Ewa Wikström

Contemporary leadership in healthcare organizations: fragmented or concurrent leadership.

PURPOSE The purpose of this paper is to gain a deeper understanding of the main contemporary challenges for healthcare leaders in their everyday work practice, and the support they need to master their experienced dilemmas. DESIGN/METHODOLOGY/APPROACH Qualitative in-depth interviews (n=52), and focus-group interviews (n=6) with 31 first-line and 45 second-line healthcare leaders are analysed in line with constructivist grounded theory. FINDINGS In this paper, two leadership models are proposed for defining and differentiating ways of meeting different logics and demands made on leaders in the healthcare sector. The first model is leadership by separating different logics and fragmentation of time. Here, leaders express a desire for support in defining, structuring, dividing, and allocating tasks. The second model is leadership by integrating different logics and currentness of solutions. In this case, leaders want support in strengthening proactive leadership and shaping the basis for participative employeeship. RESEARCH LIMITATIONS/IMPLICATIONS This research is designed to describe what people experience rather than to assess the frequency of that experience in the studied settings. However, it would be interesting to elaborate on the findings of this study using other research methodologies. PRACTICAL IMPLICATIONS The findings contribute to contextual knowledge that is of relevance in supporting healthcare leaders. This is helpful in identifying important conditions that support the establishment of leadership and employeeship, leading to improvements in healthcare practice. ORIGINALITY/VALUE The paper describes how contemporary leadership in the healthcare sector is constituted through different strategies for meeting multiple logics.

Organizing person-centred care in paediatric diabetes: multidisciplinary teams, long-term relationships and adequate documentation

BackgroundType 1 diabetes is one of the most frequent long-term endocrine childhood disorders and the Swedish National Diabetes Register for children states that adolescents (12–18 years) constitute the most vulnerable patient group in terms of metabolic control. The aim of this study was to examine how a multidisciplinary team functions when caring for adolescents with type 1 diabetes.MethodsQualitative interviews were performed with 17 health professionals at a Paediatric Diabetes Care Unit in a Swedish university hospital. The interviews were analysed to gain insight into a multidisciplinary care team’s experiences of various organizational processes and circumstances related to the provision of person-centred paediatric diabetes care.ResultsBuilding long-term relationships with adolescents, the establishment of a multidisciplinary care team and ensuring adequate documentation are vital for the delivery of person-centred care (PCC). Furthermore, a PCC process and/or practice requires more than the mere expression of person-centred values. The contribution of this study is that it highlights the necessity of facilitating and safeguarding the organization of PCC, for which three processes are central: 1. Facilitating long-term relationships with adolescents and their families; 2. Facilitating multi-professional teamwork; and 3. Ensuring adequate documentation.ConclusionThree processes emerged as important for the functioning of the multidisciplinary team when caring for adolescents with type 1 diabetes: building a long- term relationship, integrating knowledge by means of multidisciplinary team work and ensuring adequate documentation. This study demonstrates the importance of clearly defining and making use of the specific role of each team member in the paediatric diabetes care unit (PDCU). Team members should receive training in PCC and a PCC approach should form the foundation of all diabetes care. Every adolescent suffering from type 1 diabetes should be offered individual treatment and support according to her/his needs. However, more research is required to determine how a PCC approach can be integrated into adolescent diabetes care, and especially how PCC education programmes for team members should be implemented.

Multiple Balances in Workplace Dialogue: Experiences of an Intervention in Health Care.

Purpose – This paper aims to illuminate and analyse the participants’ experiences of the influences of a dialogue intervention. Cooperation and coordination in health care require planning of dialogically oriented communication to prevent stress and ill health and to promote health, well-being, learning and efficiency in the organisation. Design/methodology/approach – An intervention method based on dialogue theory, with Socratic provocations and concrete workplace examples enhanced authenticity of conversations. A qualitative study, using qualitative content analysis, entailed interviews with 24 nurses, assistant nurses and paramedics, strategically selected from 156 intervention participants. Findings – Two themes emerged, dialogue-learning processes and dialogue-promoting communicative actions. The first includes risk-taking to overcome resistance and fear of dialogue, expressing openly thoughts and feelings on concrete issues and taboo subjects, listening to and reflecting on one’s own and others’ per...

Constructing accountability in inter-organisational collaboration: the implications of a narrow performance-based focus.

PURPOSE The purpose of this paper is to analyse how accounts of collaboration practice were made and used to construct accountability in the empirical context of coordination associations, a Swedish form of collaboration between four authorities in health and social care. They feature pooled budgets, joint leadership and joint reporting systems, intended to facilitate both collaboration and (shared) accountability. DESIGN/METHODOLOGY/APPROACH Empirical data were collected in field observations in local, regional and national settings. In addition, the study is based on analysis of local association documents such as evaluations and annual reports, and analysis of national agency reports. FINDINGS Accountability is constructed hierarchically with a narrow focus on performance, and horizontal (shared) accountability as well as outcomes are de-emphasised. Through this narrow construction of accountability the coordination associations are re-created as hierarchical and accountability is delegated rather than shared. RESEARCH LIMITATIONS/IMPLICATIONS Features such as pooled budgets, joint leadership and joint reporting systems can support collaboration but do not necessarily translate into shared accountability if accountability is interpreted and constructed hierarchically. PRACTICAL IMPLICATIONS When practice conforms to what is counted and accounted for, using the hierarchical and narrow construction of accountability, the result may be that the associations become an additional authority. That would increase rather than decrease fragmentation in the field. ORIGINALITY/VALUE This research derives from first-hand observations of actor-to-actor episodes complemented with the analysis of documents and reports. It provides critical analysis of the construction and evaluation of accounts and accountability related to practice and performance in collaboration. The main contribution is the finding that despite the conditions intended to facilitate inter-organisational collaboration and horizontal accountability, the hierarchical accountability persisted.

The policy process for health promotion

Aims: The paper aims to contribute to our understanding of the policy process in health promotion by addressing the following questions: What are the characteristics of the policy process in health promotion? How do policy entrepreneurs influence project implementation? Methods: This is a qualitative study with an explorative case study design that uses three different data sources: qualitative interviews, written documents and observations. Results: The paper examines several factors (determinants) that influence the policy process and that, to a lesser extent, are addressed by current models in health policy research. Legitimacy, financial capacity, available structure and political timing are all important determinants that influence the policy process. Policy entrepreneurs, with established networks and knowledge of the environment and its procedures, create legitimacy and provide opportunities for action; however, indistinct organizational boundaries among roles and poorly defined individual responsibilities create policy process uncertainty. As a result, there are lengthy discussions and few decisions, both of which delay the progress of a project. Conclusions: This paper’s theoretical contribution is its analysis of the relationship of policy-making to linear models, via a discussion of policy entrepreneurs, and their importance in the policy process. The paper concludes that we need to consider the influence of policy entrepreneurs, whom build legitimacy and seize action opportunities by coupling the three streams in the policy process, as they help bring projects to fruition. Furthermore, the study points to the importance of policy entrepreneurs throughout the policy process. The paper has practical implications for practitioners whom work with the implementation of community policies.

Environmental and capacity requirements are critical for implementing and sustaining a drug prevention program: a multiple case study of “Clubs against drugs”

Background“Clubs against drugs” (CAD) is a comprehensive program with a systems approach to prevention with the intention of preventing drug use in nightclub environment. In 2001 CAD was developed and implemented in Stockholm and was disseminated to 20 other municipalities in Sweden up until 2010. This study investigates the factors related to the implementation and compares Stockholm to the rest of the municipalities.MethodsA sequential exploratory method was used which consisted of three steps including a questionnaire and two rounds of interviews. Questionnaires included all communities and the interviews included twelve respondents from three example municipalities in the first phase and four respondents from Stockholm in the second phase. The interviews were analyzed using content analysis.ResultsIn Stockholm the program was described as having been implemented and sustained over time. The implementation in the example municipalities was perceived as difficult with many obstacles and achieving sustainability was also described as difficult. Two of three municipalities were not active at the time of this study, illustrating that the program only lasted a few years. Factors identified as being related to implementation outcomes were need assessments, participation, support, collaboration and local enthusiasts.ConclusionsThe capacity to implement and sustain CAD differed substantially between Stockholm and the other municipalities. If the prerequisites and capacity are not sufficient the implementation is not likely to be successful, even when the activities are promoted on a national level like CAD. The needs of the interventions and the capacity to implement the program should be examined before adopting the program. This was not done, probably because the drive to spread the activity was not sufficiently questioned.

Iterative co-creation for improved hand hygiene and aseptic techniques in the operating room : experiences from the safe hands study

BackgroundHand hygiene and aseptic techniques are essential preventives in combating hospital-acquired infections. However, implementation of these strategies in the operating room remains suboptimal. There is a paucity of intervention studies providing detailed information on effective methods for change. This study aimed to evaluate the process of implementing a theory-driven knowledge translation program for improved use of hand hygiene and aseptic techniques in the operating room.MethodsThe study was set in an operating department of a university hospital. The intervention was underpinned by theories on organizational learning, culture and person centeredness. Qualitative process data were collected via participant observations and analyzed using a thematic approach.ResultsDoubts that hand-hygiene practices are effective in preventing hospital acquired infections, strong boundaries and distrust between professional groups and a lack of psychological safety were identified as barriers towards change. Facilitated interprofessional dialogue and learning in “safe spaces” worked as mechanisms for motivation and engagement. Allowing for the free expression of different opinions, doubts and viewing resistance as a natural part of any change was effective in engaging all professional categories in co-creation of clinical relevant solutions to improve hand hygiene.ConclusionEnabling nurses and physicians to think and talk differently about hospital acquired infections and hand hygiene requires a shift from the concept of one-way directed compliance towards change and learning as the result of a participatory and meaning-making process. The present study is a part of the Safe Hands project, and is registered with ClinicalTrials.gov (ID: NCT02983136). Date of registration 2016/11/28, retrospectively registered.