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- Bernhardsson, Susanne, 1958-
(författare)
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Advancing evidence-based practice in primary care physiotherapy : Guideline implementation, clinical practice, and patient preferences
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Research on physiotherapy treatment interventions has increased dramatically in the past 25 years and it is a challenge to transfer research findings into clinical practice, so that patients benefit from effective treatment. Development of clinical practice guidelines is a potentially useful strategy to implement research evidence into practice. However, the impact of guideline implementation in Swedish primary care physiotherapy is unknown. To achieve evidence-based practice (EBP), research evidence should be integrated with clinical expertise and patient preferences, but knowledge is limited about these factors in Swedish primary care physiotherapy.The overall aim of this thesis was to increase understanding of factors of importance for the implementation of EBP in Swedish primary care physiotherapy. Specific aims were: to translate and adapt a questionnaire for the measurement of EBP and guidelines; to investigate physiotherapists’ attitudes, knowledge and behaviour related to EBP and guidelines; to examine clinical practice patterns; to evaluate the effects of a tailored guideline implementation strategy; and to explore patients’ preferences for physiotherapy.The thesis comprises four studies (A-D), reported in five papers. In Study A, a questionnaire for the measurement of EBP and guidelines was translated, cross-culturally adapted, and tested for validity (n=10) and reliability (n=42). Study B was a cross-sectional study in which this questionnaire was used to survey primary care physiotherapists in the county council Region Västra Götaland (n=271). In Study C, a strategy for the implementation of guidelines was developed and evaluated, using the same questionnaire (n=271 at baseline, n=256 at follow-up), in a prospective controlled trial. The strategy was based on an implementation model, was tailored to address the determinants of guideline use identified in Study B, and comprised several components including an educational seminar. Study D was an exploratory qualitative study of patients with musculoskeletal disorders (n=20), using qualitative content analysis.The validity and reliability of the questionnaire was found to be satisfactory. Most physiotherapists have a positive regard for EBP and guidelines, although these attitudes are not fully reflected in the reported use of guidelines. The most important determinants of guideline use were considering guidelines important to facilitate practice and knowing how to integrate patient preferences with guidelines. The tailored, multi-component guideline implementation significantly affected awareness of, knowledge of, and access to guidelines. Use of guidelines was significantly affected among those who attended an implementation seminar. Clinical practice for common musculoskeletal conditions included interventions supported by evidence of various strengths as well as interventions with insufficient research evidence. The most frequently reported interventions were advice and exercise therapy. The interviewed patients expressed trust and confidence in the professionalism of physiotherapists and in the therapists’ ability to choose appropriate treatment, rendering treatment preferences subordinate. This trust seemed to foster active engagement in their physiotherapy.In conclusion: The adapted questionnaire can be used to reliably measure EBP in physiotherapy. The positive attitudes found do not necessarily translate to guideline use, due to several perceived barriers. The tailored guideline implementation strategy used can be effective to reduce barriers and contribute to increased use of guidelines. The clinical practice patterns identified suggest that physiotherapists rely both on research evidence and their clinical expertise when choosing treatment methods. Patients’ trust in their physiotherapist’s competence and preference for active engagement in their therapy need to be embraced by the clinician and, together with the therapist’s clinical expertise, integrated with guideline use in the clinical decision making. Further research is needed on how the EBP components and different knowledge sources can be integrated in physiotherapy practice, as well as on implementation effects on patient outcomes.
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| 2. |
- Westerlund, Stina, 1968-
(författare)
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Lust och olust : elevers erfarenheter i textilslöjd
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim of the thesis is to investigate and analyse students’ expressions of pleasure and displeasure and how these are manifested in actions in the teaching of textile sloyd in lower secondary education. The study’s focus is on students’ expressions of pleasure and displeasure in social action in the working processes of textile sloyd and on how these expressions can be related to learning. The empirical material consists of observations, video and audio recordings, individual interviews and focus group interviews, where video and audio recordings were used as stimulated recall. In all, 32 lessons in textile sloyd and 49 students aged 14-15 years were observed at four different schools. Theoretically, the thesis is based on Mead’s practical intersubjectivity and on Dewey’s theory of experience-based learning and dependence on emotions and actions. Pleasure and displeasure constitute valuating partial aspects of emotions. Based on a socio-cultural perspective, emotions are regarded as practices which arise from different predispositions’ dependence on the social context. The study’s analytical approach is hermeneutical. Critical incidents regarding students’ expressions of pleasure and displeasure in social action found in observations and video and audio recordings were analysed in terms of Mead’s concept of gestures. The events were combined with what the students describe as critical incidents of pleasure and displeasure in the interviews and focus group talks. The material was then thematised. Several situations were then subjected to deeper analysis based on sociality and a change in perspective and related to different concepts of learning. The result of the thesis shows a tripartite semantic structure where students’ pleasure and displeasure in textile sloyd are mainly based on textile sloyd’s specific educational community, students’ relationship to the sloyd object and their experience of the working process. Social interaction, humour and mutual acknowledgement proved to be of importance for the function of pleasure and displeasure in the students’ working processes. The students’ experience of pleasure and displeasure depended on their control of the work, the characteristics of different craft techniques and their awareness of time. Pleasure and displeasure in textile sloyd found an expression in four overarching emotional practices with decisive importance for the students’ opportunities for learning: the repudiating, insecure, accepting and incorporating emotional practice. The study also provides an insight into how different cultural factors enable a certain scope for pleasure and displeasure. In this connection, social changes in relation to objects are discussed, as are changes in sociality and emotionality. Based on the pair of concepts of authenticity and ephemerality and closeness and intensity, cultural changes are visualised that are conceivably important for the students’ experiences of pleasure and displeasure in textile sloyd.
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