare visits in the past 12 months, number of alcohol conversations, and characteristics of alcohol conversations (duration, contents, experience, effects).

Results

Results showed that Swedish respondents were more likely to have had alcohol conversations (OR = 1.99; 95%CI = 1.64–2.41; p = < 0.001) compared to Dutch respondents. In Sweden, alcohol conversations were more often perceived as routine (p = < 0.001), were longer (p = < 0.001), and more often contained verbal information about alcohol’s health effects (p = 0.007) or written information (p = 0.001) than in the Netherlands. In Sweden, 40+ year-olds were less likely to report a positive effect compared to the youngest respondents. In the Netherlands, men, sick-listed respondents, and risky drinkers, and in Sweden those that reported “other” occupational status such as parental leave, were more likely to have had alcohol conversations.

Conclusions

The results suggest that alcohol conversations are more common in healthcare practice in Sweden than in the Netherlands. However, positive effects of alcohol conversations were less likely to be reported among older respondents in Sweden. Our results indicate that alcohol preventative work should be improved in both countries, with more focus on risky drinkers and the content of the conversations in Sweden, and expanding alcohol screening in the Netherlands.

Characteristics of successful changes in health care organizations: an interview study with physicians, registered nurses and assistant nurses

BACKGROUND

Health care organizations are constantly changing as a result of technological advancements, ageing populations, changing disease patterns, new discoveries for the treatment of diseases and political reforms and policy initiatives. Changes can be challenging because they contradict humans' basic need for a stable environment. The present study poses the question: what characterizes successful organizational changes in health care? The aim was to investigate the characteristics of changes of relevance for the work of health care professionals that they deemed successful.

METHODS

The study was based on semi-structured interviews with 30 health care professionals: 11 physicians, 12 registered nurses and seven assistant nurses employed in the Swedish health care system. An inductive approach was applied using questions based on the existing literature on organizational change and change responses. The questions concerned the interviewees' experiences and perceptions of any changes that they considered to have affected their work, regardless of whether these changes were "objectively" large or small changes. The interviewees' responses were analysed using directed content analysis.

RESULTS

The analysis yielded three categories concerning characteristics of successful changes: having the opportunity to influence the change; being prepared for the change; valuing the change. The interviewees emphasized the importance of having the opportunity to influence the organizational changes that are implemented. Changes that were initiated by the professionals themselves were considered the easiest and were rarely resisted. Changes that were clearly communicated to allow for preparation increased the chances for success. The interviewees did not support organizational changes that were perceived to be implemented unexpectedly and/or without prior communication. They conveyed that it was important for them to understand the need for and benefits of organizational changes. They particularly valued and perceived as successful organizational changes with a patient focus, with clear benefits to patients.

CONCLUSIONS

Organizational changes in health care are more likely to succeed when health care professionals have the opportunity to influence the change, feel prepared for the change and recognize the value of the change, including perceiving the benefit of the change for patients.

Planning injury prevention training for youth handball players: application of the generalisable six-step intervention development process

Background

Youth handball players are vulnerable to injuries. Because there is no available injury prevention training specifically developed for youth handball players targeting both upper and lower limbs or incorporating psychological aspects of injury, we undertook the ‘Implementing injury Prevention training ROutines in TEams and Clubs in youth Team handball (I-PROTECT)’ project. We used an ecological participatory design incorporating the perspectives of multiple stakeholders (health beneficiaries, programme deliverers and policy makers). The aim of this paper was to describe the process of developing the I-PROTECT model, featuring injury prevention training and an accompanying implementation strategy.

Design

We used the generalisable six-step intervention development process, outlined to guide researchers when developing implementable, evidence-based sports injury prevention interventions, to develop the I-PROTECT model. The six-step process involves establishing a research–stakeholder collaborative partnership to (1) identify and synthesise research evidence and clinical experience; (2) consult with relevant experts; (3) engage end users to ensure their needs, capacity and values are considered; (4) test the feasibility and acceptability of the intervention; (5) evaluate the intervention against theory; and (6) obtain feedback from early implementers. Two community handball clubs in southern Sweden, offering organised training for youth male and female players, and the district handball federation, participate in the intervention development. Drafts of the I-PROTECT model will be developed and revised with key stakeholder advice and input throughout all six steps.

Conclusion

The I-PROTECT model described will be an end user-driven intervention, including evidence-based, theory-informed and context-specific injury prevention training for youth handball, and an associated implementation strategy.

Advancing the use of organization theory in implementation science

Healthcare settings and systems have been slow to adopt and implement many effective cancer prevention and control interventions. Understanding the factors that determine successful implementation is essential to accelerating the translation of effective interventions into practice. Many scholars have studied the determinants of implementation, and much of this research has been guided by the Consolidated Framework for Implementation Research (CFIR). The CFIR categorizes implementation determinants at five levels (characteristics of the intervention, inner setting, individual, processes, and outer setting). Of these five levels, determinants at the level of the outer setting are the least developed. Extensive research in fields other than healthcare suggest that determinants at the level of the outer setting (e.g., funding streams, contracting practices, and public policy) play a central role in shaping when and how an organization implements new structures and practices. Thus, a more comprehensive understanding of outer-setting determinants is critical to efforts to accelerate the implementation of effective cancer control interventions. The Cancer Prevention and Control Research Network (CPCRN) created a cross-center workgroup to review organizational theories and begin to contribute to the creation of a future framework of constructs related to outer setting determinants. In this paper, we report findings from the review of three organizational theories: Institutional Theory, Transaction Cost Economics, and Contingency Theory. To demonstrate the applicability of this work to implementation science and practice, we have applied findings to three case studies of CPCRN researchers' efforts to implement colorectal cancer screening interventions in Federally Qualified Health Centers.

Psychometric properties of the Ethos Brief Index (EBI) using factorial structure and Rasch Analysis among patients with obstructive sleep apnea before and after CPAP treatment is initiated

BACKGROUND

Continuous positive airway treatment (CPAP) is the recommended treatment for patients with obstructive sleep apnea (OSA). Outcome measures often focus on clinical and/or self-rated variables related to the medical condition. However, a brief validated instrument focusing on the whole life situation (i.e., ethos) suitable for clinical practice is missing. The aim of this study was to investigate factorial structure, categorical functioning of the response scale, and differential item functioning across sub-populations of the Ethos Brief Index (EBI) among patients with obstructive sleep apnea (OSA) before and after initiation of continuous positive airway pressure (CPAP).

METHODS

A prospective design, including 193 patients with OSA (68% men, 59.66 years, SD 11.51) from two CPAP clinics, was used. Clinical assessment and overnight respiratory polygraphy were used to diagnose patients. Questionnaires administered before and after 6 months of CPAP treatment included EBI, Epworth Sleepiness Scale (ESS), Hospital Anxiety and Depression Scale, and global perceived health (initial item in SF-36). The validity and reliability of the EBI were investigated using Rasch and confirmatory factor analysis models. Measurement invariance, unidimensionality, and differential item functioning across gender groups, Apnea-Hypopnea Index, and ESS groups were assessed.

RESULTS

The reliability of the EBI was confirmed using composite reliability and Cronbach's alpha. The results supported unidimensionality of the EBI in confirmatory factor analysis and the Rasch model. No differential item functioning was found. A latent profile analysis yielded two profiles of patients with low (n = 42) and high (n = 151) ethos. Patients in the low ethos group were younger and had higher depression scores, lower perceived health, and higher body mass index.

CONCLUSIONS

The EBI is a valid tool with robust psychometric properties suitable for use among patients with OSA before and after treatment with CPAP is initiated. Future studies should focus on its predictive validity.

To do or not to do-balancing governance and professional autonomy to abandon low-value practices: a study protocol

BACKGROUND

Many interventions used in health care lack evidence of effectiveness and may be unnecessary or even cause harm, and should therefore be de-implemented. Lists of such ineffective, low-value practices are common, but these lists have little chance of leading to improvements without sufficient knowledge regarding how de-implementation can be governed and carried out. However, decisions regarding de-implementation are not only a matter of scientific evidence; the puzzle is far more complex with political, economic, and relational interests play a role. This project aims at exploring the governance of de-implementation of low-value practices from the perspectives of national and regional governments and senior management at provider organizations.

METHODS

Theories of complexity science and organizational alignment are used, and interviews are conducted with stakeholders involved in the governance of low-value practice de-implementation, including national and regional governments (focusing on two contrasting regions in Sweden) and senior management at provider organizations. In addition, an ongoing process for governing de-implementation in accordance with current recommendations is followed over an 18-month period to explore how governance is conducted in practice. A framework for the governance of de-implementation and policy suggestions will be developed to guide de-implementation governance.

DISCUSSION

This study contributes to knowledge about the governance of de-implementation of low-value care practices. The study provides rich empirical data from multiple system levels regarding how de-implementation of low-value practices is currently governed. The study also makes a theoretical contribution by applying the theories of complexity and organizational alignment, which may provide generalizable knowledge about the interplay between stakeholders across system levels and how and why certain factors influence the governance of de-implementation. The project employs a solution-oriented perspective by developing a framework for de-implementation of low-value practices and suggesting practical strategies to improve the governance of de-implementation. The framework and strategies can thereafter be evaluated for validity and impact in future studies.

Factors influencing use of telegenetic counseling: perceptions of health care professionals in Sweden

Genetic counseling services are increasing in demand and limited in access due to barriers such as lack of professional genetic counselors, vast geographic distances, and physical hurdles. This research focuses on an alternative mode of delivery for genetic counseling in Sweden, in order to overcome some of the mentioned barriers. The aim of this study is to identify factors that influence the implementation and use of telegenetic counseling in clinical practice, according to health care professionals in Southeast Sweden. Telegenetic counseling refers to the use of video-conferencing as a means to provide genetic counseling. Qualitative, semi-structured interviews with 16 genetic counseling providers took place and phenomenographic analysis was applied. Significant excerpts were identified in each transcript, which led to sub-categories that constructed the main findings. Three categories emerged from the data: (1) requirements for optimal use, (2) impact on clinical practice, and (3) patient benefits. Each category consists of two or three sub-categories, in total seven sub-categories. These findings could potentially be used to improve access and uptake of telegenetic counseling in Sweden and in other countries with a similar health care system. This could benefit not only remote patient populations, as described in previous research, but also large family groups and patients experiencing obstacles in accessing genetic counseling, such as those with a psychiatric illness or time constraints, and be a useful way to make genetic counseling available in the new era of genomics.

Facilitators for using data from a quality registry in local quality improvement work: a cross-sectional survey of the Danish Cardiac Rehabilitation Database

OBJECTIVES

To investigate use of data from a clinical quality registry for cardiac rehabilitation in Denmark, considering the extent to which data are used for local quality improvement and what facilitates the use of these data, with a particular focus on whether there are differences between frontline staff and managers.

DESIGN

Cross-sectional nationwide survey study.

SETTING, METHODS AND PARTICIPANTS

A previously validated, Swedish questionnaire regarding use of data from clinical quality registries was translated and emailed to frontline staff, mid-level managers and heads of departments (n=175) in all 30 hospital departments participating in the Danish Cardiac Rehabilitation Database. Data were analysed descriptively and through multiple linear regression.

RESULTS

Survey response rate was 58% (101/175). Reports of registry use at department level (measured through an index comprising seven items; score min 0, max 7, where a low score indicates less use of data) varied significantly between groups of respondents: frontline staff mean score 1.3 (SD=2.0), mid-level management mean 2.4 (SD=2.3) and heads of departments mean 3.0 (SD=2.5), p=0.006. Overall, department level use of data was positively associated with higher perceived data quality and usefulness (regression coefficient=0.22, p=0.019), management request for data (regression coefficient=0.40, p=0.008) and personal motivation of the respondent (regression coefficient=1.63, p<0.001). Among managers, use of registry data was associated with data quality and usefulness (regression coefficient=0.43, p=0.027), and among frontline staff, reported data use was associated with management involvement in quality improvement work (regression coefficient=0.90, p=0.017) and personal motivation (regression coefficient=1.66, p<0.001).

CONCLUSIONS

The findings suggest relatively sparse use of data in local quality improvement work. A complex interplay of factors seem to be associated with data use with varying aspects being of importance for frontline staff and managers.

[Appropriate use of vitamin D assessments in primary health care: Impact of new strategies for the introduction and follow-up of analyses in Östergötland]

Systematic reviews and meta-analyses have shown that there is little justification for vitamin D supplements to prevent infections, cancer and cardiovascular disease. Despite the limited evidence of effectiveness, the total number of ordered serum 25-hydroxyvitamin D (25(OH)D) tests has increased considerably in recent years. There seems to be an overuse of this test that does not provide meaningful benefit for patients. A passive introduction of new tests leads generally to a slow initiation of value-based diagnostics, as well as overuse and underuse of diagnostic tests. In this study, in Region Östergötland, we applied a »Choosing wisely« model that reversed a rising trend of 25(OH)D tests and reduced the number of unnecessary tests. The findings point to the need for strategic plans for introducing new analyses and approaches to counteract misuse of laboratory diagnostics. We recommend »Choosing wisely« models for the introduction of new analyses to facilitate appropriate laboratory diagnostics and to counteract long-term overuse.

Implementation of change in health care in Sweden: a qualitative study of professionals' change responses

BACKGROUND

Implementation of evidence-based practices in health care implies change. Understanding health care professionals' change responses may be critical for facilitating implementation to achieve an evidence-based practice in the rapidly changing health care environment. The aim of this study was to investigate health care professionals' responses to organizational and workplace changes that have affected their work.

METHODS

We conducted interviews with 30 health care professionals (physicians, registered nurses and assistant nurses) employed in the Swedish health care system. An inductive approach was applied, using a semi-structured interview guide developed by the authors. We used an analytical framework first published in 1999 to analyze the informants' change responses in which change responses are perceived as a continuum ranging from a strong acceptance of change to strong resistance to change, describing seven forms of change responses along this continuum. Change response is conceptualized as a tridimensional attitude composed of three components: cognitive, affective and intentional/behavioral.

RESULTS

Analysis of the data yielded 10 types of change responses, which could be mapped onto 5 of the 7 change response categories in the framework. Participants did not report change responses that corresponded with the two most extreme forms of responses in the framework, i.e., commitment and aggressive resistance. Most of the change responses were classified as either indifference or passive resistance to changes. Involvement in or support for changes occurred when the health care professionals initiated the changes themselves or when the changes featured their active input and when changes were seen as well founded and well communicated. We did not identify any change responses that could not be fitted into the framework.

CONCLUSIONS

We found the framework to be useful for a nuanced understanding of how people respond to changes. This knowledge of change responses is useful for the management of changes and for efforts to achieve more successful implementation of evidence-based practices in health care.

Adherence to planned risk management interventions in Swedish forensic care: What is said and done according to patient records

Both structured and unstructured clinical risk assessments within forensic care aim to prevent violence by informing risk management, but research about their preventive role is inconclusive. The aim of this study was to investigate risk management interventions that were planned and realized during forensic care by analysing patient records. Records from a forensic clinic in Sweden, covering 14 patients and 526 months, were reviewed. Eight main types of risk management interventions were evaluated by content analysis: monitoring, supervision, assessment, treatment, victim protection, acute coercion, security level and police interventions. Most planned risk management interventions were realized, both in structured and clinical risk assessments. However, most realized interventions were not planned, making them more open to subjective decisions. Analysing risk management interventions actually planned and realized in clinical settings can reveal the preventive role of structured risk assessments and how different interventions mediate violence risk.

Can patients contribute to safer care in meetings with healthcare professionals? A crosssectional survey of patient perceptions and beliefs

Objectives

To investigate patients’ perceptions of their meetings with healthcare professionals and the extent to which they believe they can influence patient safety in these meetings.

Design

Cross-sectional survey of patients using a study-specific questionnaire. Data were analysed using both parametric and non-parametric statistics.

Setting

The study was conducted in primary and secondary care in three county councils in southeast Sweden by means of a survey questionnaire despatched in January 2017.

Participants

Survey data were collected from 1445 patients, 333 of whom were complainants (patients who had filed a complaint about being harmed in healthcare) and 1112 regular patients (patients recruited from healthcare units).

Main outcome measures

Patients’ perceptions of meetings with physicians and nurses, beliefs concerning patients’ contributions to safer care and whether the patients had suffered harm in healthcare during the past 10 years.

Results

Most respondents reported that it was easy to ask physicians and nurses questions (84.9% and 86.6%) and to point out if something felt odd in their care (77.7% and 80.7%). In general, complainants agreed to a higher extent compared with regular patients that patients can contribute to safer care (mean 1.92 and 2.13, p<0.001). Almost one-third (31.2%) of the respondents (both complainants and regular patients) reported that they had suffered harm in healthcare during the past 10 years.

Conclusions

Most respondents believed that healthcare professionals can facilitate patient interaction and increase patient safety by encouraging patients to ask questions and take an active part in their care. Further research will need to identify strategies to support such questioning in routine practice and ensure that it achieves its intended goals.

Context matters in implementation science: a scoping review of determinant frameworks that describe contextual determinants for implementation outcomes

BACKGROUND

The relevance of context in implementation science is reflected in the numerous theories, frameworks, models and taxonomies that have been proposed to analyse determinants of implementation (in this paper referred to as determinant frameworks). This scoping review aimed to investigate and map how determinant frameworks used in implementation science were developed, what terms are used for contextual determinants for implementation, how the context is conceptualized, and which context dimensions that can be discerned.

METHODS

A scoping review was conducted. MEDLINE and EMBASE were searched from inception to October 2017, and supplemented with implementation science text books and known published overviews. Publications in English that described a determinant framework (theory, model, taxonomy or checklist), of which context was one determinant, were eligible. Screening and inclusion were done in duplicate. Extracted data were analysed to address the study aims. A qualitative content analysis with an inductive approach was carried out concerning the development and core context dimensions of the frameworks. The review is reported according to the PRISMA guidelines.

RESULTS

The database searches yielded a total of 1113 publications, of which 67 were considered potentially relevant based on the predetermined eligibility criteria, and retrieved in full text. Seventeen unique determinant frameworks were identified and included. Most were developed based on the literature and/or the developers' implementation experiences. Six of the frameworks explicitly referred to "context", but only four frameworks provided a specific definition of the concept. Instead, context was defined indirectly by description of various categories and sub-categories that together made up the context. Twelve context dimensions were identified, pertaining to different aggregation levels. The most widely addressed context dimensions were organizational support, financial resources, social relations and support, and leadership.

CONCLUSIONS

The findings suggest variation with regard to how the frameworks were developed and considerable inconsistency in terms used for contextual determinants, how context is conceptualized, and which contextual determinants are accounted for in frameworks used in implementation science. Common context dimensions were identified, which can facilitate research that incorporates a theory of context, i.e. assumptions about how different dimensions may influence each other and affect implementation outcomes. A thoughtful application of the concept and a more consistent terminology would enhance transparency, simplify communication among researchers, and facilitate comparison across studies.

Implementing internet-delivered cognitive behavioural therapy for patients with cardiovascular disease and psychological distress: a scoping review

BACKGROUND

Comorbid psychological distress (i.e. insomnia and depression) is experienced by 20-40% of patients with cardiovascular disease. This has a considerable impact on their health and quality of life, leading to frequent re-hospitalisations, higher healthcare costs and a shorter life expectancy. Internet-based cognitive behavioural therapy shows great potential for treating psychological distress in cardiovascular disease. Effective and feasible treatments can, however, only benefit patients if they are fully implemented in clinical care.

AIM

This scoping review aimed to explore the literature for internet-based cognitive behavioural therapy in cardiovascular disease and for strategies to implement the intervention.

METHODS

We searched electronic databases, journals and internet sources to find original studies about internet-based cognitive behavioural therapy in cardiovascular disease, adhering to scoping methodology guidelines. After identifying 267 titles, we screened 40 abstracts and chose 11 full-text articles for full-text screening. The results sections in four articles were searched for outcomes that related to the effectiveness and implementation of internet-based cognitive behavioural therapy by directed qualitative content analysis using an implementation framework.

RESULTS

Three of the four articles fulfilling the inclusion criteria concerned internet-based cognitive behavioural therapy for treating mild to moderate depressive symptoms in cardiovascular disease, and none focused on insomnia. The studies showed evidence for the effectiveness of internet-based cognitive behavioural therapy, and/or described patient factors influencing clinical effectiveness. Our qualitative content analysis showed that many implementation aspects and stakeholder perspectives remain unexplored.

CONCLUSIONS

Internet-based cognitive behavioural therapy promises to alleviate patient suffering in cardiovascular disease. There is, however, little research about internet-based cognitive behavioural therapy for cardiovascular disease, and about how this evidence-based intervention is implemented.

Patients' experiences of physical activity on prescription with access to counsellors in routine care: a qualitative study in Sweden

Background

Physical activity on prescription (PAP) has been implemented in several countries, including Sweden, to support patients who might benefit from increased physical activity. This study explores the experiences of recipients of PAP in routine health care in Sweden that offers the recipients support from physical activity counsellors. The aim was to explore influences on engagement in physical activity by PAP recipients’ from a long-term perspective.

Methods

We conducted individual semi-structured interviews using a topic guide with a purposively selected sample of 13 adult PAP recipients 1.5 to 2.5 years after PAP. Interviews were recorded, transcribed verbatim and analysed through inductive and deductive content analysis. The questions were informed by Capability-Opportunity-Motivation-Behaviour (COM-B), which was also used as a framework to analyse the data by means of categorizing the factors (influences on the behaviour).

Results

Ten factors (i.e. sub-categories) that influenced the participants’ engagement in physical activity were identified. PAP recipients’ capability to engage in physical activity was associated with adapting the PAP to the individual’s physical capacity and taking into account the individual’s previous experiences of physical activity. PAP recipients’ opportunity to engage in physical activity was related to receiving a prescription, receiving professional counselling and follow-up from a physical activity counsellor, collaboration between prescriber and counsellor, having access to appropriate activities, having a balanced life situation and having support from someone who encouraged continued physical activity. PAP recipients’ motivation to engage in physical activity was associated with the desire to improve his or her health condition and finding activities that encouraged continuation.

Conclusions

PAP recipients’ engagement in physical activity was influenced by their capability, opportunity and motivation to undertake this behaviour. Numerous extraneous factors influence capability and motivation. Physical activity counsellors were found to be important for sustained activity because they use an individual approach to counselling and flexible follow-up adapted to each individual’s need of support.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6535-5) contains supplementary material, which is available to authorized users.

"Struggling with practices" - a qualitative study of factors influencing the implementation of clinical quality registries for cardiac rehabilitation in England and Denmark

Background

The use of clinical quality registries as means for data driven improvement in healthcare seem promising. However, their use has been shown to be challenged by a number of aspects, and we suggest some may be related to poor implementation. There is a paucity of literature regarding barriers and facilitators for registry implementation, in particular aspects related to data collection and entry. We aimed to illuminate this by exploring how staff perceive the implementation process related to the registries within the field of cardiac rehabilitation in England and Denmark.

Methods

A qualitative, interview-based study with staff involved in collecting and/or entering data into the two case registries (England N = 12, Denmark N = 12). Interviews were analysed using content analysis. The Consolidated Framework for Implementation Research was used to guide interviews and the interpretation of results.

Results

The analysis identified both similarities and differences within and between the studied registries, and resulted in clarification of staffs´ experiences in an overarching theme: ´Struggling with practices´ and five categories; the data entry process, registry quality, resources and management support, quality improvement and the wider healthcare context. Overall, implementation received little focused attention. There was a lack of active support from management, and staff may experience a struggle of fitting use of a registry into a busy and complex everyday practice.

Conclusion

The study highlights factors that may be important to consider when planning and implementing a new clinical quality registry within the field of cardiac rehabilitation, and is possibly transferrable to other fields. The results may thus be useful for policy makers, administrators and managers within the field and beyond. Targeting barriers and utilizing knowledge of facilitating factors is vital in order to improve the process of registry implementation, hence helping to achieve the intended improvement of care processes and outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3940-5) contains supplementary material, which is available to authorized users.

Next of kin's perceptions of the meaning of participation in the care of older persons in nursing homes: a phenomenographic study

BACKGROUND

Being involved in the care of a loved one is a desire of many next of kin. However, according to several studies of the perceptions of nursing home staff, the involvement of next of kin is not an obvious part of care. To be able to involve next of kin in care at nursing homes, the perceptions of what participation means are an important piece of knowledge. The aim of this study was therefore to describe variations in next of kin's perceptions of the meaning of participation in the care of older persons living in nursing homes.

METHODS

Eighteen next of kin of older persons living in ten nursing homes in Sweden were recruited for interviews. The study design was based on a phenomenographic approach, focusing on the qualitatively different ways in which a person perceives, experiences or conceptualises a phenomenon or certain aspect of reality.

RESULTS

Five categories emerged from analysis of the interviews, representing the next of kin's perceptions of the meaning of participation in the care of older persons in nursing homes: be present; communicate; monitor; do practical tasks; and to represent. The next of kin expressed meanings that belonged to more than one category, and the categories were interdependent.

CONCLUSIONS

Our results indicate that there are several meanings of next of kin's perceptions of participation at nursing homes. Nursing home staff's knowledge of these perceptions is important to enable next of kin to participate according to their own preferences.

Validation of CollaboRATE and SURE - two short questionnaires to measure shared decision making during CPAP initiation

Adherence to continuous positive airway pressure (CPAP) treatment tends to be low. Brief validated instruments focusing on shared decision making have not been used in a CPAP context. The aim was to investigate factorial structure, categorical functioning of the response scale and differential item functioning across sub-populations of the CollaboRATE and Sure questionnaires among patients with obstructive sleep apnea (OSA) before CPAP treatment is initiated. A prospective design, including 193 objectively diagnosed (polygraphy) OSA patients (68% men, 59.7 years, SD 11.5) from two CPAP clinics was used. Data were collected with the following questionnaires; Sure, CollaboRATE, Attitudes to CPAP Inventory, Epworth sleepiness scale, minimal insomnia symptoms scale, and hospital anxiety and depression scale. Objective CPAP use was collected after 6 months; 49% demonstrated decisional conflict on SURE and 51% scored low levels of shared decision making on CollaboRATE. Unidimensionality was found for both CollaboRATE (one factor explaining 57.4%) and SURE (one factor explaining 53.7%), as well as local independence. Differential item functioning showed both to be invariant across both male and female patients. Internal consistency (Cronbach's alpha 0.83) and composite reliability (0.89) were good. Latent class analyses showed that patients with low decisional conflict and high shared decision making were more adherent to CPAP treatment. CollaboRATE and SURE provided good validity and reliability scores to measure shared decision making and decisional conflict in relation to CPAP treatment. The questionnaires can be used by healthcare personnel as a tool to simplify the assessment of shared decision making.

Facilitators to support the implementation of injury prevention training in youth handball: A concept mapping approach

There is a need for research to identify effective implementation strategies for injury prevention training within real-world community sports. The aim of this ecological participatory study was to identify facilitators, among stakeholders at multiple levels, that could help injury prevention training become part of regular training routines in youth team handball. Concept mapping, a mixed-method approach for qualitative data collection and quantitative data analysis, was used. Stakeholders (n = 196) of two community team handball clubs (29% players, 13% coaches, 38% caregivers, 11% club, district and national handball administrators, 9% unknown) participated in a brainstorming process. After the research team synthesized the 235 generated statements, 50 stakeholders (34% players, 22% coaches, 24% caregivers, 20% administrators) sorted 89 unique facilitator statements into clusters and rated them for importance and feasibility. Multidimensional scaling and hierarchical cluster analysis yielded five clusters (stress value 0.231): "Understanding and applying knowledge," "Education, knowledge, and consistency," "Set-up and exercises," "Inspiration, motivation, and routines," and "Club policy and expert collaboration." The cluster "Understanding and applying knowledge" had the highest mean importance (3.17 out of 4) and feasibility (2.93) ratings. The 32 statements rated as both highly important and feasible (Go-zone) indicate action is required at the individual (end-users) and organizational (policymakers) levels to implement injury prevention training. Results suggest that developing evidence-based context-specific injury prevention training, incorporating physiological, biomechanical and psychological components, and an associated context-specific implementation plan in partnership with all stakeholders should be a high priority to facilitate the implementation of injury prevention training in youth team handball.

Determinants of patient participation for safer care: A qualitative study of physicians' experiences and perceptions

OBJECTIVE

There is a paucity of research on physicians' perspectives on involving patients to achieve safer care. This study aims to explore determinants of patient participation for safer care, according to physicians in Swedish health care.

METHODS

We used a deductive descriptive design, applying qualitative content analysis based on the Capability-Opportunity-Motivation-Behaviour framework. Semi-structured interviews were conducted with 13 physicians in different types of health care units, to achieve a heterogeneous sample. The main outcome measure was barriers and facilitators to patient participation of potential relevance for patient safety.

RESULTS

Analysis of the data yielded 14 determinants (ie, subcategories) functioning as barriers and/or facilitators to patient participation of potential relevance for patient safety. These determinants were mapped to five categories: physicians' capability to involve patients in their care; patients' capability to become involved in their care, as perceived by the physicians; physicians' opportunity to achieve patient participation in their care; physicians' motivation to involve patients in their care; and patients' motivation to become involved in their care, as perceived by the physicians.

CONCLUSION

There are many barriers to patient participation to achieve safer care. There are also facilitators, but these tend to depend on initiatives of individual physicians and patients, because organizational-level support may be lacking. Many of the determinants are interdependent, with physicians' perceived time constraints influencing other barriers.

Implementation of a politically initiated national clinical guideline for cardiac rehabilitation in hospitals and municipalities in Denmark

A politically initiated national clinical guideline was launched in Denmark in 2013 to improve quality and equality of cardiac rehabilitation (CR) services. The guideline is to be implemented in both hospital and community (municipality) settings due to shared responsibility for provision of CR services. Little is known about implementation outcomes of a guideline in these two settings. We aimed to study this by determining the extent to which Danish CR services in hospitals and municipalities adhered to national recommendations following the launch of the guideline. The study employed an observational, longitudinal design. Data were gathered by a questionnaire survey to compare CR services at baseline, measured in 2013 immediately before the guideline was launched, with CR services at a two-year follow up in 2015. All Danish hospital departments offering CR services (N = 36) and all municipalities (N = 98) were included. Data were analysed using inferential statistics. Hospitals reported improvement of both content and quality of CR services. Municipalities reported no change in content of services, and lower level of fulfilment of one quality aspect. The results suggest that the guideline had different impact in hospitals and municipalities and that the differences in content and quality of services between the two settings increased in the study period, thus contradicting the guideline´s aim of uniform, evidence-based content of CR services across settings.