| 31. |
- Klompstra, Leonie, 1982-
(författare)
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Physical activity in patients with heart failure : motivations, self-efficacy and the potential of exergaming
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Adherence to recommendations for physical activity is low in patients with heart failure (HF). It is essential to explore to what extent and why patients with HF are physically active. Self-efficacy and motivation for physical activity are important in becoming more physically active, but the role of self-efficacy in the relationship between motivation and physical activity in patients with HF is unknown. Alternative approaches to motivate and increase self-efficacy to exercise are needed. One of these alternatives might be using exergames (games to improve physical exercise). Therefore, it is important to obtain more knowledge on the potential of exergaming to increase physical activity.The overall aim was to describe the physical activity in patients with HF, with special focus on motivations and self-efficacy in physical activity, and to describe the potential of exergaming to improve exercise capacity.Methods: Study I (n = 154) and II (n = 101) in this thesis had a cross-sectional survey design. Study III (n = 32) was a 12-week pilot intervention study, including an exergame platform at home, with a pretest-posttest design. Study IV (n = 14) described the experiences of exergaming in patients who participated in the intervention group of a randomized controlled study in which they had access to an exergame platform at home.Results: In total, 34% of the patients with HF had a low level of physical activity, 46% had a moderate level, 23% reported a high level. Higher education, higher selfefficacy, and higher motivation were significantly associated with a higher amount of physical activity. Barriers to exercise were reported to be difficult to overcome and psychological motivations were the most important motivations to be physically active. Women had significantly higher total motivation to be physically active. Self-efficacy mediated the relationship between exercise motivation and physical activity; motivation leads to a higher self-efficacy towards physical activity.More than half of the patients significantly increased their exercise capacity after 12 weeks of using an exergame platform at home. Lower NYHA-class and shorter time since diagnosis were factors significantly related to the increase in exercise capacity. The mean time spent exergaming was 28 minutes per day. Having grandchildren and being male were related to more time spent exergaming.The analysis of the qualitative data resulted in three categories describing patients’ experience of exergaming: (i) making exergaming work, (ii) added value of exergaming, (iii) no appeal of exergaming.Conclusion: One-third of the patients with HF had a low level of physical activity in their daily life. Level of education, exercise self-efficacy, and motivation were important factors to take into account when advising patients with HF about physical activity. In addition to a high level of motivation to be physically active, it is important that patients with HF have a high degree of exercise self-efficacy.Exergaming has the potential to increase exercise capacity in patients with HF. The results also showed that this technology might be suitable for some patients while others may prefer other kinds of physical activity.
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| 32. |
- Lindh Falk, Annika, 1967-
(författare)
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Interprofessional Collaboration in Health Care : Education and Practice
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Interprofessional collaboration is of global interest for addressing to the complex health care needs and improving patient safety in health care. Professionals have to develop collaborative skills and the ability to share knowledge. Interprofessional education describes learning activities where students learn with, from and about each other to improve collaboration. The dimension of interprofessional collaboration is complex and includes different collaborative competencies to bring about the best for the patients. To become a professional, often understood as someone exerting expertise within a specific field of practice, involves a learning process that challenges the boundaries of the professions. Boundaries are not only barriers, but also places that increase learning. There is a complexity to studying the phenomenon of interprofessional collaboration and learning regarding how it occurs in education and health care practice. By using a sociomaterial perspective on practice, it is possible to more robustly explore the collaborative context.Aim: The overarching aim of the thesis has been to explore interprofessional collaboration and learning in health care education and in interprofessional health care practice. More specifically, the research questions in the thesis were answered in two studies regarding how professional knowledge is developed and shared in interprofessional undergraduate health care education and in interprofessional health care practice.Methods: A questionnaire was distributed to students from a medicine, nursing, physiotherapy and occupational therapy programme who participated in a two-week period of practice at an Interprofessional Training Ward in Linköping. The data was analysed quantitatively to explore how female and male students experienced their professional identity formation. The open-ended responses were analysed using a sociomaterial perspective on practice.An ethnographic study was conducted in a hospital setting during a period of one year, during which two interprofessional teams were observed. A theory-driven analysis was made using a sociomaterial perspective on practice, and this provided a lens through which the nature of interprofessional collaboration and knowledge sharing could be observed.Findings: The main findings from the questionnaire showed that the practice architectures of the Interprofessional Training Ward, prefigured practices where different professional responsibilities were enacted in ways that were reproducing expected and unexpected roles in a traditional health care practice. That disrupted the students´ practical and general understandings of professional responsibilities and the nature of professional work including their professional identity formation.The findings from the ethnographic study showed different patterns of how knowledge was shared among professionals in their daily work practice as it unfolded, like chains of actions. The patterns arose through activities where collaboration between professionals was planned beforehand, and at other times it arose in more spontaneous or responsive ways. Due to the way the activities were arranged, the nursing assistants were totally or partially excluded from the collaborative practices.Conclusions: The way that educational and health care practices were arranged had an influence on the patterns of interactions between the students as well as the professionals. The arrangement at the Interprofessional Training Ward enabled and constrained the possibilities for students to learn professional and interprofessional competencies. Professional practices in health care hung together through chains of actions that influenced interprofessional collaboration and learning. The relations between human actors, material objects and artifacts are of importance for understanding interprofessional practices.
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| 33. |
- Ljunggren, Stefan, 1988-
(författare)
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Lipoproteomics : Environmental and Genetic Factors Affecting High-Density Lipoprotein (HDL)
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Lipoprotein particles act as lipid transporters in the blood stream, and measuring cholesterol content in specific subclasses of lipoprotein particles has long been, and still is, a frequently used tool to estimate the risk of cardiovascular disease (CVD). High-density lipoprotein (HDL) is a subclass of lipoproteins often regarded as providing protection against CVD via several functions including reverse cholesterol transport and anti-inflammatory capacities. However, the precise relationship between HDL cholesterol levels and health outcome is still unclear. Lately, new approaches to study HDL composition and function have therefore become more important.HDL function is to a large extent dependent on its proteome, containing more than 100 proteins. Investigating the proteome in individuals with altered gene expression for HDL-associated proteins or with known exposure to environmental contaminants may reveal new insights into how HDL metabolism is affected by various factors. This is of interest in order to better understand the role of HDL in CVD.Papers I and II focus on two different mutations in a structural HDL protein, apolipoprotein A-I (L202P and K131del), and one mutation in the scavenger receptor class B-1 (P297S), which is involved in selective lipid uptake of cholesterol mainly into hepatocytes and adrenal cells. The HDL proteome was analyzed using two-dimensional gel electrophoresis and mass spectrometry. The L202P mutation was identified in HDL of the heterozygote carriers together with a significant decrease of apolipoprotein E and increased zinc-alpha-2-glycoprotein. By contrast, the second apolipoprotein AI mutation (K131del) was associated with significantly elevated alpha-1-antitrypsin and transthyretin levels. Protein analyses of the scavenger receptor class B1 P297S heterozygotes showed a significant increase in HDL apoL-1 along with increased free apoE. The carriers showed no difference in antioxidative capability but a significant increase in apoA-I methionine oxidation.Papers III and IV focus on persistent organic pollutants that may influence HDL composition and function. These compounds accumulate in humans, and exposure has been linked to an increased risk of CVD. To provide a better understanding of the HDL system in relation to pollutants, a population living in a contaminated area was studied. Persistent organic pollutants in isolated HDL were quantified using high-resolution gas chromatography mass spectrometry and significantly increased levels were found in individuals with CVD as compared to healthy controls. Furthermore, there was a significant negative association between the pollutants and paraoxonase-1 anti-oxidant activity. Studying the proteome with nano-liquid chromatography tandem mass spectrometry led to the identification of 118 proteins in HDL, of which ten were significantly associated with the persistent organic pollutants.In summary, the present studies demonstrate protein pattern alterations in HDL associated with inherited genetic variants or pollutant exposure. The studies also provide a set of methods that are useful tools to further comprehend the complexity of lipoprotein metabolism and function. The results are important in order to improve our understanding of HDL in CVD and to explain an increased risk of CVD associated with exposure to organic pollutants.
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| 34. |
- Loftås, Per, 1964-
(författare)
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Response to neoadjuvant treatment in rectal cancer surgery
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Rectal cancer is one of the three most common malignancies in Sweden with an annual incidence of about 2000 cases. Current treatment consists of surgical resection of the rectum including the loco-regional lymph nodes in the mesorectum. In advanced cases, neoadjuvant chemo-radiotherapy (CRT) prior to the operative treatment reduces local recurrences and enables surgery. The neoadjuvant treatment can also eradicate the tumour completely, i.e. complete response. This research project was designed to investigate the effects of preoperative radiotherapy/ CRT and analyze methods to predict response to CRT.Study I investigated the expression of the FXYD-3 protein with immunohistochemistry in rectal cancer, with or without preoperative radiotherapy. The results from the total cohort showed that, strong FXYD-3 expression was correlated to infiltrative tumour growth (p = 0.02). In the radiotherapy group, strong FXYD-3 expression was related to an unfavourable prognosis (p = 0.02). Tumours with strong FXYD-3 expression had less tumour necrosis (p = 0.02) after radiotherapy. FXYD-3 expression in the primary tumour was increased compared to normal mucosa (p=0.008). We concluded that FXYD-3 expression was a prognostic factor in patients receiving preoperative radiotherapy for rectal cancer.Study II investigated FXYD-3 expression in tumours that developed local recurrences following surgery and compared this with expression in tumours that did not develop local recurrences. There was no difference in the expression of FXYD-3 between the group that developed local recurrences and the group that did not develop local recurrences. There was no difference in survival between those with strong or weak FXYD-3 expression. We concluded that this study could not confirm the findings from study 1 i.e. that FXYD-3 expression has prognostic significance in rectal cancer.Study III was a register-based study on the incidence and effects of complete response to neoadjuvant treatment. Eight per cent of the patients with adequate CRT to achieve complete response also had a complete histological response of the luminal tumor in the resected bowel. Sixteen per cent of that group had remaining lymph node metastases in the operative specimen. Chemotherapy together with radiotherapy doubled the chance of complete response in the luminal tumour. Patients with remaining lymph node metastases had a lower survival rate compared to those without. We concluded that residual nodal involvement after neoadjuvant treatment was an important factor for reduced survival after complete response in the luminal tumour.Study IV followed up the results from the previous study by re-evaluating magnetic resonance imaging (MRI)- images in patients with complete tumour response. Two experienced MRI radiologists performed blinded re-staging of post CRT MR- images from patients with complete response in the luminal tumour. One group with lymph node metastases and another one without were studied and the results compared with the pathology reports. The sensitivity, specificity, and positive and negative predicted values for correct staging of positive lymph nodes was 37%, 84%, 70% and 57%. The size of the largest lymph node (4.5 mm, p=0.04) seemed to indicate presence of a tumour positive lymph node. We concluded that MRI couldn’t correctly stage patients for lymph node metastases in patients with complete response to CRT in the luminal tumour.
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| 35. |
- Lönnqvist, Susanna, 1986-
(författare)
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Applications of human skin in vitro
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Chronic wounds are a substantial problem in today’s health care and place significant strains on the patient. Successful modelling of the wound healing process is pivotal for the advancement of wound treatment research. Wound healing is a dynamic and multifactorial process involving all constituents of the skin. The progression from haemostasis and inflammation to proliferation of epidermal keratinocytes and dermal fibroblasts, and final scar maturation can be halted and result in a chronic wound that fails to re-epithelialise. The wound healing process constitutes an example of dynamic reciprocity in tissue where cellular changes take place on cues from the extracellular matrix and vice versa when tissue homeostasis is disturbed. The extracellular matrix provides a structural context for the resident cells and the epidermal keratinocytes, and a functioning interplay between the two tissue compartments is crucial for successful wound healing to take place. Work included in this thesis has applied viable human full thickness skin in vitro to investigate the re-epithelialisation process and barrier function of intact skin.The use of full thickness skin in vitro can take into account the contextual aspect of the process where the epidermal keratinocytes are activated and obtain a migratory phenotype, and are continuously dependent on the cues from the extracellular matrix and support of the dermis. When utilising skin for studies on re-epithelialisation, circular standardised full thickness wounds were created and cultured for up to four weeks in tissue culture. In paper I, the organisation of a thick neoepidermis was investigated in the in vitro wound healing model when resident cells were provided with a porous suspended three dimensional gelatin scaffold. In paper II we investigated the use of a fluorescent staining conventionally used for proliferation studies to facilitate the tracing of transplanted epidermal cells in in vitro wounds, in order to improve and expand the use of the model. In paper III the model was utilised to investigate the treatment approach of acidification of wounds to evaluate the suitability of such intervention in regards to keratinocyte function and re-epithelialisation. Studies on re-epithelialisation with the aid of the in vitro wound healing model provided insight in neoepidermal structure with porous gelatin scaffolding in the wound, a novel methodological approach to tracing cells and response to constrained wound healing environment. In paper IV, intact human skin was evaluated for modelling the cytotoxic response after exposure to a known irritant compound. To study barrier function, intact skin was exposed to irritants by restricting exposure topically, and full thickness skin in vitro was found suitable for modelling cytotoxicity responses. Employing human full thickness skin in vitro makes use of the actual target tissue of interest with epidermal and dermal cells, and full barrier function.
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| 36. |
- Neher, Margit, 1959-
(författare)
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Learning Challenges Associated with Evidence-Based Practice in Rheumatology
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Rheumatology is a field of practice that is undergoing many changes, leading to growing demand for rheumatology practitioners to keep up-to-date about the research developments in their field and to implement new findings and recommendations into clinical practice. Research within implementation science has shown that there are numerous barriers to the clinical use of research-based knowledge in health care. Implementation of evidencebased practice (EBP) requires a great deal of learning on the part of practitioners. It is likely that practitioners in rheumatology face similar challenges to those in other clinical fields, but there is a paucity of research concerning the implementation of EBP in rheumatology and the learning required.Aims: The overall aim of the research project was to generate knowledge concerning the learning challenges associated with evidence-based practice in rheumatology.Methods: Qualitative methods were used to explore the use of knowledge sources in rheumatology nursing and the learning opportunities in clinical rheumatology for participants belonging to five professional groups. Quantitative methods sought to examine to what extent evidence-based practice was implemented in clinical rheumatology practice and which individual and organizational factors affected research use. A theory-based study analysed the learning processes associated with achieving an evidence-based practice.Results: Four sources of knowledge were identified for rheumatology nursing practice: interaction with other people in the workplace (peers in particular) and previous knowledge and experience were perceived as preferred sources of knowledge, while written materials and contacts outside the workplace were less privileged. Learning opportunities occurring during daily practice were perceived by participants of all professional groups to consist predominantly of interactions with professional peers in the workplace. Participants perceived a lack of recognized learning opportunities such as continuing professional education and regular participation in rheumatology-specific courses and conferences. Participants also expressed that time for reflection and up-dating knowledge was short in everyday clinical work. The quantitative data showed that while the general interest for EBP was high in rheumatology practice, individual interest and professional self-efficacy related to EBP varied. A longer work-experience in rheumatology, better self-efficacy concerning the use research-based knowledge and more experience from research activities were positively associated with the use of research in practice. The theoretical analysis showed that challenges of implementing evidence-based practice concern not only the acquisition of research-based knowledge and the integration of this knowledge in practice, but also the abandonment of outdated practices.Conclusions: In this thesis, implementation of EBP in rheumatology has been shown to be a complex issue. Social, contextual and individual aspects were found to be involved in the learning processes, the use of knowledge sources and learning opportunities, as well as in the EBP-relevant behaviours that are enacted in clinical rheumatology. The thesis hopes to contribute to a better understanding of the learning challenges in connection with the implementation of EBP in rheumatology practice.
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| 37. |
- Nilsson, Anna, 1984-
(författare)
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Mechanisms Behind Illness-Induced Anorexia
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Loss of appetite is together with fever and malaise hallmarks of infection. Loosing appetite during an acute infection such as influenza does not result in any longlasting effects, but loosing appetite during chronic diseases such as cancer or AIDS constitutes a risk factor for mortality. Food intake regulation during inflammation is orchestrated by the brain in response to peripheral inflammatory signals. It is known that expression of the prostaglandin synthesizing enzyme cyclooxygenase 2 (COX-2) is crucial for the mechanisms underlying inflammation-induced anorexia, and that prostaglandin E2 (PGE2) is involved in anorexia induced by interleukin-1 beta (IL-1β). In this thesis I examined the prostaglandin-pathways proposed to be involved in anorexia. We show that acute anorexia is dependent on COX-2 expression, while cancer-induced anorexia is mediated by cyclooxygenase 1 (COX-1), at least in the initial stages, suggesting that the signaling pathways for chronic- and acute anorexia are distinct. We were able to demonstrate that the pathway underlying acute anorexia is distinct from that of fever, and that taste aversion is prostaglandin independent. We could also show that both acute and chronic anorexia-cachexia is dependent on expression of myeloid differentiation primary response gene (MyD88) in hematopoietic/myeloid cells.In summary, the findings presented in this thesis suggest that anorexia is a result of many different signaling pathways, as opposed to what is the case for several other inflammatory symptoms such as fever and malaise, where the pathways have been shown to be very exclusive. This provides new insight into the diversity of the pathways underlying inflammatory symptoms, which is fundamental for the ability to present potential, symptom-specific drug targets.
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| 38. |
- Raffetseder, Johanna
(författare)
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Interplay of human macrophages and Mycobacterium tuberculosis phenotypes
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Mycobacterium tuberculosis (Mtb) is the pathogen causing tuberculosis (TB), a disease most often affecting the lung. 1.5 million people die annually due to TB, mainly in low-income countries. Usually considered a disease of the poor, also developed nations recently put TB back on their agenda, fueled by the HIV epidemic and the global emergence of drug-resistant Mtb strains. HIV-coinfection is a predisposing factor for TB, and infection with multi-drug resistant and extremely drug resistant strains significantly impedes and lengthens antibiotic treatment, and increases fatality. Mtb is transmitted from a sick individual via coughing, and resident macrophages are the first cells to encounter the bacterium upon inhalation. These cells phagocytose intruders and subject them to a range of destructive mechanisms, aiming at killing pathogens and protecting the host. Mtb, however, has evolved to cope with host pressures, and has developed mechanisms to submerge macrophage defenses. Among these, inhibition of phagosomal maturation and adaptation to the intracellular environment are important features. Mtb profoundly alters its phenotype inside host cells, characterized by altered metabolism and slower growth. These adaptations contribute to the ability of Mtb to remain dormant inside a host during latent TB infection, a state that can last for decades. According to recent estimates, one third of the world’s population is latently infected with Mtb, which represents a huge reservoir for active TB disease. Mtb is also intrinsically tolerant to many antibiotics, and adaptation to host pressures enhances tolerance to first-line TB drugs. Therefore, TB antibiotic therapy takes 6 to 9 months, and current treatment regimens involve a combination of several antibiotics. Patient noncompliance due to therapeutic side effects as well as insufficient penetration of drugs into TB lesions are reasons for treatment failure and can lead to the rise of drug-resistant populations. In view of the global spread of drug-resistant strains, new antibiotics and treatment strategies are urgently needed.In this thesis, we studied the interplay of the primary host cell of Mtb, human macrophages, and different Mtb phenotypes. A low-burden infection resulted in restriction of Mtb replication via phagolysosomal effectors and the maintenance of an inactive Mtb phenotype reminiscent of dormant bacteria. Macrophages remained viable for up to 14 days, and profiling of secreted cytokines mirrored a silent infection. On the contrary, higher bacterial numbers inside macrophages could not be controlled by phagolysosomal functions, and intracellular Mtb shifted their phenotype towards active replication. Although slowed mycobacterial replication is believed to render Mtb tolerant to antibiotics, we did not observe such an effect. Mtb-induced macrophage cell death is dependent on ESAT6, a small mycobacterial virulence factor involved in host cell necrosis and the spread of the pathogen. Although well-studied, the fate of ESAT6 inside infected macrophages has been enigmatic. Cultivation of Mtb is commonly carried out in broth containing detergent to avoid aggregation of bacilli due to their waxy cell wall. Altering cultivation conditions revealed the presence of a mycobacterial capsule, and ESAT6 situated on the mycobacterial surface. Infection of macrophages with this encapsulated Mtb phenotype resulted in rapid ESAT6-dependent host cell death, and ESAT6 staining was lost as bacilli were ingested by macrophages. These observations could reflect the earlier reported integration of ESAT6 into membranes followed by membrane rupture and host cell death.In conclusion, the work presented in this thesis shows that the phenotype of Mtb has a significant impact on the struggle between the pathogen and human macrophages. Taking the bacterial phenotype into account can lead to the development of drugs active against altered bacterial populations that are not targeted by conventional antibiotics. Furthermore, deeper knowledge on Mtb virulence factors can inform the development of virulence blockers, a new class of antibiotics with great therapeutic potential.
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| 39. |
- Rakar, Jonathan
(författare)
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Fibroblast Differentiation and Models of Human Skin
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This thesis combines three publications and one manuscript, covering two principal topics: functional differentiation of human fibroblasts and laboratory models of human skin. The two topics favourably unite in the realm of tissue engineering. This thesis is therefore split into three main parts: 1. a discussion of phenotypic plasticity as it pertains to fibroblasts and the stem cell continuum; 2. a short review of engineered tissue, with particular focus on soluble factors and materials; and, 3. a motivated review of the biology, diversity and culture of skin, including skin construction.The intended goal of our research endeavor was to achieve the formulation of a bioactive therapy for skin regeneration. The main hypothesis was that fibroblast-to-keratinocyte differentiation would facilitate wound healing, and that the protocol for such a method could be adapted to clinical translation. The foundation for the hypothesis lay in the differentiation capabilities of primary dermal fibroblasts (Paper I). However, the goal has not yet been achieved. Instead, intermediate work on the construction of skin for the purpose of creating a model test-bed has resulted in two other publications. The use of excised human skin, a formidable reference sample for tissue engineered skin, has been used to investigate a gelatinbased material in re-epithelialization (Paper II). A first attempt at standardizing a constructed skin model also resulted in a publication: an evaluation of melanocyte influences on keratinocyte-mediated contraction (Paper III).The introduction of melanocytes into a skin model raised questions about other appendages of the integumentary system. Our previous experience with preadipocyte isolation and identification, and our attempts at constructing three-dimensional adipose tissue, motivated further investigations into fibroblast-to-adipocyte differentiation. We investigated the possibility of activating thermogenesis in fibroblasts, a property otherwise reserved for cells of the adipogenic and myogenic lineages. Our attempts were successful, and are presently in manuscript form (Paper IV). Some further experiments and optimizations are necessary before establishing a reproducible protocol for thermogenic induction.The knowledge obtained through these scientific inquiries have moved us closer to achieving our goals, but methodological advances are still necessary. In the meantime, we have new test-beds for investigating different interactions in skin, and that enables many new questions to be asked and answered.
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| 40. |
- Ridelberg, Mikaela, 1982-
(författare)
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Towards safer care in Sweden? : Studies of influences on patient safety
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Patient safety has progressed in 15 years from being a relatively insignificant issue to a position high on the agenda for health care providers, managers and policymakers as well as the general public. Sweden has seen increased national, regional and local patient safety efforts since 2011 when a new patient safety law was introduced and a four-year financial incentive plan was launched to encourage county councils to carry out specified measures and meet certain patient safety related criteria. However, little is known about what structures and processes contribute to improved patient safety outcomes and how the context influences the results.The overall aim of this thesis was to generate knowledge for improved understanding and explanation of influences on patient safety in the county councils in Sweden. To address this issue, five studies were conducted: interviews with nurses and infection control practitioners, surveys to patient safety officers and a document analysis of patient safety reports. Patient safety officers are healthcare professionals who hold key positions in their county council’s patient safety work. The findings from the studies were structured through a framework based on Donabedian’s triad (with a contextual element added) and applying a learning perspective, highlight areas that are potentially important to improve the patient safety in Swedish county councils.Study I showed that the conditions for the county councils’ patient safety work could be improved. Conducting root-cause analysis and attaining an organizational culture that encourages reporting and avoids blame were perceived to be of importance for improving patient safety. Study II showed that nurses perceived facilitators and barriers for improved patient safety at several system levels. Study III revealed many different types of obstacles to effective surveillance of health care-associated infections (HAIs), the majority belonging to the early stages of the surveillance process. Many of the obstacles described by the infection control practitioners restricted the use of results in efforts to reduce HAIs. Study IV of the Patient Safety Reports identified 14 different structure elements of patient safety work, 31 process elements and 23 outcome elements. These reports were perceived by patient safety officers to be useful for providing a structure for patient safety work in the county councils, for enhancing the focus on patient safety issues and for learning from the patient safety work that is undertaken. In Study V the patient safety officers rated efforts to reduce the use of antibiotics and improved communication between health care practitioners and patients as most important for attaining current and future levels of patient safety in their county council. The patient safety officers also perceived that the most successful county councils regarding patient safety have good leadership support, a long-term commitment and a functional work organisation for patient safety work.Taken together, the five studies of this thesis demonstrate that patient safety is a multifaceted problem that requires multifaceted solutions. The findings point to an insufficient transition of assembled data and information into action and learning for improved patient safety.
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