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Clinical Pathway Implementation and Teamwork in Swedish Intensive Care: Challenges in Evidence-Based Practice and Interprofessional Collaboration
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Caring Sciences. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centrum för klinisk forskning i Sörmland (CKFD). (Vårdvetenskap)
2018 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Teamarbete och implementering av standardiserade vårdplaner inom svensk intensivvård : Utmaninga med interprofessionellt samarbete och evidensbaserad praktik (Swedish)
Abstract [en]

Suboptimal quality of care is an evident issue in current healthcare services. Clinical pathways (CPs) have the potential to facilitate evidence-based practice and interprofessional teamwork, and thereby improve patient safety and quality of care.

The overall aim of the thesis was to develop comprehensive empirical knowledge and understanding of CP implementation and teamwork in Swedish intensive care units (ICUs). Four studies were included (I-IV).

Study I was a survey including all Swedish ICUs (N84) and a document analysis of CP examples (n12). In total, 17 (20%) ICUs used CPs and many had implementation plans. The quality, extent and content of the CPs (n56) varied greatly, with sometimes insufficient interprofessionalism, evidence base and renewal.

Study II was a mixed method including ICUs using CPs. The implementation processes were retrospectively explored through questionnaire data (n15) and qualitative content analysis of interviews with key informants (n10). The CP implementation was revealed as a process directed at realizing the usefulness and creating new habits, which requires enthusiasm, support and time.

Studies III and IV were grounded theory studies in an action research project in an ICU. Study III explored everyday teamwork through focus group interviews with registered nurses, assistant nurses and anesthesiologists, as well as an individual interview with a physiotherapist (n38). Teamwork was revealed as an act of ‘balancing intertwined responsibilities.’ The type of teamwork fluctuated as the team processes were affected by circumstantial factors and involved individuals. Study IV prospectively explored the implementation process of a CP during a five-year period through repeated focus groups and individual interviews, questionnaires and logbooks/field notes, including the interprofessional project group, staff and managers (n71), and retrospective screening of health records (n136). ‘Struggling for a feasible tool’ was revealed as a central phenomenon. The implementation process included contextual and processual circumstances that enforced negotiations to achieve progress, which made the process tentative and prolonged and had consequences on the process output.

In conclusion, CP implementation processes are affected by multiple interplaying factors. Although progress has been achieved in evidence-based practice and interprofessional collaboration there is still potential for substantial improvements, emphasizing a need for further facilitation.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2018. , p. 89
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1425
Keywords [en]
Desicion support, Standardized care plans, Research utilization, Organisation, Caring sciences
Keywords [sv]
Beslutstöd, Vårdplanering, Organisation, Forskningsanvändning, Vårdvetenskap
National Category
Anesthesiology and Intensive Care
Research subject
Caring Sciences
Identifiers
URN: urn:nbn:se:uu:diva-339967ISBN: 978-91-513-0227-0 (print)OAI: oai:DiVA.org:uu-339967DiVA, id: diva2:1178478
Public defence
2018-03-23, Sal IX, Universitetshuset, Biskopsgatan 3, Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2018-02-26 Created: 2018-01-29 Last updated: 2018-04-03
List of papers
1. Prevalence and quality of clinical pathways in Swedish intensive care units: a national survey
Open this publication in new window or tab >>Prevalence and quality of clinical pathways in Swedish intensive care units: a national survey
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2014 (English)In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 20, no 1, p. 48-57Article in journal (Refereed) Published
Abstract [en]

RATIONALE, AIMS AND OBJECTIVES

To identify the prevalence of clinical pathways (CPs) in Swedish intensive care units (ICUs) and to explore the quality, content and evidence base of the documents.

METHODS

A descriptive and explorative survey of all Swedish ICUs (N84) and a review of submitted examples of CPs (n12) were conducted.

RESULTS

CPs were in use at 20% of the Swedish ICUs. There was a significant geographic variation but no relationship between the use of CPs and category of hospital, type of ICU, size of ICU or type of health record applied. In total, 56 CPs were reported within a range of scopes and extensions. The content of the ICUs' CPs, as well as the degree to which they were interprofessional, evidence based, and renewed varied.

CONCLUSIONS

Progress has been made in relation to CPs in recent years, but there is potential for further improvements. None of the ICUs had CPs that contained all key characteristics of a high-quality, interprofessional and evidence-based CP identified in the literature. Greater knowledge sharing and cooperation within the field would be beneficial, and further research is needed.

Keywords
clinical pathways, evidence-based practice, intensive care, organization, professional practice, standardized care plans
National Category
Medical and Health Sciences
Research subject
Anaesthesiology and Intensive Care; Health Care Research; Caring Sciences
Identifiers
urn:nbn:se:uu:diva-207939 (URN)10.1111/jep.12078 (DOI)000330802100008 ()24033437 (PubMedID)
Projects
Standardiserade vårdplaner inom svensk intensivvård
Available from: 2013-09-22 Created: 2013-09-21 Last updated: 2018-01-29Bibliographically approved
2. Factors affecting the implementation process of clinical pathways: A mixed method study within the context of Swedish intensive care
Open this publication in new window or tab >>Factors affecting the implementation process of clinical pathways: A mixed method study within the context of Swedish intensive care
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2015 (English)In: Journal of Evaluation In Clinical Practice, ISSN 1356-1294, E-ISSN 1365-2753, Vol. 21, no 2, p. 255-261Article in journal (Refereed) Published
Abstract [en]

RATIONALE, AIMS AND OBJECTIVES: Clinical pathways (CPs) can improve quality of care on intensive care units (ICUs), but are infrequently utilized and of varying quality. Knowledge regarding factors that facilitate versus hinder successful implementation of CPs is insufficient and a better understanding of the activities and individuals involved is needed. The aim of this study was to explore the implementation process of CPs within the context of ICUs.

METHODS: An exploratory design with a sequential mixed method was used. A CP survey, including all Swedish ICUs, was used to collect quantitative data from ICUs using CPs (n = 15) and interviews with key informants (n = 10) were used to collect qualitative data from the same ICUs. Descriptive statistics and qualitative content analysis were used, and the quantitative and qualitative findings were integrated.

RESULTS: The CP implementation was conceptualized according to two interplaying themes: a process to realize the usefulness of CPs and create new habits; and a necessity of enthusiasm, support and time. Multiple factors affected the process and those factors were organized in six main categories and 14 subcategories.

CONCLUSIONS: Bottom-up initiatives, interprofessional project groups and small ICUs seem to enhance successful implementation of CPs while inadequate electronic health record systems, insufficient support and time constrains can be barriers. Support regarding the whole implementation process from centralized units at the local hospitals, as well as cooperation between ICUs and national guidance, has the potential to raise the quality of CPs and benefit the progress of CP implementation.

National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:uu:diva-244833 (URN)10.1111/jep.12301 (DOI)000351871200013 ()25678495 (PubMedID)
Available from: 2015-02-21 Created: 2015-02-21 Last updated: 2018-01-29Bibliographically approved
3. Balancing intertwined responsibilities: A grounded theory study of teamwork in everyday intensive care unit practice
Open this publication in new window or tab >>Balancing intertwined responsibilities: A grounded theory study of teamwork in everyday intensive care unit practice
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2017 (English)In: Journal of Interprofessional Care, ISSN 1356-1820, E-ISSN 1469-9567, Vol. 31, no 2, p. 233-244Article in journal (Refereed) Published
Abstract [en]

This study aimed to describe and explain teamwork and factors that influence team processes in everyday practice in an intensive care unit (ICU) from a staff perspective. The setting was a Swedish ICU. Data were collected from 38 ICU staff in focus groups with registered nurses, assistant nurses, and anaesthetists, and in one individual interview with a physiotherapist. Constant comparative analysis according to grounded theory was conducted, and to identify the relations between the emerged categories, the paradigm model was applied. The core category to emerge from the data was balancing intertwined responsibilities. In addition, eleven categories that related to the core category emerged. These categories described and explained the phenomenon's contextual conditions, causal conditions, and intervening conditions, as well as the staff actions/interactions and the consequences that arose. The findings indicated that the type of teamwork fluctuated due to circumstantial factors. Based on the findings and on current literature, strategies that can optimise interprofessional teamwork are presented. The analysis generated a conceptual model, which aims to contribute to existing frameworks by adding new dimensions about perceptions of team processes within an ICU related to staff actions/interactions. This model may be utilised to enhance the understanding of existing contexts and processes when designing and implementing interventions to facilitate teamwork in the pursuit of improving healthcare quality and patient safety.

Keywords
Grounded theory, intensive care unit, interprofessional care, interviews, practice, roles, teamwork
National Category
Health Sciences
Identifiers
urn:nbn:se:uu:diva-317286 (URN)10.1080/13561820.2016.1255184 (DOI)000395098400017 ()28140715 (PubMedID)
Available from: 2017-03-13 Created: 2017-03-13 Last updated: 2018-01-29Bibliographically approved
4. Struggeling for a feasible tool- the process of implementing a clinical pathway in intensive care: A grounded theory study
Open this publication in new window or tab >>Struggeling for a feasible tool- the process of implementing a clinical pathway in intensive care: A grounded theory study
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(English)Manuscript (preprint) (Other academic)
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:uu:diva-337410 (URN)
Available from: 2017-12-26 Created: 2017-12-26 Last updated: 2018-01-29

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