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Bjurling-Sjöberg, Petronella
Alternative names
Publications (7 of 7) Show all publications
Bjurling-Sjöberg, P. (2018). Clinical Pathway Implementation and Teamwork in Swedish Intensive Care: Challenges in Evidence-Based Practice and Interprofessional Collaboration. (Doctoral dissertation). Uppsala: Acta Universitatis Upsaliensis
Open this publication in new window or tab >>Clinical Pathway Implementation and Teamwork in Swedish Intensive Care: Challenges in Evidence-Based Practice and Interprofessional Collaboration
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Alternative title[sv]
Teamarbete och implementering av standardiserade vårdplaner inom svensk intensivvård : Utmaninga med interprofessionellt samarbete och evidensbaserad praktik
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
Desicion support, Standardized care plans, Research utilization, Organisation, Caring sciences, Beslutstöd, Vårdplanering, Organisation, Forskningsanvändning, Vårdvetenskap
National Category
Anesthesiology and Intensive Care
Research subject
Caring Sciences
Identifiers
urn:nbn:se:uu:diva-339967 (URN)978-91-513-0227-0 (ISBN)
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
Bjurling-Sjöberg, P., Wadensten, B., Pöder, U., Jansson, I. & Nordgren, L. (2018). Struggling for a feasible tool - the process of implementing a clinical pathway in intensive care: A grounded theory study. BMC Health Services Research, 18, Article ID 831.
Open this publication in new window or tab >>Struggling for a feasible tool - the process of implementing a clinical pathway in intensive care: A grounded theory study
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2018 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 18, article id 831Article in journal (Refereed) Published
Abstract [en]

Background: Clinical pathways can enhance care quality, promote patient safety and optimize resource utilization. However, they are infrequently utilized in intensive care. This study aimed to explain the implementation process of a clinical pathway based on a bottom-up approach in an intensive care context.

Methods: The setting was an 11-bed general intensive care unit in Sweden. An action research project was conducted to implement a clinical pathway for patients on mechanical ventilation. The project was managed by a local interprofessional core group and was externally facilitated by two researchers. Grounded theory was used by the researchers to explain the implementation process. The sampling in the study was purposeful and theoretical and included registered nurses (n31), assistant nurses (n26), anesthesiologists (n11), a physiotherapist (n1), first- and second-line managers (n2), and health records from patients on mechanical ventilation (n136). Data were collected from 2011 to 2016 through questionnaires, repeated focus groups, individual interviews, logbooks/field notes and health records. Constant comparative analysis was conducted, including both qualitative data and descriptive statistics from the quantitative data.

Results: A conceptual model of the clinical pathway implementation process emerged, and a central phenomenon, which was conceptualized as 'Struggling for a feasible tool,' was the core category that linked all categories. The phenomenon evolved from the 'Triggers' ('Perceiving suboptimal practice' and 'Receiving external inspiration and support'), pervaded the 'Implementation process' ('Contextual circumstances,' 'Processual circumstances' and 'Negotiating to achieve progress'), and led to the process 'Output' ('Varying utilization' and 'Improvements in understanding and practice'). The categories included both facilitating and impeding factors that made the implementation process tentative and prolonged but also educational.

Conclusions: The findings provide a novel understanding of a bottom-up implementation of a clinical pathway in an intensive care context. Despite resonating well with existing implementation frameworks/theories, the conceptual model further illuminates the complex interaction between different circumstances and negotiations and how this interplay has consequences for the implementation process and output. The findings advocate a bottom-up approach but also emphasize the need for strategic priority, interprofessional participation, skilled facilitators and further collaboration.

National Category
Health Care Service and Management, Health Policy and Services and Health Economy Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:uu:diva-364675 (URN)10.1186/s12913-018-3629-1 (DOI)000449346000002 ()30400985 (PubMedID)
Available from: 2018-10-31 Created: 2018-10-31 Last updated: 2019-01-04Bibliographically approved
Bjurling-Sjöberg, P., Wadensten, B., Pöder, U., Jansson, I. & Nordgren, L. (2017). Balancing intertwined responsibilities: A grounded theory study of teamwork in everyday intensive care unit practice. Journal of Interprofessional Care, 31(2), 233-244
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
Bjurling-Sjöberg, P., Wadensten, B., Pöder, U., Nordgren, L. & Jansson, I. (2015). Factors affecting the implementation process of clinical pathways: A mixed method study within the context of Swedish intensive care. Journal of Evaluation In Clinical Practice, 21(2), 255-261
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
Bjurling-Sjöberg, P., Jansson, I., Wadensten, B., Engström, G. & Pöder, U. (2014). Prevalence and quality of clinical pathways in Swedish intensive care units: a national survey. Journal of Evaluation In Clinical Practice, 20(1), 48-57
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
Bjurling-Sjöberg, P., Engström, G., Lyckner, S. & Rydlo, C. (2013). Intensive care nurses' conceptions of a critical pathway in caring for aortic-surgery patients: a phenomenographic study. Intensive & Critical Care Nursing, 29(3), 166-173
Open this publication in new window or tab >>Intensive care nurses' conceptions of a critical pathway in caring for aortic-surgery patients: a phenomenographic study
2013 (English)In: Intensive & Critical Care Nursing, ISSN 0964-3397, E-ISSN 1532-4036, Vol. 29, no 3, p. 166-173Article in journal (Refereed) Published
Abstract [en]

The aim of the present study was to identify and describe intensive care nurses' different conceptions of a critical pathway in caring for patients that have undergone aortic-surgery. Individual semi-structured interviews with eight specialist registered nurses at a Swedish intensive care unit were conducted and phenomenographically analysed. Three descriptive categories, with a total of five sub-categories, constituted the outcome-space of how the pathway was conceived of in caring: as a guide open to individual patients needs (clinical judgement governs caring and patient autonomy governs caring), as an instrument to promote patient safety (a source of knowledge, a planning tool and a reference standard) and as a source of support for professional confidence. In accordance with current literature, the nurses in the present study identified a number of advantages in applying the pathway in caring even if they were also conscious that the use of a pathway can give rise to unreflective standardisation. The nurses' conceptions indicate that the pathway prescribed for managing patients who have undergone aortic surgery is supportive and facilitates patient safety without jeopardising respect for the patient's individual care needs. This insight may be used to influence a thoughtful dialogue about the practice of pathways in intensive care.

Keywords
Critical pathways, Caring, Intensive care, Aortic aneurysm, Clinical pathways, Standardized care plans
National Category
Nursing
Identifiers
urn:nbn:se:uu:diva-207938 (URN)10.1016/j.iccn.2012.11.002 (DOI)000209293100006 ()23340011 (PubMedID)
Available from: 2013-09-22 Created: 2013-09-21 Last updated: 2017-12-06Bibliographically approved
Lyckner, S., Bjurling Sjöberg, P. & Engström, G. (2010). Critical pathway for patients undergoing aortic-surgery: impact on postoperativecare at an intensive care unit in Sweden. International Journal of Care Pathways, 14(1), 10-14
Open this publication in new window or tab >>Critical pathway for patients undergoing aortic-surgery: impact on postoperativecare at an intensive care unit in Sweden
2010 (English)In: International Journal of Care Pathways, Vol. 14, no 1, p. 10-14Article in journal (Refereed) Published
Abstract [en]

The aim of the present study was to identify and describe intensive care nurses’different conceptions of a critical pathway in caring for patients that have undergone aorticsurgery.Individual semi-structured interviews with eight specialist registered nurses at aSwedish intensive care unit were conducted and phenomenographically analysed. Three descriptivecategories, with a total of five sub-categories, constituted the outcome-space of how thepathway was conceived of in caring: as a guide open to individual patients needs (clinical judgementgoverns caring and patient autonomy governs caring), as an instrument to promote patientsafety (a source of knowledge, a planning tool and a reference standard) and as a source ofsupport for professional confidence.In accordance with current literature, the nurses in the present study identified a number ofadvantages in applying the pathway in caring even if they were also conscious that the use of apathway can give rise to unreflective standardisation. The nurses’ conceptions indicate that thepathway prescribed for managing patients who have undergone aortic surgery is supportive andfacilitates patient safety without jeopardising respect for the patient’s individual care needs.This insight may be used to influence a thoughtful dialogue about the practice of pathways inintensive care.

Keywords
Critical pathways, clinical pathway, caring, aotic surgery, intensive care, standardized care plans
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-207950 (URN)10.1258/jicp.2009.009018 (DOI)
Available from: 2013-09-22 Created: 2013-09-22 Last updated: 2014-03-19Bibliographically approved
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