| 1. |
- Carlén, Kristina
(författare)
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Predictors of mental health in adolescents - with a salutogenic perspective
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Mental health in adolescence is an increasing public health concern. Over half of all mental disorders debut by 14 years of age and remain largely untreated up to adulthood, which underlines the importance of early detection. Mental health is a complex concept that consists of both mental well-being and mental ill-health (including mental health problems and mental disorders). However, the development of mental health during the transition period from childhood to adulthood is dependent on the coping strategies used to meet everyday stressors. Therefore, the framework is salutogenic, looking at the world from a resource perspective to promote mental well-being. However, finding predictors also include identifying risk factors of mental ill-health.The overall aim of the thesis was to investigate predictors of mental health in adolescents from a longitudinal perspective. The Finnish Family Competence (FFC) study was used with adolescents at 15 years of age and their parents, with a follow-up at 18 years of age. Also, Swedish data material was used, The Longitudinal Research on Development In Adolescence (LoRDIA) with adolescents at 12-13 years and a follow-up at 17 years. In sub-studies I, II, and III the outcome was a probable mental health diagnosis determined by a standardised Development and Well-being Assessment (DAWBA) interview. In sub-study IV the outcome was perceived mental health status (MHS).The results showed that a strong sense of coherence was associated with a decreased risk for subsequent mental disorders (sub-study I) and that self-esteem was negatively associated with future mental well-being (sub[1]study IV). Further, low levels of mental health problems reported by the adolescents (sub-study II) or by their parents (sub-study III) were related to a decreased risk for subsequent mental disorders. There was a gender aspect that affected the results and which showed girls as having more internal mental health problems or mental disorders. Other factors indicating an increased risk of mental ill-health were parental low age at childbirth and socioeconomic factors such as the mother’s low educational level, father’s blue-collar profession, and a poor economic situation in the family.The results from this thesis underline the importance of having a salutogenic approach when dealing with mental health in adolescence to identify coping resources for stressors in Antonovsky’s ‘River of Life’. The school might be an arena for creating interventions with a resource perspective for strengthening a sense of coherence and self-esteem, and for alleviating perceived mental health problems.
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| 2. |
- Mårtensson, Sophie
(författare)
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Bridging the gap between caring theory and nursing practice : Learning experiences of undergraduate nursing students in a caring behavior course
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Healthcare providers are obligated to practice with scientific knowledge in order to deliver high quality and safe care based on patients’ needs. Despite this obligation, complaints from care recipients and their significant others regarding healthcare providers’ lack of compassion and competent care in their professional encounters have increased. In the discipline of nursing, theoretical structures of caring, conceptualized as behaviors, have been established as the heart and core value of guidance in all nursing practice. In nursing education, however, caring has tended to be taught as an intangible aspect of nursing practice, described as hidden curricula, thus, focus more on developing knowledge and psychomotor skills instead of learning caring behaviors. Studies that examine how undergraduate nursing students can learn caring behaviors explicitly are rare. Thus, a stronger emphasis on the learning of caring in the context of a caring behavior course that uses a variety of learning didactics is needed. Without adequate theoretical structures for caring-based observational behavioral instruments assessing verbal and non-verbal caring and non-caring behaviors, there is little evidence to help develop the learning of caring behaviors.Aim: The overall aim of this thesis was to study how a caring behavior course in undergraduate nursing education influenced students’ learning of caring behaviors.Method: This thesis was conducted among undergraduate nursing students at a university in Sweden. The participants attended a 7.5-credit (five-week) Caring Behavior Course (the CBC) in semester four during spring and fall 2018 and spring 2019. The CBC was facilitated through a student-centered learning approach intertwined into reflective practice with the learning didactics of narrative pedagogy and simulation; it comprised six voluntary lectures, five mandatory seminars, and two mandatory caring behavior simulation days and examinations. All data were collected from the students participating in the CBC. Two of the four scientific papers constituting this thesis had a qualitative design based on focus group interviews (paper I) and individual written reflections (paper II). Analyses was conducted using qualitative content analysis. One paper had an instrument development design to develop and test an observational behavioral instrument based on Swanson’s Theory of Caring (paper III). Lastly, one paper had a quantitative observational design using the CBCS on video-recorded observational behavioral data collected in the CBC (paper IV). Analyses was conducted using descriptive statistics and Wilcoxon signed rank test (paper IV).Results: The undergraduate nursing students’ participation in the CBC influenced their learning of caring behaviors. It deepened their understanding and knowledge of caring. The students became aware that learning caring is a task that requires effort because the meaning of caring encompasses nurses’ active engagement in practicing caring behaviors. These findings are also supported through the observational behavioral instrument, through the developed Caring Behavior Coding Scheme based on Swanson’s Theory of Caring; it was found that participation in the CBC influenced the undergraduate nursing students verbal and non-verbal caring and non-caring behaviors.Conclusions: This thesis demonstrated that bridging the gap between caring theory and nursing practice in the CBC using a variety of learning didactics influenced undergraduate nursing students’ learning of caring behaviors. The results contributed to strengthening the knowledge that caring and learning are parallel processes in the undergraduate nursing students’ development into becoming compassionate and competent caring nurses, with the intended outcome of patient healing and well-being.
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| 3. |
- Ahonen, Hanna
(författare)
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The multifaceted concept of oral health : Studies on a Swedish general population and perspectives of persons with experience of long-term CPAP-treated obstructive sleep apnea
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Oral health is a multifaceted and changeable part of our overall health and well-being as it contributes to important everyday functions such as eating, talking, and conveying feelings. Our oral health can be affected by a range of determinants, one of which is obstructive sleep apnea [OSA] treated with continuous positive airway pressure [CPAP]. Even though xerostomia has been frequently reported upon, the possible relationship between oral health and CPAP-treated OSA is not clearly understood. The World Dental Federation [FDI] recently proposed a definition and theoretical framework of oral health, intended to be globally applicable and to move dentistry toward a more promotive approach. By using the FDI’s framework as a basis for exploration, studies in a general population can increase the understanding of different aspects of oral health and set the frame of reference for whether and how CPAP-treated OSA can be experienced to affect a person’s oral health.The overall aim of this thesis was to gain a deeper understanding of how the FDI’s theoretical framework of oral health can be applied in a general population and how oral health is experienced in a specific population of persons with increased risk for adverse oral health.The FDI’s framework was explored with empirical data from a general population (N=630) and a population of persons with experience of CPAP-treated OSA (N=18). In papers I and II, the FDI framework was tested and evaluated with quantitative methods (principal component analysis and structural equation modeling), using cross-sectional data from the Jönköping studies. In papers III and IV, qualitative methods (directed content analysis and critical incident technique) were used where personal views and experiences were explored using individual semi-structured interviews.The findings in paper I showed that factors such as dental caries, periodontal disease, experience of xerostomia, and aesthetic satisfaction can be included in the FDI’s component the core elements of oral health. In paper II, driving determinants and moderating factors were found to have direct effects on all core elements of oral health except aesthetic satisfaction. Three of the core elements of oral health (oral health-related quality of life, aesthetic satisfaction, and xerostomia) had direct effects on the latent variable overall health and well-being. Driving determinants and moderating factors had no direct effect on overall health and well-being, and no indirect effects were found. In paper III, the study participants’ views on oral health determinants were described and could be categorized into all the FDI framework dimensions. The component driving determinants could include a range of determinants affecting a person’s oral health such as CPAP treatment, age, the influence of family and social surroundings, interdental cleaning, willingness to change when needed, and relationship with oral healthcare professionals. In paper IV, the study participants described both negative and positive experiences occurring with or without their CPAP. The negative experiences included increased xerostomia, pain or discomfort, tooth wear, and negative feelings. The positive experiences included decreased xerostomia and improved oral health habits due to improved sleep. Many of the difficulties could be managed by easily accessible facilitators. The experiences the study participants described could be included in all the FDI framework components.In conclusion, the FDI’s framework can be applied in a general population to describe different components of oral health, and is also useful to describe a person’s views and experiences of oral health in a specific population. CPAP treatment could be considered an oral health determinant as it can affect a person’s oral health. Both positive and negative experiences can contribute to CPAP adherence as negative experiences often can be successfully managed.
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| 4. |
- Aronson, Olov, 1991-
(författare)
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Understanding the social integration of adolescents of foreign origin : Longitudinal investigations of inter-origin friendship formation
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The present dissertation aims to understand some of the opportunities for, and influences on, the social integration of adolescents of foreign origin in Sweden. Informed by previous research, the dissertation suggests that successful social integration involves friendship formation between peers of similar origins (intra-origin friendship formation) as well as friendship formation between peers of different origins (inter-origin friendship formation). Social integration can be difficult to achieve in practice because most individuals tend to be homophilic and form intra-origin friendships rather than inter-origin friendships.Four studies based on longitudinal data are presented in the dissertation. The first study seeks to widen the understanding of refugee girls’ friendship formation through a qualitative analysis of interviews with refugee girls. The second study estimates stochastic actor-oriented models to investigate the friendship formation of adolescents with supportive and/or controlling parent-child relationships. The third article presents cross-lagged panel models for the reciprocal longitudinal associations between friendship formation and two forms of leisure: visits to youth centers and participation in structured leisure activities. Finally, the fourth study uses stochastic actor-oriented models to analyze with whom adolescents form friendships when they are involved in different forms of digital leisure, including online communication, video watching, and digital gaming.The refugee girls in the qualitative study stated that they formed close friendships with family members, such as cousins and siblings, rather than with peers of native origin because they experienced the latter as too dissimilar from themselves. The adolescents in the first quantitative study formed relatively more inter-origin friendships when their parents were supportive and fewer inter-origin friendships when their parents were controlling. According to the third study, visits to youth centers were associated with a larger number of intra-origin friendships among adolescents of foreign origin, while participation in structured leisure activities, such as sports and cultural projects, was related to more friendship formation regardless of origin. The fourth study suggested that native adolescents who were involved in digital gaming formed fewer friendships with native peers and had fewer friends outside of the school class, and foreign adolescents who communicated more online formed fewer friendships with native classmates but more friendships outside of the school class.All four studies indicate that the social integration of adolescents of foreign origin is not an automatic process that invariably happens when adolescents of different origins are mixed in the same location. When adolescents organize their own social lives away from the involvement of adults, they seem to remain or become more homophilic and form more friendships with peers of their own origin. By contrast, native and foreign adolescents tend to form more inter-origin friendships when adults provide them with support and structured social activities. In other words, the social integration of foreign adolescents seems to require supportive and committed adults, who contribute to facilitating inter-origin friendship formation.
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| 5. |
- Bergerum, Carolina, 1967-
(författare)
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Patient and public involvement in hospital quality improvement interventions : the mechanisms, monitoring and management
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- This dissertation focuses on the mechanisms, monitoring and management of patient and public involvement in hospital quality improvement (QI) interventions. Findings from a literature review generated an initial programme theory (PT) on active patient involvement in healthcare QI interventions (Paper 1). Empirical studies were also undertaken in order to describe what was actually happening in the hospital QI teams and what patients and professionals experience influence their joint involvement (Paper 2), and to compare hospital leaders’ and managers’ experiences of managing QI interventions involving patients and the public (Paper 3). Finally, it was studied how patient-reported measures stimulate patient involvement in QI interventions in practice (Paper 4). The research had a qualitative design. The approach was descriptive and comparative, and the studies were carried out prospectively. Data were collected in two hospital organisations in Sweden and in one hospital organisation in the Netherlands. Data collection methods were a literature search (Paper 1), interviews and field observations (Paper 2 and 3) and data collection meetings (Paper 4). Altogether, 93 team meetings and meetings between the team leaders and management were attended and a total of 20 days of study visits with different forms of meetings were made. Twelve patients, 12 healthcare professionals and 17 and 8 hospital leaders and managers, respectively, participated in the interviews and data collection meetings. Realist synthesis was used to formulate the initial PT (Paper 1). Constructivist grounded theory was used to analyse and describe what was happening in the QI teams and how it was experienced by the team members (Paper 2). To compare hospital leaders’ and managers’ different, contextual meanings in Sweden and the Netherlands, the reflexive thematic analysis informed by critical realism was used (Paper 3). To order, manage and map data from 31 examples of local QI interventions associated to patient-reported measures, the framework method was used (Paper 4). The results formulate a generic PT on the mechanisms, monitoring and management perspectives of co-produced QI interventions in hospital services where patients and the public are involved. The PT provides a hypothesis on the various mechanisms at play and outcomes obtained at the different levels of hospital organisations in the process. It is argued that focus should be on experiences, interaction, relationships and dialogue, integration of context, and the matching of hospital resources to patient and public demands and needs. Subsequently, the outcome will be the resources and reasoning interplay resulting in actions and processes, experiences and knowledge, ‘product’ benefits, emotions, judgements and motivations. Monitoring constitutes an important feedback loop to enable such learnings. The PT aligns the perspectives of the clinical microsystem, improvement science and the service-dominant logic, and has a potential to explain how patient and public involvement in QI interventions might work.
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| 6. |
- Diaz Cruz, Maria Araceli
(författare)
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Exploring vitamin D and steroid hormone receptors – from healthy elderly to prostate cancer cells
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The genetic background together with environmental factors and lifestyle are key contributors to the health of an individual. Genetic background is inherited and irreversible unless mutations occur. However, lifestyle habits (i.e., diet, stress, physical activity, smoking, and alcohol consumption) are modifiable factors that contribute to health or disease by affecting methylation of DNA, which regulates transcription of genes.One of the most relevant lifestyle habits for health is maintaining adequate vitamin D levels in the body as vitamin D promotes calcium and phosphate absorption, supports the nervous and immune system function, and protects bone and muscle structure. Extreme low levels of vitamin D, vitamin D deficiency, has become a global public health concern, especially in the elderly population as vitamin D deficiency can lead to several health problems such as bone fracture, decreased muscle strength, cardiovascular and autoimmune diseases, depression, and breast, pancreatic, and prostate cancer.Prostate cancer is an uncontrolled growth of cells within the prostate gland in the male reproductive system. Human prostate carcinomas are sensitive to androgens, and hormonal ablation therapy gives a temporary remission, followed by a relapse to an androgen-insensitive state. This indicates that steroid hormones, especially androgens, play a significant role in human prostatic carcinogenesis. The molecular effect of vitamin D as a steroid hormone and which steroid hormone receptor (SHR) mediates this effect are not fully understood.This research project aims to increase our knowledge about SHRs, primarily the vitamin D receptors, in both health and disease, focusing on genomic, epigenomic, and transcriptomic perspectives in healthy elderly individuals and prostate cancer cells.The results from the studies in this thesis could help us understand the importance of a healthy lifestyle, which includes vitamin D for health, where we found specific methylation markers involved in the down-regulation of cancer pathways that are associated with high physical activity and vitamin D supplementation. We have further confirmed that SHRs rarely work in isolation but rather as a crosstalk at the genomic level to regulate their transcription. Hopefully, this will help clarify the modulation of transcriptional responses in SHRs and explain the development of steroid hormone-dependent cancers such as prostate cancer. Last, but not least, we revealed that genetic and transcriptional markers are associated with the putative vitamin D receptor the protein disulfide isomerase family A member 3 (PDIA3). The genetic markers were detected in a healthy elderly population under vitamin D supplementation. The transcriptional markers, PDIA3, and a novel discovered isoform of PDIA3 (PDIA3N) were related to the androgen and cancer stage of prostate cancer cells and therefore are proposed as candidate markers for clinical diagnosis of prostate cancer.Altogether, these findings support the relevance of studying vitamin D and steroid hormone receptors, especially the PDIA3 receptor, to understand some of the factors related to healthy aging and the etiology and progression of prostate cancer.
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| 7. |
- Egonsdotter, Gunilla
(författare)
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Datorbaserade simuleringar i socionomutbildningen : reflektion och social barnavård
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Socionomutbildningen i Sverige syftar till att ge blivande socialarbetare såväl vetenskaplig som praktisk professionell kunskap. En för utbildningen central fråga handlar dock om hur teori och praktik bäst kan integreras. Risken, menar kritiker, är att teori och praktik separeras: teori blir något som förmedlas i klassrummet och praktik något som studenterna ges tillgång till genom fältförlagda studier i olika professionella miljöer. Mot bakgrund av denna utmaning har olika didaktiska tillvägagångssätt prövats för att koppla samman teori med praktik. Ett sådant tillvägagångssätt är simuleringar, vilket innebär att professionella utmaningar i socialt arbete på olika sätt efterliknas i klassrummet, det vill säga i en miljö där sårbara klienter inte riskerar att komma till skada.Med denna avhandling fokuseras en specifik form av simuleringar, nämligen datorbaserade simuleringar.Avhandlingens syfte är att undersöka om en datorbaserad simulering som didaktiskt verktyg i undervisning av socionomstudenter främjar studenters reflektionsförmåga i sociala barnavårdsärenden. Vidare inbegriper syftet att ge en bild av den internationella omfattningen av liknande didaktiska utvecklingsarbeten samt diskutera möjligheterna av att använda datorbaserade simuleringar också i forskningssyfte.Avhandlingsarbetet bestod av två delar: dels en konstruktionsfas, dels en undersökningsfas.Under konstruktionsfasen utformades den datorbaserade simuleringen SimChild, vars avsikt är att utveckla svenska socionomstudenters förmåga att reflektera inom ett av det sociala arbetets viktigaste och svåraste verksamhetsfält, den sociala barnavården. Under övningar med SimChild antar studenter rollen som yrkesutövande socionomer och ställs inför uppgiften att individuellt göra bedömningar och fatta beslut i ett barnavårdsärende. Den skriftliga information som studenterna successivt får tillgång till är, som ofta är fallet i faktiska ärenden, knapphändig och motstridig. Deltagarna i simuleringen får tillgång till samma ärendebeskrivning men med den viktiga skillnaden att bakgrundsinformation om till exempel barnets etnicitet alternativt kön varieras slumpmässigt. Efter den individuella delen av övningen samlas deltagarna i lärarledda seminarier och får då tillgång till aggregerade data om hur skillnader i bakgrundsvariabler påverkat bedömningar och beslut. Från dessa utgångspunkter ges de möjligheter att reflektera över hur stereotypa uppfattningar om till exempel kön eller etnicitet kan påverka professionellt socialt arbete.Med undersökningsfasen fokuserades den betydelse etnicitet kan ha för bedömningar och beslut genom att barnets namn varierades på ett sätt som skulle kunna indikera olika etniciteter. Studier av sådana SimChild-övningar genomfördes vid tre lärosäten med totalt 176 socionomstudenter. Efter individuella bedömningar och beslut samlades undersökningens respondenter i fokusgrupper som för dem fick ersätta de seminarier som annars följer det individuella arbetet i SimChild. Aggregerade sammanställningar av individuella bedömningar och beslut för respektive lärosäte presenterades och låg till grund för fokusgruppsdiskussionerna. Tre fokusgrupper bestående av vardera åtta studenter, totalt 24 studenter, organiserades i direkt anslutning till de avslutade individuella bedömningen. Fokusgruppsdiskussionerna indikerade att denna typ av datorsimulering kan främja studenters reflektion och självinsikter (artikel I). Studie II illustrerar hur studenterna kunde bli medvetna om hur stereotypa föreställningar kan påverka bedömning i ett barnavårdsärende.Utöver de båda studierna av socionomstudenters upplevelser av SimChild ingår i avhandlingen ytterligare två studier som på olika sätt syftar till att fördjupa diskussionen om användningen av datorbaserade simuleringar i socialt arbete. En scoping review av internationell forskning, med 16 ingående publikationer, visar att datorbaserade simuleringar i utbildning av socialarbetare fortfarande är i en prövande, preliminär fas. Av översikten framgår att datorbaserade simuleringar främst används för att främja specifika färdigheter men också förmåga till reflektion eftersträvas. I den sista artikeln (IV) diskuteras huruvida utvecklingen av datorbaserade simuleringar för undervisningsbruk kan bidra till utvecklingen också av forskningsmetoder i socialt arbete. Diskussionen illustreras med data från en pilotstudie med 63 studenter och flera forskningsfördelar med simuleringar framhålls: studiers externa validitet främjas av realismen i simuleringen medan den interna validiteten främjas genom möjligheter till kontroll.Reflektion utgör en viktig teoretisk ram för avhandlingen och kan förstås som länken mellan socialarbetarens teoretiska kunskaper och praktiska färdigheter. För att förstå studenternas bedömningar och tolkningar i samband med den datorbaserade simuleringen utgår analysen från begreppen reflektion i handling, reflektion över handling och reflektion inför handling. Utöver dessa begrepp tar analysen även avstamp i kritisk reflektion, vilket bland annat innebär att synliggöra studenters förgivettagna föreställningar.En central slutsats i avhandlingen är att simuleringar av SimChilds typ gör det möjligt för socionomstudenter att se skillnader i beslut och bedömningar, reflektera över varför dessa skillnader uppstår och reflektera över den betydelse sådana skillnader kan få för klienter.
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| 8. |
- Emmesjö, Lina
(författare)
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Within an integrated home health care model : Registered nurses’, physicians’, patients’ and their next of kin’s perspectives
- 2024
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Many older patients receive health care from several different healthcare organizations, which may lead uncertainty about the responsibility for their healthcare needs. Integrated care has been argued to aid the healthcare system by addressing the challenge of the complex care needs of older patients with multiple health problems. Previous research has stated that integrated care models often have been developed with a focus on a single diagnosis, which risks overlooking the extensive and complex care needs of older patients. Prior research has also expressed the need to deepen knowledge about how integrated care models influence health care professionals, patients and their next of kin. Moreover, it is important to understand how the COVID-19 pandemic affected integrated care models which may expand knowledge about integrated home health care in crisis situations.The overall aim is to study expectations, perceptions and experiences of integrated home health care through the perspective of registered nurses, physicians, patients and their next of kin.Inductive qualitative designs where data was collected through interviews and field notes in the setting of the mobile integrated care model with a home health care physician (MICM) with registered nurses, physicians and patients and next of kin. Analysis was conducted using qualitative content analysis, phenomenography, and thematic analysis.The emphasis on person-centered care in the MICM was evident in the perceptions of the healthcare professionals about the patients and their next of kin, whom they viewed as persons, not simply recipients of health care. Differences were found in the health care provided in the MICM and in comparison, to other healthcare organizations which did not align with the person-centered care ethics. However, providing health care to patients in their own home benefited the provision of person-centered care – the value base of the MICM. The MICM was created with the goal of implementing individually tailored and coherent health care with increased continuity. The healthcare professionals viewed individual medical healthcare plans as co-created with each patient, and yet no patient could recall participating in this co-creation. The coherency of the MICM was regarded as having been improved by teamwork between the registered nurse and the home healthcare physician. Collaborations with other healthcare professionals rarely occurred and should be improved in the future. Participants reported varying experiences of continuity in the MICM, which influenced the possibility of building relationships. Providing continuity with a home healthcare physician for patients is therefore preferable. The work described in this thesis was conducted during the COVID-19 pandemic. The thesis provides unique insights into an integrated care model during a crisis situation, which the healthcare system may face in similar or different ways in the future. The MICM was upheld as the best way to work in home health care, especially as patients and their next of kin regarded the model as making their daily lives easier.
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| 9. |
- Fröding, Elin
(författare)
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Patient safety and suicide : learning in theory and practice from investigations of suicide as patient harm
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Suicide is a global public health challenge, around 700 000 people die from suicide every year. A large proportion was in contact with healthcare close in time before death, suggesting healthcare to be an important resource in the work with prevention of suicide.The overall aim of this thesis was to increase the knowledge and understanding of suicide as an incident of patient harm, and to find possibilities of changes in the approach to suicide investigations which could contribute to increased learning and improve suicide prevention in healthcare.Four studies were performed: in the first two studies we reviewed investigations of healthcare performed of suicide cases reported to the supervisory authority as patient harm. Study III was a scoping narrative literature review of the problems with the current approaches to investigations of suicide as patient harm and possible changes for improvement. Study IV was an interview study in which I explored the requirements for valuable investigations of suicide from the views of persons with lived experience of suicidality and professionals. All studies were performed in a Swedish context.The majority of suicides reported as incidents of patient harm were reported by a psychiatry healthcare provider. Most suicides occurred shortly after the last contact with healthcare and during outpatient care. Demographically, these cases were representative compared to the suicide cases in the entire population.As incidents of patient harm, suicides differ from most other kinds of reported patient harm in some ways. Only a small proportion occurs in hospitals, most occur in the home of the patient without any witnesses or staff around. Suicide is an act performed by the patient himself/herself and is usually the final outcome of the complex interplay of several different variables with different impacts in different contexts, varying over time and between individuals.It was found that the adaptation of the investigations to the requirements of the supervisory authority contributed to the fact that the learning from the healthcare’s investigations of suicide has levelled off, the same shortcomings and actions were reported over time. The investigations were performed with a strict healthcare provider perspective, with focus on the last contact with the patient, routines, and what went wrong. This resulted in suggested measures for improvement at an organizational micro level without organizational sustainability over time and with a risk to not address organizational system deficiencies.The investigations of suicide as potential patient harm should integrate current knowledge in suicidology and patient safety to enable learning and insights valuable for healthcare improvement. This include a holistic perspective of the patient’s situation, analysis of a longer time period and factors of importance for suicidality, suicide prevention, and patient safety, professionalization of the investigations, analyses across organizational boundaries, and focus on learning. A framework to guide this analysis is suggested in this thesis.The development of knowledge in the science fields of patient safety and suicidology imply the need for a cultural shift in the understanding of suicide as an incident of patient harm. Instead of making a difficult and often to some extent speculative assessment if a suicide had been prevented if other actions had been performed in the contacts with healthcare, and therefore should be investigated and reported as a severe patient harm, or not, the focus in the analyses should be on risk management over time. I propose a framework with factors of importance for a safe healthcare at suicidality to guide this analysis.
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| 10. |
- Gremyr, Andreas
(författare)
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Improving health with and for individuals with schizophrenia using a learning health system approach : From idea to daily practice
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Psychotic disorders like schizophrenia have a typical onset in early adulthood with symptoms of hallucinations and disturbances of thought. Despite knowledge on what constitutes effective schizophrenia care, more than 70% of treatment attempts fail in Sweden, sometimes leading to early death. An appraisal of schizophrenia care shows a lack of ways to jointly plan and evaluate care, and an absence of a trustworthy theory-of-change. The Learning Health System (LHS) is a vision that has been translated into theories and models associated with improved outcomes for patients with other chronic conditions. The aim of this thesis is to enhance the understanding of the applicability of the LHS vision in the context of schizophrenia care, from the perspectives of both individuals and the health system in enabling coproduction of better health by addressing two research questions:i) How can improvement of health for individuals with schizophrenia and improvement of system performance be supported by coproduction in an LHS model?ii) Can an LHS-based intervention, i.e. the use of a point of care dashboard, contribute to better health for individuals with schizophrenia?Studying the existing published knowledge of LHS show that the concept has not yet been applied in mental healthcare settings but has potential to increase patient coproduction, continuous improvement and better health. Different forms of coproduction are supported in the most comprehensive LHS models and applications, ranging from dashboards at point of care to platforms that can help facilitate improvement initiatives.A case study, focused on studying the use and usefulness of a point-of-care dashboard at patient visits in outpatient care at the Department of Schizophrenia Spectrum Disorders at Sahlgrenska University Hospital in western Sweden. Use of the dashboard is associated with improved communication and health for patients. Assessment of the dashboard-project’s complexity using the Non-adoption, abandonment, scale-up, spread and sustainability complexity assessment tool (NASSS-CAT) was perceived as helpful in evaluating challenges and provided insight that can guide future development. An LHS model, that builds on both the reviewing of the literature and practical testing, is proposed.Further research is proposed in two areas, exploration of how dashboard initiatives can support coproduction and better health for individuals with complex chronic conditions and further development of LHS models by studying different LHS initiatives regarding system properties, forms of coproduction at play and effects on health outcomes for individuals and populations.
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