Elisabeth Björk Brämberg

Implementation of evidence-based rehabilitation for non-specific back pain and common mental health problems: a process evaluation of a nationwide initiative

BackgroundNationwide implementation of guaranteed access to evidence-based rehabilitation was established in Sweden in 2009, through an Act of the Swedish Government. The rehabilitation guarantee’s primary goal was to increase the rate of return-to-work, reduce and prevent long-term absenteeism after diagnoses related to back pain and common mental health problems. This study aims to develop knowledge about factors influencing large-scale implementation of complex and extensive interventions in healthcare settings.MethodsThree different data sources questionnaires, interviews and documents were used in data collection and analysis. The data were analysed using iterative thematic analysis.ResultsThe following main facilitators contributed to realization of the rehabilitation guarantee: financial incentives, establishment of project organization, recruitment, in-service training and previous experiences of working in similar projects. Barriers were: the rehabilitation guarantee’s short-term project-form, clinicians’ attitudes to and competence in working towards return-to-work, lack of guidelines describing treatment modalities in multimodal rehabilitation, and lack of well-defined criteria for inclusion of patients. Documents revealed that the return-to-work goal became less pronounced during the implementation process. Instead, care and health were more often described in documents used to disseminate information about the rehabilitation guarantee. Intermediate outcomes found were: patients with rehabilitation needs were given more adequate priority, increased readiness for future implementation efforts, and increased general competence in psychotherapy, and team-work, which thus became available to patient groups other than those covered by the rehabilitation guarantee.ConclusionsTo facilitate implementation of established national policy goals in clinical practice, tools are needed that specifically aim at changing clinicians’ attitudes and behaviours in relation to such goals. Our results underline the importance of investing both time and sufficient resources in the activities and in supporting the implementation process.

Essential features influencing collaboration in team-based non-specific back pain rehabilitation: Findings from a mixed methods study.

ABSTRACT The aim of the study presented in this article was to explore how professionals, without guidelines for implementing interprofessional teamwork, experience the collaboration within team-based rehabilitation for people with back pain and how this collaboration influences their clinical practice. This study employed a mixed methods design. A questionnaire was answered by 383 participants and 17 participants were interviewed. The interviews were analysed using content analysis. The quantitative results showed that the participants were satisfied with their team-based collaboration. Thirty percent reported that staff changes in the past year had influenced their clinical practice, of which 57% reported that these changes had had negative consequences. The qualitative findings revealed that essential features for an effective collaboration were shared basic values and supporting each other. Furthermore, aspects such as having enough time for reflection, staff continuity, and a shared view of the team members’ roles were identified as aspects which influenced the clinical practice. Important clinical implications for nurturing and developing a collaboration in team-based rehabilitation are to create shared basic values and a unified view of all team members’ roles and their contributions to the team. These aspects need to be emphasised on an ongoing basis and not only when the team is formed.

Effective teamwork in primary healthcare through a structured patient-sorting system - a qualitative study on staff members’ conceptions

BackgroundPrimary healthcare meets increased demands from an aging population concerning quality and availability while concurrently dealing with a growing shortage of general practitioners and imperfect efficiency in healthcare processes. Reorganization and team development can improve quality and performance but projects in primary care frequently do not attain the targeted results. By developing and introducing a structured patient-sorting system a primary healthcare centre in Western Sweden increased its access rate significantly and employed its medical professionals more efficiently. The aim of this study was to explore staff members’ conceptions of the structured patient-sorting system in order to gain an inside perspective on this project.MethodsIn this qualitative study 16 interviews were conducted over a period of two years and data was analysed using a phenomenographic approach to identify the various conceptions of the eleven participants.ResultsThree categories of description were identified: The system was conceptualized as 1) a framework for the development of patient-centred processes that were clear and consistent, 2) a promotor of professional development and a shared ideal of cooperative practice and 3) a common denominator and catalyst in conflict management.In an overall perspective the system was conceived as being an appropriate platform for promoting transformation into an effective patient-centred primary healthcare team in which organizational development was perceived as a continuous participative process demanding the commitment of all team members.ConclusionsThis study demonstrates that the introduction of a structured patient-sorting system makes it possible for several important change processes to take place concurrently: improvement of healthcare processes, empowerment of professionals and team development. It therefore indicates the importance of an appropriate, contextualized framework to support multiple concomitant quality improvement processes. Knowledge from this study can be used to assist and improve future implementations in primary healthcare centres.

The effects of multimodal rehabilitation on pain-related sickness absence - an observational study.

Abstract Purpose: The aim of the current study was to examine the effects on sickness absence of multimodal rehabilitation delivered within the framework of a national implementation of evidence based rehabilitation, the rehabilitation guarantee for nonspecific musculoskeletal pain. Method: This was an observational matched controlled study of all persons receiving multimodal rehabilitation from the last quarter of 2009 until the end of 2010. The matching was based on age, sex, sickness absence the quarter before intervention start and pain-related diagnosis. The participants were followed by register data for 6 or 12 months. The matched controls received rehabilitation in accordance with treatment-as-usual. Results: Of the participants, 54% (N = 3636) were on registered sickness absence at baseline and the quarter before rehabilitation. The average difference in number of days of sickness absence between the participants who received multimodal rehabilitation and the matched controls was to the advantage of the matched controls, 14.7 days (CI 11.7; 17.7, p ≤ 0.001) at 6-month follow-up and 9.5 days (CI 6.7; 12.3, p ≤ 0.001) at 12-month follow-up. A significant difference in newly granted disability pensions was found in favor of the intervention. Conclusions: When implemented nationwide, multimodal rehabilitation appears not to reduce sickness absence compared to treatment-as-usual. Implications for Rehabilitation A nationwide implementation of multimodal rehabilitation was not effective in reducing sickness absence compared to treatment-as-usual for persons with nonspecific musculoskeletal pain. Multimodal rehabilitation was effective in reducing the risk of future disability pension for persons with nonspecific musculoskeletal pain compared to treatment-as-usual. To be effective in reducing sick leave multimodal rehabilitation must be started within 60 days of sick leave. The evidence for positive effect of multimodal rehabilitation is mainly for sick listed patients. Prevention of sick leave for persons not being on sick leave should not be extrapolated from evidence for multimodal rehabilitation.

Nationwide implementation of a national policy for evidence-based rehabilitation with focus on facilitating return to work: a survey of perceived use, facilitators, and barriers

Abstract Aim: The aim is to assess whether the national policy for evidence-based rehabilitation with a focus on facilitating return-to-work is being implemented in health-care units in Sweden and which factors influence its implementation. Methods: A survey design was used to investigate the implementation. Data were collected at county council management level (process leaders) and clinical level (clinicians in primary and secondary care) using web surveys. Data were analyzed using SPSS, presented as descriptive statistics. Results: The response rate among the process leaders was 88% (n = 30). Twenty-eight percent reported that they had already introduced workplace interventions. A majority of the county councils’ process leaders responded that the national policy was not clearly defined. The response rate among clinicians was 72% (n = 580). Few clinicians working with patients with common mental disorders or musculoskeletal disorders responded that they were in contact with a patient’s employer, the occupational health services or the employment office (9–18%). Nearly, all clinicians responded that they often/always discuss work-related problems with their patients. Conclusions: The policy had been implemented or was to be implemented before the end of 2015. Lack of clearly stated goals, training, and guidelines were, however, barriers to implementation. Implications for rehabilitation Clinicians’ positive attitudes and willingness to discuss workplace interventions with their patients were important facilitators related to the implementation of a nationwide policy for workplace interventions/rehabilitation. A lack of clearly stated goals, training, and guidelines were barriers related to the implementation. The development of evidence-based policies regarding rehabilitation and its implementation has to rely on very structured and clear descriptions of what to do, preferably with the help of practice guidelines. Nationwide implementation of rehabilitation policies has to allow time for preparation including communication of goals and competence assurance in a close collaboration with the end users, namely clinicians and patients. AbbreviationsCBT Cognitive behavioral therapyCFIR Consolidated framework for implementation researchCMD Common mental disordersIPT Interpersonal psychotherapyMMR Multimodal rehabilitationRG Rehabilitation guaranteeRTW Return to workSPSS Statistical package for the social sciences