Digital transformation in schools of two southern regions of Sweden through implementation-informed approach: A mixed-methods study protocol

BACKGROUND

The enhancement of-or even a shift from-traditional teaching and learning processes to corresponding digital practices has been rapidly occurring during the last two decades. The evidence of this ongoing change is still modest or even weak. However, the adaptation of implementation science in educational settings, a research approach which arose in the healthcare field, offers promising results for systematic and sustained improvements in schools. The aim of this study is to understand how the systematic professional development of teachers and schools principals (the intervention) to use digital learning materials and learning analytics dashboards (the innovations) could allow for innovative and lasting impacts in terms of a sustained implementation strategy, improved teaching practices and student outcomes, as well as evidence-based design of digital learning material and learning analytics dashboards.

METHODS

This longitudinal study uses a quasi-experimental cluster design with schools as the unit. The researchers will enroll gradually 145 experimental schools in the study. In the experimental schools the research team will form a School Team, consisting of teachers/learning-technologists, school principals, and researchers, to support teachers' use of the innovations, with student achievement as the dependent variable. For the experimental schools, the intervention is based on the four longitudinal stages comprising the Active Implementation Framework. With an anticipated student sample of about 13,000 students in grades 1-9, student outcomes data are going to be analyzed using hierarchical linear models.

DISCUSSION

The project seeks to address a pronounced need for favorable conditions for children's learning supported by a specific implementation framework targeting teachers, and to contribute with knowledge about the promotion of improved teaching practices and student outcomes. The project will build capacity using implementation of educational technology in Swedish educational settings.

Essential content for teaching implementation practice in healthcare: a mixed-methods study of teams offering capacity-building initiatives

BACKGROUND

Applying the knowledge gained through implementation science can support the uptake of research evidence into practice; however, those doing and supporting implementation (implementation practitioners) may face barriers to applying implementation science in their work. One strategy to enhance individuals' and teams' ability to apply implementation science in practice is through training and professional development opportunities (capacity-building initiatives). Although there is an increasing demand for and offerings of implementation practice capacity-building initiatives, there is no universal agreement on what content should be included. In this study we aimed to explore what capacity-building developers and deliverers identify as essential training content for teaching implementation practice.

METHODS

We conducted a convergent mixed-methods study with participants who had developed and/or delivered a capacity-building initiative focused on teaching implementation practice. Participants completed an online questionnaire to provide details on their capacity-building initiatives; took part in an interview or focus group to explore their questionnaire responses in depth; and offered course materials for review. We analyzed a subset of data that focused on the capacity-building initiatives' content and curriculum. We used descriptive statistics for quantitative data and conventional content analysis for qualitative data, with the data sets merged during the analytic phase. We presented frequency counts for each category to highlight commonalities and differences across capacity-building initiatives.

RESULTS

Thirty-three individuals representing 20 capacity-building initiatives participated. Study participants identified several core content areas included in their capacity-building initiatives: (1) taking a process approach to implementation; (2) identifying and applying implementation theories, models, frameworks, and approaches; (3) learning implementation steps and skills; (4) developing relational skills. In addition, study participants described offering applied and pragmatic content (e.g., tools and resources), and tailoring and evolving the capacity-building initiative content to address emerging trends in implementation science. Study participants highlighted some challenges learners face when acquiring and applying implementation practice knowledge and skills.

CONCLUSIONS

This study synthesized what experienced capacity-building initiative developers and deliverers identify as essential content for teaching implementation practice. These findings can inform the development, refinement, and delivery of capacity-building initiatives, as well as future research directions, to enhance the translation of implementation science into practice.

Built to last? Barriers and facilitators of healthcare program sustainability: a systematic integrative review

OBJECTIVE

To identify barriers and facilitators associated with the sustainability of implemented and evaluated improvement programs in healthcare delivery systems.

DATA SOURCES AND STUDY SETTING

Six academic databases were searched to identify relevant peer-reviewed journal articles published in English between July 2011 and June 2022. Studies were included if they reported on healthcare program sustainability and explicitly identified barriers to, and facilitators of, sustainability.

STUDY DESIGN

A systematic integrative review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Study quality was appraised using Hawker's Quality Assessment Tool.

DATA COLLECTION/EXTRACTION METHODS

A team of reviewers screened eligible studies against the inclusion criteria and extracted the data independently using a purpose-designed Excel spreadsheet. Barriers and facilitators were extracted and mapped to the Integrated Sustainability Framework (ISF). Frequency counts of reported barriers/facilitators were performed across the included studies.

RESULTS

Of the 124 studies included in this review, almost half utilised qualitative designs (n = 52; 41.9%) and roughly one third were conducted in the USA (n = 43; 34.7%). Few studies (n = 29; 23.4%) reported on program sustainability beyond 5 years of program implementation and only 16 of them (55.2%) defined sustainability. Factors related to the ISF categories of inner setting (n = 99; 79.8%), process (n = 99; 79.8%) and intervention characteristics (n = 72; 58.1%) were most frequently reported. Leadership/support (n = 61; 49.2%), training/support/supervision (n = 54; 43.5%) and staffing/turnover (n = 50; 40.3%) were commonly identified barriers or facilitators of sustainability across included studies. Forty-six (37.1%) studies reported on the outer setting category: funding (n = 26; 56.5%), external leadership by stakeholders (n = 16; 34.8%), and socio-political context (n = 14; 30.4%). Eight studies (6.5%) reported on discontinued programs, with factors including funding and resourcing, poor fit, limited planning, and intervention complexity contributing to discontinuation.

CONCLUSIONS

This review highlights the importance of taking into consideration the inner setting, processes, intervention characteristics and outer setting factors when sustaining healthcare programs, and the need for long-term program evaluations. There is a need to apply consistent definitions and implementation frameworks across studies to strengthen evidence in this area.

TRIAL REGISTRATION

https://bmjopen.bmj.com/content/7/11/e018568 .

Problematic substance use among patients in a Swedish outpatient psychiatry setting: staff and manager perceptions of digital options for increased intervention access

BACKGROUND

Approximately 50% of the patients who globally seek help in psychiatry have been assessed with problematic substance use or been diagnosed with substance use disorder (SUD). Given the high treatment gap for mental health care, in particular SUD, these individuals risk poorer treatment outcomes in psychiatry. Integrated treatment for psychiatric and SUD disorders has been proposed to reduce the treatment gap for SUD, but access to integrated treatment is low. Digital interventions addressing SUD in psychiatry could potentially make treatment available to patients who otherwise would not have access. In this study "digital interventions" comprise an umbrella term covering all kinds of interventions from minimal motivational app-based interventions to internet-based interventions with and without human guidance, up to remote sessions in telepsychiatry. This study aims to explore healthcare staff perceptions of referring patients to digital interventions for reducing problematic substance use, whether or not diagnosed as SUD, in the psychiatric outpatient setting.

METHOD

The study was exploratory with a qualitative design. Data were collected in the Swedish outpatient psychiatry setting, via individual semi-structured interviews with managers, and focus groups with healthcare staff. An adapted form of phenomenological hermeneutical analysis was used to analyze the data.

RESULTS

Three themes emerged from the analysis. The first theme was Encountering obstacles on the path to future implementation of digital interventions, with sub-themes: Lacking resources and Feeling concerned about technical solutions. The second theme was Searching for ways forward to achieve increased access to care, with sub-themes: Blended care could facilitate integrated care and Addressing variations in patients' technical skills. The third theme was Taking steps towards the future, with sub-themes: Wanting to know more about digital interventions and Formulating a vision for the future.

CONCLUSIONS

The study reveals a concern that implementing digital interventions in psychiatry will create additional work or be technically challenging. The staff see significant advantages from the patient perspective, but they feel that they themselves need training in implementing digital interventions. In order to establish constructive implementation of digital interventions for SUD in psychiatry, staff attitudes and concerns need to be considered and addressed. This study was conducted within the Swedish healthcare system and the findings may not generalize to other countries with differing healthcare systems.

Information and support to patients when the waiting time guarantee cannot be fulfilled: a qualitative study

BACKGROUND

Long waiting times for health care services are a prominent health policy issue. Waiting time guarantees may limit time to assessment and treatment.

METHODS

This study aims to investigate the information and support given to patients when the waiting time guarantee cannot be fulfilled from a care provider and administrative management perspective. Semi-structured interviews (N = 28) were conducted with administrative management and care providers (clinic staff and clinic line managers) in specialized clinics in the Stockholm Region, Sweden. Clinics were purposefully sampled for maximum variation in ownership (private, public), complexity of care, geographical location, volume of production, and waiting times. Thematic analysis was applied.

RESULTS

Care providers reported that patients received inconsistent information and support with regard to the waiting time guarantee and that information was not adapted to health literacy or individual patient needs. Contrary to local law, they made some patients responsible for finding a new care provider or arranging a new referral. Furthermore, financial interests affected whether patients were referred to other providers. Administrative management steered care providers' informing practices at specific time points (upon establishment of a new unit and after six months of operation). A specific regional support function, Region Stockholm's Care Guarantee Office, helped patients change care providers when long waiting times occurred. However, administrative management perceived that there was no established routine to assist care providers in informing patients.

CONCLUSIONS

Care providers did not consider patients' health literacy when informing them about the waiting time guarantee. Administrative management's attempts to provide information and support to care providers are not producing the results they expect. Soft-law regulations and care contracts seem insufficient, and economic mechanisms undermine care providers' willingness to inform patients. The described actions are unable to mitigate the inequality in health care that arises from differences in care-seeking behavior.

Strategies to reduce low-value care - An applied behavior analysis using a single-case design

Introduction

Implementation science has traditionally focused on the implementation of evidence-based practices, but the field has increasingly recognized the importance of addressing de-implementation (i.e., the process of reducing low-value care). Most studies on de-implementation strategies have used a combination of strategies without addressing factors that sustain the use of LVC and there is a lack of information about which strategies are most effective and what mechanisms of change might underlie these strategies. Applied behavior analysis is an approach that could be a potential method to gain insights into the mechanisms of de-implementation strategies to reduce LVC. Three research questions are addressed in this study: What contingencies (three-term contingencies or rule-governing behavior) related to the use of LVC can be found in a local context and what strategies can be developed based on an analysis of these contingencies?; Do these strategies change targeted behaviors?; How do the participants describe the strategies' contingencies and the feasibility of the applied behavior analysis approach?

Materials and methods

In this study, we used applied behavior analysis to analyze contingencies that maintain behaviors related to a chosen LVC, the unnecessary use of x-rays for knee arthrosis within a primary care center. Based on this analysis, strategies were developed and evaluated using a single-case design and a qualitative analysis of interview data.

Results

Two strategies were developed: a lecture and feedback meetings. The results from the single-case data were inconclusive but some of the findings may indicate a behavior change in the expected direction. Such a conclusion is supported by interview data showing that participants perceived an effect in response to both strategies.

Conclusion

The findings illustrate how applied behavior analysis can be used to analyze contingencies related to the use of LVC and to design strategies for de-implementation. It also shows an effect of the targeted behaviors even though the quantitative results are inconclusive. The strategies used in this study could be further improved to target the contingencies better by structuring the feedback meetings better and including more precise feedback.

Organizational influences on the use of low-value care in primary health care - a qualitative interview study with physicians in Sweden

AIM

The aim was (1) to explore organizational factors influencing the use of low-value care (LVC) as perceived by primary care physicians and (2) to explore which organizational strategies they believe are useful for reducing the use of LVC.

DESIGN

Qualitative study with semi-structured focus group discussions (FGDs) analyzed using qualitative content analysis.

SETTING

Six publicly owned primary health care centers in Stockholm.

SUBJECTS

The participants were 31 primary care physicians. The number of participants in each FGD varied between 3 and 7.

MAIN OUTCOME MEASURES

Categories and subcategories reporting organizational factors perceived to influence the use of LVC and organizational strategies considered useful for reducing the use of LVC.

RESULTS

Four types of organizational factors (resources, care processes, improvement activities, and governance) influenced the use of LVC. Resources involved time to care for patients, staff knowledge, and working tools. Care processes included work routines and the ways activities and resources were prioritized in the organization. Improvement activities involved performance measurement and improvement work to reduce LVC. Governance concerned organizational goals, higher-level decision making, and policies. Physicians suggested multiple strategies targeting these factors to reduce LVC, including increased patient-physician continuity, adjusted economic incentives, continuous professional development for physicians, and gatekeeping functions which prevent unnecessary appointments and guide patients to the appropriate point of care. .

CONCLUSION

The influence of multiple organizational factors throughout the health-care system indicates that a whole-system approach might be useful in reducing LVC.KEY POINTSWe know little about how organizational factors influence the use of low-value care (LVC) in primary health care.Physicians perceive organizational resources, care processes, improvement activities, and governance as influences on the use of LVC and LVC-reducing strategies.This study provides insights about how these factors influence LVC use.Strategies at multiple levels of the health-care system may be warranted to reduce LVC.

Strategies for de-implementation of low-value care-a scoping review

Background

The use of low-value care (LVC) is a persistent problem that calls for knowledge about strategies for de-implementation. However, studies are dispersed across many clinical fields, and there is no overview of strategies that can be used to support the de-implementation of LVC. The extent to which strategies used for implementation are also used in de-implementing LVC is unknown. The aim of this scoping review is to (1) identify strategies for the de-implementation of LVC described in the scientific literature and (2) compare de-implementation strategies to implementation strategies as specified in the Expert Recommendation for Implementing Change (ERIC) and strategies added by Perry et al.

Method

A scoping review was conducted according to recommendations outlined by Arksey and O’Malley. Four scientific databases were searched, relevant articles were snowball searched, and the journal Implementation Science was searched manually for peer-reviewed journal articles in English. Articles were included if they were empirical studies of strategies designed to reduce the use of LVC. Two reviewers conducted all abstract and full-text reviews, and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data-charting form. The strategies were first coded inductively and then mapped onto the ERIC compilation of implementation strategies.

Results

The scoping review identified a total of 71 unique de-implementation strategies described in the literature. Of these, 62 strategies could be mapped onto ERIC strategies, and four strategies onto one added category. Half (50%) of the 73 ERIC implementation strategies were used for de-implementation purposes. Five identified de-implementation strategies could not be mapped onto any of the existing strategies in ERIC.

Conclusions

Similar strategies are used for de-implementation and implementation. However, only a half of the implementation strategies included in the ERIC compilation were represented in the de-implementation studies, which may imply that some strategies are being underused or that they are not applicable for de-implementation purposes. The strategies assess and redesign workflow (a strategy previously suggested to be added to ERIC), accountability tool, and communication tool (unique new strategies for de-implementation) could complement the existing ERIC compilation when used for de-implementation purposes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01247-y.

Effects of a co-created occupational health intervention on stress and psychosocial working conditions within the construction industry: A controlled trial

Background

Work-related stress problems, i.e., burnout, depression, and anxiety, is a rising global health challenge. Poor mental health also appears to be a challenge for the construction industry, even though the occupational health focus has traditionally been on the physical work environment and musculoskeletal disorders. Yet, studies targeting the organisational level (i.e., work environment, policy) to enhance mental health within the construction industry are scant. Therefore, our first objective was to evaluate the effectiveness of a co-created occupational health intervention on stress and psychosocial working conditions within the construction industry in Sweden. The second objective was to evaluate whether the intervention was implemented as intended, i.e., implementation fidelity. The trial is registered in the ISRCTN clinical trial registry (ISRCTN16548039, http://isrctn.com/).

Methods

This is a controlled trial with one intervention and one matched control group. We co-created the program logic with stakeholders from the intervention group. The essence of the chosen intervention components, duties clarification, and structured roundmaking was enhanced planning and role clarification. We assessed adherence to the intervention and dose delivered (i.e., fidelity). We collected data on the outcomes (role clarity, team effectiveness, planning, staffing, quantitative demands, and the psychosocial safety climate) with online questionnaires at baseline, 12, and 24 months. Marginal means models adjusting for missing data patterns were applied to estimate potential differences in outcomes between groups over time.

Results

Fidelity was considered reasonably high. Yet, we found no intervention effects on the primary outcome stress. All outcomes, except role clarity deteriorated during the trial in the intervention and control group. However, the results indicate a positive effect of the intervention components on professionals' role clarity. The pandemic appears to have negatively affected stress and psychosocial working conditions.

Conclusion

The study's results suggest that co-creating occupational health interventions could be one solution for improved implementation fidelity. More studies are needed to evaluate these intervention components. Also, we recommend researchers of future intervention studies consider using missing not at random, sensitivity analysis.

National governance of de-implementation of low-value care: a qualitative study in Sweden

BACKGROUND

The de-implementation of low-value care (LVC) is important to improving patient and population health, minimizing patient harm and reducing resource waste. However, there is limited knowledge about how the de-implementation of LVC is governed and what challenges might be involved. In this study, we aimed to (1) identify key stakeholders' activities in relation to de-implementing LVC in Sweden at the national governance level and (2) identify challenges involved in the national governance of the de-implementation of LVC.

METHODS

We used a purposeful sampling strategy to identify stakeholders in Sweden having a potential role in governing the de-implementation of LVC at a national level. Twelve informants from nine stakeholder agencies/organizations were recruited using snowball sampling. Semi-structured interviews were conducted, transcribed and analysed using inductive thematic analysis.

RESULTS

Four potential activities for governing the de-implementation of LVC at a national level were identified: recommendations, health technology assessment, control over pharmaceutical products and a national system for knowledge management. Challenges involved included various vested interests that result in the maintenance of LVC and a low overall priority of working with the de-implementation of LVC compared with the implementation of new evidence. Ambiguous evidence made it difficult to clearly determine whether a practice was LVC. Unclear roles, where none of the stakeholders perceived that they had a formal mandate to govern the de-implementation of LVC, further contributed to the challenges involved in governing that de-implementation.

CONCLUSIONS

Various activities were performed to govern the de-implementation of LVC at a national level in Sweden; however, these were limited and had a lower priority relative to the implementation of new methods. Challenges involved relate to unfavourable change incentives, ambiguous evidence, and unclear roles to govern the de-implementation of LVC. Addressing these challenges could make the national-level governance of de-implementation more systematic and thereby help create favourable conditions for reducing LVC in healthcare.

Management strategies to de-implement low-value care-an applied behavior analysis

BACKGROUND

There is a lack of knowledge about management strategies being used to de-implement low-value care (LVC). Furthermore, it is not clear from the current literature what mechanisms are involved in such strategies and how they can change physicians' behaviors. Understanding the mechanisms is important for determining a strategy's potential impact. Applied behavior analysis focuses on processes involved in increasing and decreasing behaviors. Therefore, the aim of this study is to understand what management strategies are being used to de-implement LVC and the possible mechanisms involved in those strategies, using concepts from applied behavior analysis.

METHOD

We applied a qualitative study design using an inductive approach to understand what management strategies are in use and then employed applied behavior analysis concepts to deductively analyze the mechanisms involved in them.

RESULTS

We identified eight different management strategies intended to influence LVC. Five of the strategies were developed at a regional level and had the potential to influence physicians' LVC-related behaviors either by functioning as rules on which LVC to de-implement or by initiating local strategies in each health care center that in turn could influence LVC practices. The local strategies had a stronger potential for influencing de-implementation.

CONCLUSION

Both strategies at a systemic level (regional) and on a local level (health care centers) must be considered to influence LVC-related behaviors. Strategies at the center level have a specific opportunity to impact LVC-related behaviors because they can be tailored to specific circumstances, even though some of them probably were initiated as an effect of strategies on a regional level. Using applied behavior analysis to understand these circumstances can be helpful for tailoring strategies to reduce LVC use.

Co-Creating an Occupational Health Intervention within the Construction Industry in Sweden: Stakeholder Perceptions of the Process and Output

One way to prevent work-related stress, is to implement primary occupational health interventions aimed at improving the psychosocial work environment. However, such interventions have shown a limited effect, often due to implementation failure and poor contextual fit. Co-creation, where researchers, together with end-users and other relevant stakeholders, develop the intervention is increasingly encouraged. However, few studies have evaluated the effects of co-created interventions, and participants’ experience of the co-creation process. This is one of the first studies evaluating stakeholder perceptions of co-creating an occupational health intervention. We applied a thematic analysis, with data from 12 semi-structured interviews with stakeholders involved in the co-creation. Our results show that the respondents, in general, were satisfied with engaging in the co-creation, and they reported an increased awareness regarding risk factors of stress and how these should be handled. Additionally, the respondents described trust in the intervention activities and a good fit into the context. The study indicates that co-creating occupational health interventions can enhance the implementation and the contextual fit.

Building implementation capacity in health care and welfare through team training-study protocol of a longitudinal mixed-methods evaluation of the building implementation capacity intervention

Background

To ensure the provision of high-quality safety and cost-effective health and welfare services, managers and professionals are required to introduce and ensure the routine use of clinical guidelines and other evidence-based interventions. Despite this, they often lack training and support in implementation. This project aims to investigate how a team training intervention, with the goal to build implementation capacity, influences participants’ implementation knowledge and skills, as well as how it influences implementation activities and implementation capacity within participating health and welfare organizations. Furthermore, the aim is to investigate how the organizations’ contexts influence the intervention outcomes.

Methods

The building implementation capacity (BIC) intervention builds on the behavior change wheel, which considers implementation as a matter of behavior change. The intervention will be provided to teams of managers and professionals working in health and welfare organizations and seeking support to implement a guideline- or evidence-based intervention. The intervention consists of a series of interactive workshops that provides the participating teams with the knowledge and skills to apply a systematic implementation model. A longitudinal mixed-methods evaluation, including interviews, surveys, and document analysis, will be applied over 24 months. The normalization process theory measure will be used to assess how the intervention influences implementation activities in practice and implementation capacity in the teams and the wider organizations.

Discussion

This project has an ambition to add to the knowledge concerning how to promote the uptake of research findings into health care by building implementation capacity through team training in implementation. The project’s uniqueness is that it is designed to move beyond individual-level outcomes and evaluate implementation activities and implementation capacity in participating organizations. Further, the intervention will be evaluated over 24 months to investigate long-term outcomes of implementation training.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00233-7.

Challenges to ensuring valid and useful waiting time monitoring - a qualitative study in Swedish specialist care

BACKGROUND

Access to health care is an essential health policy issue. In several countries, waiting time guarantees mandate set time limits for assessment and treatment. High-quality waiting time data are necessary to evaluate and improve waiting times. This study's aim was to investigate health care providers and administrative management professionals' perceptions of validity and usefulness of waiting time reporting in specialist care.

METHODS

Semi-structured interviews (n = 28) were conducted with administrative management and care professionals (line managers and care providers) in specialized clinics in the Stockholm Region, Sweden. Clinic-specific data from the waiting time registry was used in the care provider interviews to assess face validity. Clinics were purposefully sampled for maximum variation in complexity of care, volume of production, geographical location, private or public ownership, and local waiting times. Thematic analysis was used.

RESULTS

The waiting time registry was perceived to have low validity and usefulness. Perceived validity and usefulness were interconnected, with mechanisms that reinforced the connection. Structural and cognitive barriers to validity included technical and procedural errors, errors caused by role division, misinterpretation of guidelines, diverging interpretations of nonregulated cases and extensive willful manipulation of data.

CONCLUSIONS

We identify four misconceptions underpinning the current waiting time reporting system: passive dissemination of guidelines is sufficient as implemented, cognitive load of care providers to report waiting times is negligible, soft-law regulation and presentation of outcome data is sufficient to drive improvement, and self-reported data linked to incentives poses a low risk of data corruption. To counter low validity and usefulness, we propose the following for policy makers and administrative management when developing and implementing waiting time monitoring: communicate guidelines with instructions for operationalization, address barriers to implementation, ensure quality through monitoring of implementation and adherence to guidelines, develop IT ontology together with professionals, avoid parallel measurement infrastructures, ensure waiting times are presented to suit management needs, provide timely waiting time data, enable the study of single cases, minimize manual data entry, and perform spot-checks or external validity checks. Several of these strategies should be transferable to waiting time monitoring in other contexts.

Effect and process evaluation of a multicomponent public health intervention to increase the use of primary care-based mental health services amongst children with a migrant background in Stockholm, Sweden: a protocol for a mixed-methods study

INTRODUCTION

The overall aim of the project is to understand how to increase access to, and use of, primary care-based mental health services for children and youth from a migrant background with mild to moderate mental health problems.

METHODS AND ANALYSIS

The study will be undertaken in Haninge municipality in Stockholm, Sweden. The study has three intervention components: (1) A health communication intervention targeting parents of children/youth with a migrant background; (2) Training of professionals and volunteers who potentially have contact with parents and children with a migrant background, in order to increase the number of referrals to primary care-based mental health services, and (3) Increasing access to care at a primary care-based mental health service for children, using various strategies to lower barriers to care. The complex multicomponent intervention will be studied with an effect and a process evaluation methodology.

ETHICS AND DISSEMINATION

All planned studied are approved by the Swedish Ethical Review Authority dnr 2017-135-31/5, 2019-06275, 2020-03640, 2020-06341, 2020-03642 and 2020-04180. Informed consent, written or verbal, will be obtained from all participants. The results of the project will be published continually in peer-reviewed scientific journals and disseminated to relevant stakeholders nationally and within Haninge municipality.

How do healthcare professionals make decisions concerning low-value care practices? Study protocol of a factorial survey experiment on de-implementation

BACKGROUND

A large number of practices used in health care lack evidence of effectiveness and may be unnecessary or even cause harm. As such, they should be de-implemented. While there are multiple actors involved in de-implementation of such low-value care (LVC) practices, ultimately, the decision to abandon a practice is often made by each health care professional. A recent scoping review identified 6 types of factors affecting the utilization vs. abandonment of LVC practices. These factors concern health care professionals, patients, outer context, inner context, processes, and the characteristics of LVC practice itself. However, it is unclear how professionals weigh these different factors in and how these determinants influence their decisions about abandoning LVC practices. This project aims to investigate how health care professionals account for various factors as they make decisions regarding de-implementation of LVC practices.

METHODS

This project will be carried out in two main steps. First, a factorial survey experiment (a vignette study) will be applied to empirically test the relevance of factors previously identified in the literature for health care professionals' decision-making about de-implementation. Second, interactive workshops with relevant stakeholders will be carried out to develop a framework for professionals' decision-making and to offer suggestions for interventions to support de-implementation of LVC practices.

DISCUSSION

The project has the potential to contribute to improved understanding of the decision-making involved in de-implementation of LVC practices. We will identify which factors are more important when they make judgments about utilizing versus abandoning LVC practices. The results will provide the basis for recommendations concerning appropriate interventions to support de-implementation decision-making processes.

A Participatory Intervention to Improve the Psychosocial Work Environment and Mental Health in Human Service Organisations. A Mixed Methods Evaluation Study

Work-related stress is a global problem causing suffering and economic costs. In Sweden, employees in human service occupations are overrepresented among persons on sick leave due to mental health problems such as stress-related disorders. The psychosocial work environment is one contributing factor for this problem, making it urgent to identify effective methods to decrease stress at the workplace. The aim of the study is to evaluate a participatory intervention to improve the psychosocial work environment and mental health using an embedded mixed methods design. The study is a controlled trial with a parallel process evaluation exploring fidelity and participants’ reactions to the intervention activities, experiences of learning and changes in behaviours and work routines. We collected data through documentation, interviews and three waves of questionnaires. Our results show small changes in behaviours and work routines and no positive effects of the intervention on the psychosocial work environment nor health outcomes. One explanation is end-users’ perceived lack of involvement over the process causing the intervention to be seen as a burden. Another explanation is that the intervention activities were perceived targeting the wrong organisational level. A representative participation over both content and process can be an effective strategy to change psychosocial working conditions and mental health.

A dynamic systems view of clinical genomics: a rich picture of the landscape in Australia using a complexity science lens

Background

Clinical genomics represents a paradigm shifting change to health service delivery and practice across many conditions and life-stages. Introducing this complex technology into an already complex health system is a significant challenge that cannot be managed in a reductionist way. To build robust and sustainable, high quality delivery systems we need to step back and view the interconnected landscape of policymakers, funders, managers, multidisciplinary teams of clinicians, patients and their families, and health care, research, education, and philanthropic institutions as a dynamic whole. This study holistically mapped the landscape of clinical genomics within Australia by developing a complex graphic: a rich picture. Using complex systems theory, we then identified key features, challenges and leverage points of implementing clinical genomics.

Methods

We used a multi-stage, exploratory, qualitative approach. We extracted data from grey literature, empirical literature, and data collected by the Australian Genomic Health Alliance. Nine key informants working in clinical genomics critiqued early drafts of the picture, and validated the final version.

Results

The final graphic depicts 24 stakeholder groups relevant to implementation of genomics into Australia. Clinical genomics lies at the intersection of four nested systems, with interplay between government, professional bodies and patient advocacy groups. Barriers and uncertainties are also shown. Analysis using complexity theory showed far-reaching interdependencies around funding, and identified unintended consequences.

Conclusion

The rich picture of the clinical genomic landscape in Australia is the first to show key stakeholders, agencies and processes and their interdependencies. Participants who critiqued our results were instantly intrigued and engaged by the graphics, searching for their place in the whole and often commenting on insights they gained from seeing the influences and impacts of other stakeholder groups on their own work. Funding patterns showed unintended consequences of increased burdens for clinicians and inequity of access for patients. Showing the system as a dynamic whole is the only way to understand key drivers and barriers to largescale interventions. Trial Registration: Not applicable

Supplementary Information

The online version contains supplementary material available at 10.1186/s12920-021-00910-5.

Determinants for the use and de-implementation of low-value care in health care: a scoping review

BACKGROUND

A considerable proportion of interventions provided to patients lack evidence of their effectiveness. This implies that patients may receive ineffective, unnecessary or even harmful care. However, despite some empirical studies in the field, there has been no synthesis of determinants impacting the use of low-value care (LVC) and the process of de-implementing LVC.

AIM

The aim was to identify determinants influencing the use of LVC, as well as determinants for de-implementation of LVC practices in health care.

METHODS

A scoping review was performed based on the framework by Arksey and O'Malley. We searched four scientific databases, conducted snowball searches of relevant articles and hand searched the journal Implementation Science for peer-reviewed journal articles in English. Articles were included if they were empirical studies reporting on determinants for the use of LVC or de-implementation of LVC. The abstract review and the full-text review were conducted in duplicate and conflicting decisions were discussed until consensus was reached. Data were charted using a piloted data charting form and the determinants were inductively coded and categorised in an iterative process conducted by the project group.

RESULTS

In total, 101 citations were included in the review. Of these, 92 reported on determinants for the use of LVC and nine on determinants for de-implementation. The studies were conducted in a range of health care settings and investigated a variety of LVC practices with LVC medication prescriptions, imaging and screening procedures being the most common. The identified determinants for the use of LVC as well as for de-implementation of LVC practices broadly concerned: patients, professionals, outer context, inner context, process and evidence and LVC practice. The results were discussed in relation to the Consolidated Framework for Implementation Research.

CONCLUSION

The identified determinants largely overlap with existing implementation frameworks, although patient expectations and professionals' fear of malpractice appear to be more prominent determinants for the use and de-implementation of LVC. Thus, existing implementation determinant frameworks may require adaptation to be transferable to de-implementation. Strategies to reduce the use of LVC should specifically consider determinants for the use and de-implementation of LVC.

REGISTRATION

The review has not been registered.

Change and improvement 50 years in the making: a scoping review of the use of soft systems methodology in healthcare

Introduction

Improving the quality of healthcare has proven to be a challenging task despite longstanding efforts. Approaches to improvements that consider the strong influence of local context as well as stakeholders’ differing views on the situation are warranted. Soft systems methodology (SSM) includes contextual and multi-perspectival features. However, the way SSM has been applied and the outcomes of using SSM to stimulate productive change in healthcare have not been sufficiently investigated.

Aim

This scoping review aimed to examine and map the use and outcomes of SSM in healthcare settings.

Method

The review was based on Arksey and O’Malley’s framework. We searched six academic databases to January 2019 for peer-reviewed journal articles in English. We also reviewed reference lists of included citations. Articles were included if they were empirical studies focused on the application of SSM in a healthcare setting. Two reviewers conducted the abstract review and one reviewer conducted the full-text review and extracted data on study characteristics, ways of applying SSM and the outcomes of SSM initiatives. Study quality was assessed using Hawker’s Quality Assessment Tool.

Result

A total of 49 studies were included in the final review. SSM had been used in a range of healthcare settings and for a variety of problem situations. The results revealed an inconsistent use of SSM including departing from Checkland’s original vision, applying different tools and involving stakeholders idiosyncratically. The quality of included studies varied and reporting of how SSM had been applied was sometimes inadequate. SSM had most often been used to understand a problem situation and to suggest potential improvements to the situation but to a lesser extent to implement and evaluate these improvements.

Conclusion

SSM is flexible and applicable to a range of problem situations in healthcare settings. However, better reporting of how SSM has been applied as well as evaluation of different types of outcomes, including implementation and intervention outcomes, is needed in order to appreciate more fully the utility and contribution of SSM in healthcare.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05929-5.

Why do they do it? A grounded theory study of the use of low-value care among primary health care physicians

Background

The use of low-value care (LVC) is widespread and has an impact on both the use of resources and the quality of care. However, few studies have thus far studied the factors influencing the use of LVC from the perspective of the practitioners themselves. The aim of this study is to understand why physicians within primary care use LVC.

Methods

Six primary health care centers in the Stockholm Region were purposively selected. Focus group discussions were conducted with physicians (n = 31) working in the centers. The discussions were coded inductively using a grounded theory approach.

Results

Three main reasons for performing LVC were identified. Uncertainty and disagreement about what not to do was related to being unaware of the LVC status of a practice, guidelines perceived as conflicting, guidelines perceived to be irrelevant for the target patient population, or a lack of trust in the guidelines. Perceived pressure from others concerned patient pressure, pressure from other physicians, or pressure from the health care system. A desire to do something for the patients was associated with the fact that the visit in itself prompts action, symptoms to relieve, or that patients' emotions need to be reassured. The three reasons are interdependent. Uncertainty and disagreement about what not to do have made it more difficult to handle the pressure from others and to refrain from doing something for the patients. The pressure from others and the desire to do something for the patients enhanced the uncertainty and disagreement about what not to do. Furthermore, the pressure from others influenced the desire to do something for the patients.

Conclusions

Three reasons work together to explain primary care physicians’ use of LVC: uncertainty and disagreement about what not to do, perceived pressure from others, and the desire to do something for the patients. The reasons may, in turn, be influenced by the health care system, but the decision nevertheless seemed to be up to the individual physician. The findings suggest that the de-implementation of LVC needs to address the three reasons from a systems perspective.

Theories, models, and frameworks for de-implementation of low-value care: A scoping review of the literature

Background:

The aim of this scoping review was to identify theories, models, and frameworks for understanding the processes and determinants of de-implementing low-value care (LVC). We investigated theories, models, and frameworks developed specifically for de-implementation of LVC (conceptual studies) and those that were originally developed for implementation of evidence-based practices but were applied in studies to analyze de-implementation of LVC (empirical studies).

Methods:

We performed a scoping review to identify theories, models, and frameworks used to describe, guide, or explain de-implementation of LVC, encompassing four stages following the identification of the research question: (1) identifying relevant studies; (2) study selection; (3) charting the data; and (4) collating, summarizing, and reporting the results. The database searches yielded 9,642 citations. After removing duplicates, 6,653 remained for the abstract screening process. After screening the abstracts, 76 citations remained. Of these, 10 studies were included in the review.

Results:

We identified 10 studies describing theories, models, and frameworks that have been used to understand de-implementation of LVC. Five studies presented theories, models, or frameworks developed specifically for de-implementation of LVC (i.e., conceptual studies) and five studies applied an existing theory, model, or framework concerning implementation of evidence-based practices (i.e., empirical studies).

Conclusion:

Most of the theories, models, and frameworks that are used to analyze LVC suggest a multi-level understanding of de-implementation of LVC. The role of the patient is inconsistent in these theories, models, and frameworks; patients are accounted for in some but not in others. The findings point to the need for more research to identify the most important processes and determinants for successful de-implementation of LVC and to explore differences between de-implementation and implementation.

Plain language abstract

Achieving an evidence-based practice not only depends on implementation of evidence-based interventions (programs, methods, etc.) but also requires de-implementing interventions that are not evidence-based, that is, low-value care (LVC). Thus, de-implementation is the other side of the coin of an evidence-based practice. However, this is quite a new topic and knowledge is lacking concerning how de-implementation and implementation processes and determinants might differ. It is almost mandatory for implementation researchers to use theories, models, and frameworks (i.e., “theoretical approaches”) to describe, guide, or explain implementation processes and determinants. To what extent are such approaches also used with regard to de-implementation of LVC? And what are the characteristics of such approaches when analyzing de-implementation processes? We reviewed the literature to explore issues such as these. We identified only 10 studies describing theoretical approaches that have been used concerning de-implementation of LVC. Five studies presented approaches developed specifically for de-implementation of LVC and five studies applied an already-existing approach usually applied to analyze implementation processes. Most of the theoretical approaches we found suggest a multi-level understanding of de-implementation of LVC, that is, successfully de-implementing LVC may require strategies that target teams, departments, and organizations and merely focus on individual health care practitioners. The findings point to the need for more research to identify the most important processes and determinants for successful de-implementation of LVC, and to explore differences between de-implementation and implementation. In terms of practice and policy implications, the study underscores the relevance of addressing multiple levels when attempting to de-implement LVC.

Built to last? The sustainability of healthcare system improvements, programmes and interventions: a systematic integrative review

INTRODUCTION

The sustainability of healthcare delivery systems is challenged by ageing populations, complex systems, increasing rates of chronic disease, increasing costs associated with new medical technologies and growing expectations by healthcare consumers. Healthcare programmes, innovations and interventions are increasingly implemented at the front lines of care to increase effectiveness and efficiency; however, little is known about how sustainability is conceptualised and measured in programme evaluations.

OBJECTIVES

We aimed to describe theoretical frameworks, definitions and measures of sustainability, as applied in published evaluations of healthcare improvement programmes and interventions.

DESIGN

Systematic integrative review.

METHODS

We searched six academic databases, CINAHL, Embase, Ovid MEDLINE, Emerald Management, Scopus and Web of Science, for peer-reviewed English journal articles (July 2011-March 2018). Articles were included if they assessed programme sustainability or sustained outcomes of a programme at the healthcare system level. Six reviewers conducted the abstract and full-text review. Data were extracted on study characteristics, definitions, terminology, theoretical frameworks, methods and tools. Hawker's Quality Assessment Tool was applied to included studies.

RESULTS

Of the 92 included studies, 75.0% were classified as high quality. Twenty-seven (29.3%) studies provided 32 different definitions of sustainability. Terms used interchangeably for sustainability included continuation, maintenance, follow-up or long term. Eighty studies (87.0%) clearly reported the timepoints at which sustainability was evaluated: 43.0% at 1-2 years and 11.3% at <12 months. Eighteen studies (19.6%) used a theoretical framework to conceptualise or assess programme sustainability, including frameworks that were not specifically designed to assess sustainability.

CONCLUSIONS

The body of literature is limited by the use of inconsistent definitions and measures of programme sustainability. Evaluations of service improvement programmes and interventions seldom used theoretical frameworks. Embedding implementation science and healthcare service researchers into the healthcare system is a promising strategy to improve the rigour of programme sustainability evaluations.

Implementation of e-mental health for depression and anxiety: A critical scoping review

The aim of this review was to scope the growth and development of implementation research of e-mental healthcare programs for anxiety and depression, the research and evaluation tools used, and the specific implementation processes and outcomes examined. A search of four electronic databases (MEDLINE, EMBASE, PsycINFO, and CINAHL) was conducted from January 2000 to January 2019. Of 33 studies identified, most (n = 28) were published in the last five years. Only 10 used an implementation framework to guide implementation or evaluation. Most studies reported on acceptability (n = 28), appropriateness (n = 23), and feasibility (n = 17). Less commonly reported implementation outcomes were fidelity (n = 10) and adoption (n = 7); with penetration (n = 4), sustainability (n = 3), and implementation cost (n = 2) being studied rarely. Of the 21 studies that used surveys to study implementation outcomes, less than half used a previously published survey (n = 9). More rigorous implementation studies, underpinned by strong theory and real-world understanding, are urgently needed.

Study protocol of a co-created primary organizational-level intervention with the aim to improve organizational and social working conditions and decrease stress within the construction industry - a controlled trial

Background

Within construction industry, physical work exposures have long been recognized as possible determinants for musculoskeletal disorders, but less attention has been given the increasing organizational and social work hazards and stress within this industry. There is to date a lack of knowledge about how to improve organizational and social working conditions and decrease stress within the construction industry.

Methods

This paper outlines the design of a controlled trial to evaluate the effectiveness of a co-created organizational-level intervention with the aim to improve role clarity, quantitative demands, staffing, planning, team effectiveness, psychosocial safety climate and stress. Two regions (> 700 employees) within one large construction company in Sweden will participate as intervention and control group. Further we present the design of the process evaluation assessing fidelity, support from managers, readiness for change and contextual factors. We will utilize questionnaires, semi-structured interviews, observations and documentation as means for data collection, hence a mixed methods approach is applied.

Discussion

The study is expected to contribute to the understanding of how adverse organizational and social working conditions and stress can be improved within the construction industry. By applying co-creation we wish to develop an intervention and implementation strategies that fit to the context, are in line with the needs of end-users and are supported by all management levels - all of which are highlighted features in successful workplace interventions.

Trial registration

ISRCTN, ISRCTN16548039. Registered 12/02/20. Retrospectively registered

Re-energising the way we manage change in healthcare: the case for soft systems methodology and its application to evidence-based practice

BACKGROUND

Updating, improving and spreading the evidence base for healthcare practices has proven to be a challenge of considerable magnitude - a wicked, multi-dimensional problem. There are many interlinked factors which determine how, why and whether any particular implementation effort or intervention succeeds. Soft Systems Methodology (SSM), strongly grounded in systems ideas and complexity science, offers a structured, yet flexible process for dealing with situations that are perceived as problematical and in need of improvement. The aim of this paper is to propose the use of SSM for managing change in healthcare by way of addressing some of the complexities. The aim is further to illustrate examples of how SSM has been used in healthcare and discuss the features of the methodology that we believe can be harnessed to improve healthcare.

DISCUSSION

SSM is particularly suited for tackling real world problems that are difficult to define and where stakeholders may have divergent views on the situation and the objectives of change. SSM engages stakeholders in a learning cycle including: finding out about the problematical situation, i.e. the context in which the problem exists, by developing a rich picture of the situation; defining it by developing conceptual models and comparing these with the real world; taking action to improve it by deciding on desirable and feasible improvements; and implementing these in an iterative manner. Although SSM has been widely used in other sectors, it has not been extensively used in healthcare. We make the case for applying SSM to implementation and improvement endeavours in healthcare using the example of getting clinicians at the hospital level to use evidence-based guidelines.

CONCLUSION

Applying SSM means taking account of the multi-dimensional nature of care settings, and dealing with entrenched and unique contexts, cultures and socio-political ecosystems - precisely those that manifest in healthcare. There are gains to be made in appreciating complexity and facilitating contextualization of interventions, and by approaching improvements in an iterative learning cycle.

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.

CareTrack Aged: the appropriateness of care delivered to Australians living in residential aged care facilities: a study protocol

INTRODUCTION

The aged population is increasing rapidly across the world and this is expected to continue. People living in residential aged care facilities (RACFs) represent amongst the sickest and frailest cohort of the aged population, with a high prevalence of chronic conditions and complex comorbidities. Given the vulnerability of RACF residents and the demands on the system, there is a need to determine the extent that care is delivered in line with best practice ('appropriate care') in RACFs. There is also a recognition that systems should provide care that optimises quality of life (QoL), which includes support for physical and psychological well-being, independence, social relationships, personal beliefs and a caring external environment. The aims of CareTrack Aged are to develop sets of indicators for appropriate care and processes of care for commonly managed conditions, and then assess the appropriateness of care delivered and QoL of residents in RACFs in Australia.

METHODS AND ANALYSIS

We will extract recommendations from clinical practice guidelines and, using expert review, convert these into sets of indicators for 15 common conditions and processes of care for people living in RACFs. We will recruit RACFs in three Australian states, and residents within these RACFs, using a stratified multistage sampling method. Experienced nurses, trained in the CareTrack Aged methods ('surveyors'), will review care records of recruited residents within a 1-month period in 2019 and 2020, and assess the care documented against the indicators of appropriate care. Surveyors will concurrently assess residents' QoL using validated questionnaires.

ETHICS AND DISSEMINATION

The study has been reviewed and approved by the Human Research Ethics Committee of Macquarie University (5201800386). The research findings will be published in international and national journals and disseminated through conferences and presentations to interested stakeholder groups, including consumers, national agencies, healthcare professionals, policymakers and researchers.

Mapping the use of soft systems methodology for change management in healthcare: a scoping review protocol

INTRODUCTION

It is notoriously challenging to implement evidence-based care and to update and improve healthcare practices. One reason for the difficulty is the complexity of healthcare and the powerful influence of context on implementation and improvement efforts. Thus, there is a need for multifaceted, flexible change methods that takes these complexities into consideration. One approach that has the potential in this regard is soft systems methodology (SSM). However, little is known about how SSM has been applied in healthcare settings, making it difficult to assess the usefulness of SSM for implementation science or improvement research. The aim of the proposed scoping review is to examine and map the use and outcomes of SSM in healthcare.

METHODS AND ANALYSIS

The review will adapt the framework outlined by Arksey and O'Malley (2005). Citations will be uncovered through a comprehensive database search of the peer-reviewed literature. Two reviewers will conduct a two-stage review and selection process where the titles/abstracts are examined followed by a screening of full texts of the selected citations. Reference lists of included citations will be snowballed to identify potential additional citations. Inclusion criteria are English language, peer-reviewed empirical papers focusing on the application of SSM in a healthcare setting. Both general information about the citations and information related to the objective of the review will be extracted from the included citations and entered into a data charting form. The extracted information will be reported in diagrams and tables and summarised to present a narrative account of the literature. The proposed review will provide information on the potential for using SSM to affect change in healthcare.

ETHICS AND DISSEMINATION

No primary data will be collected, and thus ethical permission is unnecessary. Dissemination of results include peer-reviewed publications and conference presentations.

Towards sustainable healthcare system performance in the 21st century in high-income countries: a protocol for a systematic review of the grey literature

INTRODUCTION

There is wide recognition that, if healthcare systems continue along current trajectories, they will become harder to sustain. Ageing populations, accelerating rates of chronic disease, increasing costs, inefficiencies, wasteful spending and low-value care pose significant challenges to healthcare system durability. Sustainable healthcare systems are important to patients, society, policy-makers, public and private funders, the healthcare workforce and researchers. To capture current thinking about improving healthcare system sustainability, we present a protocol for the systematic review of grey literature to capture the current state-of-knowledge and to compliment a review of peer-reviewed literature.

METHODS AND ANALYSIS

The proposed search strategy, based on the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines, includes Google Advanced Search, snowballing techniques and targeted hand searching of websites of lead organisations such as WHO, Organisation for Economic Cooperation and Development, governments, public policy institutes, universities and non-government organisations. Documents will be selected after reviewing document summaries. Included documents will undergo full-text review. The following criteria will be used: grey literature document; English language; published January 2013-March 2018; relevant to the healthcare delivery system; the content has international or national scope in high-income countries. Documents will be assessed for quality, credibility and objectivity using validated checklists. Descriptive data elements will be extracted: identified sustainability threats, definitions of sustainability, attributes of sustainable healthcare systems, solutions for improvement and outcome measures of sustainability. Data will be analysed using novel text-mining methods to identify common concept themes and meanings. This will be triangulated with the more traditional analysis and concept theming by the researchers.

ETHICS AND DISSEMINATION

No primary data will be collected, therefore ethical approval will not be sought. The results will be disseminated in peer-reviewed literature, as conference presentations and as condensed summaries for policy-makers and health system partners.

PROSPERO REGISTRATION NUMBER

CRD42018103076.

The Need for Dual Openness to Change: A Longitudinal Study Evaluating the Impact of Employees’ Openness to Organizational Change Content and Process on Intervention Outcomes

This study investigates how individual- and group-level openness to organizational change, concerning change content and process, affects intervention outcomes. The intervention aimed to improve primary health care employees’ competence in and use of information and communication technologies (ICT). Employees’ ( n = 1,042) ratings of their openness to the change content and process as well as of their workgroup’s openness to the change content before the intervention were used to predict ICT competence and its use 18 months later. Openness to the change process predicted both ICT competence and use of competence, while openness to the change content and group openness predicted use of competence only. These results show that individual- and group-level openness to organizational change are important predictors of successful outcomes. Furthermore, employees should be open both to the content of the change and to the process by which the intervention is implemented in order to maximize outcomes.

Effect of enrichment on variation and results in the light/dark test

Several confounding factors may influence the outcome of an experiment and the extent of inter-individual variation. The aim of this study was to investigate if cage enrichment induces an effect on experimental mean values and on inter-individual variation in the light/dark paradigm using diazepam as the anxiolytic drug. The behaviour of 216 naive adult male mice of two different strains (BALB/c and C57BL/6) was studied. The animals were housed in groups of four in 'non-enriched', 'enriched' (nesting material) or 'super-enriched' (nest-box, nesting material, wooden gnawing stick and PVC tube) cages. After 5 weeks the animals were assigned to one of three treatments: control (no injection), sham (saline injection i.p.) or diazepam (1 mg/kg bw i.p.) and tested in the light/dark test for 5 min. Variation data were analysed using three different methods (mean absolute deviation, coefficient of variation and power analysis). The C57BL/6 mice scored higher than BALB/c mice in activity related measurements and showed a less 'emotional' behaviour profile in the pharmacological control situation of the light/dark test. In this study the anxiolytic effect of diazepam was clear in BALB/c mice but absent in C57BL/6 mice. Mice housed in enriched and super-enriched cages gained more weight than mice in non-enriched cages, although food intake was not affected. Generally, the strain of mouse had the greatest impact on both mean values and variation. However, there was no consistent increase for one particular strain. The choice of statistical method for analysing variation may influence the interpretation of within-group variability, but none of the methods showed any significant differences between standard and enriched conditions on variability in any of the parameters measured.

Effects of epidural morphine and transdermal fentanyl analgesia on physiology and behaviour after abdominal surgery in pigs

The objective of this work was to evaluate the physiological and behavioural effects of opioid analgesic treatment in pigs subjected to abdominal surgery. Ten Swedish Landrace × Yorkshire pigs (20 ± 4 kg b.w.) were submitted for intestinal cannulation. The pigs were allocated into two groups during one preoperative, one surgical and two postoperative days. All pigs were anaesthetized with medetomidine, tiletamine and zolazepam. One group was treated with epidural morphine (0.1 mg/kg) preoperatively, and transdermal fentanyl patches (50 μg/kg/h) were applied behind the ear immediately after surgery. The other group received epidural saline (equivalent volume) and placebo patches. All pigs were regularly weighed and clinically examined and repeated blood samples were analysed for serum concentrations of cortisol, β-endorphin and fentanyl. Pre- and postoperative behaviours were evaluated by a swine specialist blinded to the treatment, three times a day, and were also videotape recorded for a total of 84 h per pig. No differences in behaviour were noted by the observer. During the first postoperative 12 h, treated pigs did not differ in activity compared with preoperative recordings, while untreated pigs were found to be less active. The treated group started to show interest in eating immediately after anaesthesia recovery, whereas the placebo group did not. During the 12–60 h postoperative period, the treated group had lower activity levels compared with the preoperative levels, which were similar to those in the placebo group. Treated pigs gained 0.5 ± 0.2 kg during the subsequent two postoperative days, whereas the untreated pigs lost weight throughout the experiment. Cortisol concentration differed immediately after the surgery: Group P had 325 ± 120 nmol/L and Group M 159 ± 49 nmol/L. β-endorphin concentration did not differ between groups. The highest serum fentanyl concentration (0.37 ± 0.3 ng/mL) was measured 24 h postoperatively. Preoperative epidural morphine in combination with postoperative transdermal fentanyl resulted in earlier return to normal activity levels and an immediate weight gain after surgery.

Investigating variations in implementation fidelity of an organizational-level occupational health intervention

BACKGROUND

The workplace has been suggested as an important arena for health promotion, but little is known about how the organizational setting influences the implementation of interventions.

PURPOSE

The aims of this study are to evaluate implementation fidelity in an organizational-level occupational health intervention and to investigate possible explanations for variations in fidelity between intervention units.

METHOD

The intervention consisted of an integration of health promotion, occupational health and safety, and a system for continuous improvements (Kaizen) and was conducted in a quasi-experimental design at a Swedish hospital. Implementation fidelity was evaluated with the Conceptual Framework for Implementation Fidelity and implementation factors used to investigate variations in fidelity with the Framework for Evaluating Organizational-level Interventions. A multi-method approach including interviews, Kaizen notes, and questionnaires was applied.

RESULTS

Implementation fidelity differed between units even though the intervention was introduced and supported in the same way. Important differences in all elements proposed in the model for evaluating organizational-level interventions, i.e., context, intervention, and mental models, were found to explain the differences in fidelity.

CONCLUSION

Implementation strategies may need to be adapted depending on the local context. Implementation fidelity, as well as pre-intervention implementation elements, is likely to affect the implementation success and needs to be assessed in intervention research. The high variation in fidelity across the units indicates the need for adjustments to the type of designs used to assess the effects of interventions. Thus, rather than using designs that aim to control variation, it may be necessary to use those that aim at exploring and explaining variation, such as adapted study designs.

Integrating health promotion with quality improvement in a Swedish hospital

Integration of workplace employee health promotion (HP) and occupational health and safety (OHS) work into organizational quality improvement systems is suggested as a way to strengthen HP and OHS activities in an organization. The aim of this article was to study what consequences integration of HP, OHS and a quality improvement system called kaizen has on the frequency and type of HP and OHS activities. A quasi-experimental study design was used where an integration of the three systems for HP, OHS respectively kaizen, was performed at six intervention units at a Swedish hospital. The remaining six units served as controls. Document analysis of all employees' written improvement suggestions (kaizen notes) during 2013 was conducted. The findings show that the intervention group had more suggestions concerning HP and OHS (n = 114) when compared with the control group (n = 78) and a greater variety of HP and OHS suggestions. In addition, only the intervention group had included HP aspects. In both groups, most kaizen notes with health consideration had a preventive focus rather than rehabilitative. The intervention, i.e. the integration of HP, OHS and kaizen work, had a favourable effect on HP and OHS work when compared with the controls. The results of the study support that this system can work in practice at hospitals.

Challenges in transferring individual learning to organizational learning in the residential care of older people

PURPOSE

The purpose of this paper is to evaluate the outcomes of a workplace learning intervention on organizational learning and to identify factors influencing the creation of organizational learning in residential care of older people.

DESIGN/METHODOLOGY/APPROACH

The study consisted of a quasi-experimental intervention for outcome evaluation. In addition, a case study design was used to identify factors influencing organizational learning. Outcomes were evaluated using the validated Dimensions of the Learning Organization Questionnaire at three time points, and interviews were conducted with nursing staff and managers.

FINDINGS

The intervention had some effects on the individual level, but no improvements in organizational learning were found. Hindering factors for creating organizational learning were poor initial learning climate, managers' uncertainty about their role, lack of ownership and responsibility among staff and managers, managers' views of personality being a more important component than staff development in older people's care, and a lack of systems for capturing acquired knowledge.

ORIGINALITY/VALUE

The study offers suggestions for the transfer of individual-level learning to organizational learning in older people's care.

Changes in minimal alveolar concentration of isoflurane following treatment with medetomidine and tiletamine/zolazepam, epidural morphine or systemic buprenorphine in pigs

The aim of this study was to determine the changes in minimal alveolar concentration (MAC) of isoflurane after treatment with medetomidine and tiletamine/zolazepam (MTZ), epidural morphine or systemic buprenorphine in 11 healthy crossbred pigs. The first part of this study was to measure the baseline values in pigs induced with isoflurane (5%) by face mask and maintained with isoflurane in air and oxygen for 2 h (ISO). Baseline isoflurane MAC was determined using mechanical stimulation. Thereafter, each pig was randomly chosen for a crossover test in which the same animal received three different treatments with at least one week in between treatments. The three treatments were as follows: induction of anaesthesia with medetomidine (0.05 mg kg(-1)) and tiletamine/zolazepam (2.5 mg kg(-1) each) given intramuscularly (MTZ); MTZ followed by epidural morphine (0.1 mg kg(-1); MTZ/M); and MTZ followed by intramuscular buprenorphine (0.1 mg kg(-1); MTZ/B). All pigs were maintained with isoflurane in oxygen and air for 2 h and their lungs were mechanically ventilated. The end-tidal isoflurane concentration, respiratory rate, inspiratory and expiratory O2 and CO2 concentrations, heart rate (HR) and arterial blood pressure were recorded every 10 min. Arterial blood gases were analysed every 20 min. Among the treatment groups, differences in isoflurane MAC were tested using GLM and Tukey's method for further comparison; P < 0.05 was adopted as significant. Isoflurane MAC was 1.9 +/- 0.3%. MTZ reduced isoflurane MAC to 0.6 +/- 0.1%. Additional morphine or buprenorphine reduced the MTZ isoflurane MAC further to 0.4 +/- 0.2 and 0.3 +/- 0.1%, respectively. During MTZ, MTZ/M and MTZ/B mean arterial blood pressure was higher and the alveolar-arterial oxygen tension difference was lower compared with ISO. In conclusion, induction of anaesthesia with MTZ reduced the isoflurane MAC in pigs by 68%. Additional epidural morphine or systemic buprenorphine decreased MTZ isoflurane MAC by 33 and 50%, respectively.

The Concentric Square Field: a multivariate test arena for analysis of explorative strategies

In this study, we describe the behavior of laboratory rats in a recently developed observation arena, the Concentric Square Field (CSF). The CSF contains a number of areas designed to provoke exploration and behaviors associated with risk assessment, risk taking and security seeking in an environment not previously experienced. The model includes sheltered, open and elevated areas, a hole board device, areas with different light conditions, and wall-enclosed corridors. The rationale behind the CSF is to meet the demand for multivariate test situations that are not predictive in the sense of previous definition of a specific purpose of measuring a certain mental state. We define multivariate as being a free choice of where to stay in areas of different qualities. In the present study, identification of risky as opposed to safe areas is based on the retrieval behavior in lactating females and hoarding of food pellets in food-deprived males. Furthermore, we describe the effects of pre-trial food deprivation, immobilization, social stress, strain differences (Sprague-Dawley, Wistar and Lister Hooded males), sex differences (Sprague-Dawley) and repeated testing. Besides the conventional statistics, a principal component analysis (PCA) helped to discriminate between the various categories tested. Our conclusion is that the multivariate and non-predictive test situation (CSF) and the use of PCA provide a good tool for ethoexperimental analysis.

The effect of transdermal delivery of fentanyl on activity in growing pigs

Recently, decreased activity levels have been observed in pigs treated postoperatively with transdermal delivery of fentanyl (TD-fentanyl) after isoflurane anaesthesia. Whether the change in behaviour is related to opioid-induced sedation or to insufficient pain relief remains to be investigated. This study was therefore undertaken to evaluate the effect of TD-fentanyl 50 μg h^-1 on the activity level with and without isoflurane anaesthesia. Eight pigs (25.4 ± 5.2 kg) were submitted to a cross-over study and given two treatments; 1) fentanyl patch applied after 30 minutes of anaesthesia (treatment A/F) and 2) fentanyl patch without anaesthesia (treatment F). The pigs' behaviour was observed from a video recording instantaneously every 10 minutes for 24 h before treatments and up to 72 h after the patch attachment. Venous blood samples were taken 1, 6, 12, 24, 48 and 72 h after the patch application. The behaviour recordings showed that TD-fentanyl did not produce sedation in any pig. No differences were found between the two treatments in activity level, weight gain or serum fentanyl concentration. This concentration measured after 24 h was 0.27 ± 0.11 ng ml^-1 and 0.47 ± 0.40 ng ml^-1 in the A/F and F group, respectively.

In conclusion, transdermal delivery of 50 μg h^-1 fentanyl did not cause inactivity in growing pigs. However, the large variations in serum fentanyl concentration indicate that drug absorption from transdermal patches is unpredictable and sometimes deficient.

Housing-related activity in rats: effects on body weight, urinary corticosterone levels, muscle properties and performance

The cage systems commonly used for housing laboratory rats often result in sedentary and overweight animals, as a consequence of restricted opportunities for physical activity combined with ad libitum feeding. This can have implications both for animal well-being and for the experimental outcome. Physical activity has several known positive effects on health and lifespan, and physical fitness might therefore be incorporated into the animal welfare concept. The aim of this study was to investigate if and how pen housing affects the physical activity and fitness of rats. Thirty-two juvenile male Sprague-Dawley rats were randomly assigned to two different housing systems for a 4-week period. Sixteen rats were kept individually in standard Makrolon type III cages (42x26x18 cm) furnished with black plastic tubes (singly-housed, SI). The remaining rats were kept in groups of eight, housed in large floor pens (150x210 cm), which were furnished with various objects to increase environmental complexity (pen-housed, PH). The body weight gain, and food and water intake of the rats were measured. During weeks 3 or 4, home cage behaviour, urinary cortiosterone/creatinine ratios (CO/CR), and muscle strength on an inclined plane, were measured. Enzyme activities and glycogen content were measured in tissue samples from m. triceps brachii taken after euthanization at the end of the study. There were no significant differences between groups for food and water intake, but PH rats weighed 14% less than SI rats after 4 weeks, and PH rats also had a more diverse behavioural pattern than SI rats. PH rats had significantly higher oxidative capacity (28% more citrate synthase (CS)) and greater glycogen content (28%) in their muscle samples than SI rats. The PH rats performed significantly better on the inclined plane, both in the muscle strength test (mean angle 75+/-0.5 degrees for PH rats and 69+/-0.4 degrees for SI rats) and the endurance strength test (mean time 233+/-22 s for PH rats and 73+/-14 s for SI rats). There was a negative correlation between body weight and results on the inclined plane for the PH rats. There were no significant differences between housing types with respect to CO/CR ratios. In conclusion, the large pen represents an environment that stimulates physical activity and more varied behaviour, which should be beneficial for the welfare of the animal.

Exploration and risk assessment in female wild house mice (Mus musculus musculus) and two laboratory strains

In an evolutionary prospective, it is possible that female mice have a differential perception of novel events than male mice and use a different behavioural strategy for risk assessment. However, female mice are less studied than male mice in behavioural tests of emotional reactivity. The aim of the present study was to investigate how wild-derived female house mice differ from domesticated female mice in their risk assessment strategy. A total of 46 adult female mice, 14 BALB/c, 16 C57BL/6 and 14 Wild mice were tested in the Concentric Square Field (CSF), Open Field (OF) and Elevated Plus Maze (EPM) at three consecutive days. Parameters from all three tests were categorized according to their relevance to activity, exploration, approach-avoidance and use of open areas-shelter. Principal Component Analysis (PCA-SIMCA) of the animals' behaviour in the CSF arena was performed both for females alone and in comparison with earlier findings in male mice under the same test conditions. The results clearly show that female wild mice had a higher avoidance of open areas than the laboratory strains. There was also a trend indicating differences in exploration and approach-avoidance between female Wild and the laboratory strains. The multivariate test, CSF, was able to detect differences between Wild and laboratory strains in three (exploration, approach-avoidance, open-shelter) of the four functional categories measured. Wild female mice also had a higher frequency of rearing and grooming and a lower duration in the corridors in the CSF. Clear strain differences were found between BALB and C57BL in all tests where BALB generally had higher risk assessment and lower risk taking than C57BL. No general sex differences were found, however the sex differences were greater in Wild mice compared to the laboratory strains.

Exploration and risk assessment: a comparative study of male house mice (Mus musculus musculus) and two laboratory strains

The ability to gather information and assess risks in novel environments is crucial for survival and fitness in the wild. Our aim was to characterise behavioural strategies of exploration and risk assessment in novel environments and to investigate in what respects wild house mice differ from domesticated mice. A total of 39 adult male mice from three genetic backgrounds (Wild, BALB/c, and C57BL/6) were tested in three behavioural tests, the concentric square field (CSF), a modified open field (OF), and a conventional elevated plus maze (EPM). In addition to spatial measures, behavioural measures of exploration and risk assessment were registered. The parameters were categorised according to their relevance to activity, exploration, approach-avoidance, and use of open areas/shelter. Wild mice had lower activity and a higher avoidance of open areas than the laboratory strains. No differences were found in exploratory motivation. The BALB/c mice avoided risk areas and showed high risk assessment (SAP), whereas C57BL/6 mice were more explorative and risk taking and showed little risk assessment. Wild mice seemed to have a different behavioural strategy of risk assessment in being more cautious before entering a potentially dangerous zone but explored all zones after assessed as nonrisky. A principal component analysis (PCA) of the animals' behaviour in the CSF arena supported these findings by clearly separating the three strains on the basis of their behavioural performances. It is concluded that there are obvious differences in behavioural strategies related to risk assessment and risk taking among wild mice versus domesticated house mice and also among laboratory strains. The relationship between the animal's risk concern and adaptability is discussed and should be a matter of importance considering animal welfare as well as the experimental aim and protocol.

The rat exposure test: a model of mouse defensive behaviors

In order to facilitate behavioral, and potentially pharmacological, analyses of risk assessment behaviors in mice, a rat exposure test (RET) was devised and evaluated. This test provides a home chamber connected via a tunnel to a rat (predator) exposure area. Familiar substrate is provided to permit burying, and mouse subjects are habituated to the apparatus prior to exposure to an amphetamine-activated rat. In comparison to toy-rat-exposed controls, rat-exposed BALB/c mice showed significantly more risk assessment [stretch attend posture (SAP) and stretch approach], freezing, and avoidance (time in the home chamber), and less time in contact with the wire mesh screen between itself and the threat stimulus. When BALB/c, C57BL/6, CD-1, and Swiss-Webster mice were compared in this test, the two inbred strains (BALB/c and C57BL/6) tended to show more extreme values of particular defensive behaviors, compared to the two outbred strains (Swiss-Webster and CD-1). C57BL/6 mice showed more avoidance and higher levels of SAP, freezing, and burying than BALB/c and more than one or both outbred strains as well. BALB/c mice showed little defensive burying, both in comparison to toy-exposed controls (Experiment 1), and in comparison to the three other strains in Experiment 2. These findings are somewhat at variance with characterizations of anxiety in C57BL/6 and BALB/c mice, based on tests utilizing novel areas and noxious stimuli, suggesting strain differences in defensiveness to such stimuli, compared to antipredator defense levels. Nonetheless, with the exception of burying in BALB/c mice, all strains showed all defensive behaviors measured to the rat stimulus. In particular, SAP levels were substantial in all strains tested, suggesting the usefulness of this test in assessment of the role of risk assessment in defense.

Human-animal interactions and animal welfare in conventionally and pen-housed rats

The main aim of the present study was to explore the significance of large group/greater pen housing (PH) versus standard Makrolon caging (ST) in three behaviour tests related to human-animal interactions in the adult male laboratory rat. The rats' perception of human interaction was tested in three behavioural tests, of which two reflected common practical procedures, capture and restraint, whereas the third was a human approach test in a Y-maze. The rats' anticipatory reactions to handling and the reactions to restraint did not differ between groups, but the ST rats approached a human hand more quickly than did the PH rats (P < 0.01). Although food intake did not differ, ST rats gained more weight (P < 0.01) and had higher total cholesterol values (P < 0.01) than PH rats. In conclusion, this study shows that housing rats in large groups in an enriched environment did not influence their anticipatory reaction to handling in normal handling situations. However, as the PH rats tended to have a longer approach latency than ST rats in the Y-maze there might be underlying differences in appraisal that are not detected in practical situations. In addition, the PH rats weighed less and had lower total cholesterol values than ST rats and their urine corticosterone values were higher. These effects are suggested to be due to higher physical activity in the PH rats, and the implications of this on the animal as a model is discussed.

A simple ethological monitoring system to assess social stress in group-housed laboratory rhesus macaques

The increasing awareness of the importance of social housing of laboratory primates results in the establishment of group housing in many facilities. Our aim was to develop a set of manageable tools to allow continuous monitoring of social relations within groups and to establish an objective, scientific ground on which changes in group composition could be based. We studied 38 adult rhesus monkeys (Macaca mulatta) grouped as five one-male/multi-female groups using focal sampling. We recorded the occurrence and direction of aggressive and non-aggressive social interactions as well as time spent inactive in proportion to social contacts, feeding and other activities. The present analysis clearly identified low-ranking animals with none or few affiliative contacts and who also spent much time inactive and separated from other low-ranking animals. This suggests that the present approach results in useful information concerning compatibility between group members and enables identification of animals experiencing high social stress.

Teat massage after milk ingestion in domestic piglets: an example of honest begging?

After milk ejection, piglets spend several minutes massaging their own teats on the sow. We examined whether this behaviour could be a mammalian counterpart to begging in young birds, and hence be explained by theories of honest begging. In one experiment, the behaviour of piglets was examined in relation to their previous milk intake. In each of 16 litters, one focal piglet was exposed to three treatments for three consecutive sucklings: 'no milk', where the piglet was withheld from the teat during milk ejection; 'extra milk', where it was fed 10 ml of extra milk directly after milk ejection; and 'control', when it received its normal intake. Average massage duration in the next three sucklings was significantly longer in the 'no milk' than in the control piglets. 'No milk' pigs massaged more intensely (number of massage movements/min), were more persistent in attempting to maintain udder contact and spent less time away from the udder. However, there were no significant differences between 'control' and 'extra milk' treatments. In a second experiment, in which we manually massaged teats for 0, 3 or 10 min, we found no significant effect of massage duration on milk output (measured by weighing piglets before and after milk ejection), although massage tended to increase output. We conclude that post-sucking massage in piglets has a number of aspects similar to honest begging in birds. Copyright 1998 The Association for the Study of Animal Behaviour. Copyright 1998 The Association for the Study of Animal Behaviour.