Since the mid 1990s, alcohol policy in Sweden has undergone major changes and the restrictive policy instruments have been weakened. Alternative and compensatory preventive measures have been sought and the workplace is repeatedly referred to as an important and appropriate arena for prevention. Universal methods, such as disseminating information and education programs, are seen as crucial in order for individuals to be able to make informed choices about their alcohol consumption. The overall purpose of this thesis is to analyze the prerequisites for and the possibilities and barriers associated with alcohol education programs at workplaces. The first paper investigates the general interest in alcohol prevention at workplaces where no interventions had been undertaken. The second paper is an effect study which investigates the effects of a short alcohol education program provided to those employed at a company in Stockholm. In the third paper, the effects of a day-long alcohol education program provided to all persons employed by a municipality are studied. The fourth paper is an interview study, in which the aim is to analyze how the participants in alcohol education programs view their participation and the content and legitimacy of the intervention. The findings suggest that interest in prevention at workplaces is low among employers. In addition, there are difficulties linked to implementation and evaluation, and in achieving and registering any substantial effects. The effect studies noted a significant increase in alcohol-related knowledge and that binge drinking decreased among those who drank the most. The employees found the education programs interesting and valuable but mostly for others, i.e. those who drink too much. Taken together, the studies suggest that it is not reasonable to believe that workplace-based prevention will become a common and effective measure or that it will compensate for the weakened alcohol policy in Sweden. / <p>At the time of the doctoral defense, the following papers were unpublished and had a status as follows: Paper 2: Accepted. Paper 3: Submitted.</p>

Medical decisions should be based on good evidence. But this does not mean that health care professionals should practice evidence-based medicine. This dissertation explores how these two positions come apart, why they come apart, and what we should do about it. I begin by answering the descriptive question, what are current standards of evidence in medicine? I then provide a detailed critique of these standards. Finally, I address the more difficult normative question, how should we determine standards of evidence in medicine? In medicine, standards of evidence have been established by the pervasive evidence-based medicine (EBM) movement. Until now, these standards have not been subjected to comprehensive philosophical scrutiny. I outline and defend a theory of knowledge – a version of Helen Longino’s Critical Contextual Empiricism (CCE) – which enables me to critically evaluate EBM. My version of CCE emphasizes the critical evaluation of background assumptions. In accordance with this, I identify and critically evaluate the three substantive assumptions underlying EBM. First, I argue that medicine should not be held to the restrictive definition of science assumed by proponents of EBM. Second, I argue that epidemiological evidence should not be the only “base” of medical decisions. Third, I argue that not only is the particular hierarchy of evidence assumed by EBM unjustified, but that any attempt to hierarchically rank research methods is incoherent and unjustifiably restricts medical knowledge. Current standards of evidence divert attention from many legitimate sources of evidence. This distorts medical research and practice. In the remainder of the dissertation I propose means for improving not only current standards of medical evidence but also the process of producing and defending future standards. On the basis of four CCE norms, I argue that we have reason to protect and promote those features of the medical community that facilitate diversity, transparency, and critical interaction. Only then can we ensure that the medical community retains its ability to produce evidence that is both rigorous and relevant to practice.

Organizational theory can assist in better understanding how changes made in clinical practice can be sustained in healthcare organizations. Organizational learning and knowledge transfer theories were used to develop and test a theoretical model, “Sustaining in Memory” (SIM) model, to explore how organizations disperse or distribute newly transferred knowledge in knowledge reservoirs situated in the organization. Three hypotheses were generated from the theoretical model and tested with data from a cross sectional postal survey of 148 patient/resident care units in one large Canadian province where a CPG on prevention of falls was widely disseminated. Findings confirmed that fall prevention practice knowledge was transferred and embedded in all six knowledge reservoirs; however, there were three specific knowledge reservoirs that were found to be significant predictors of perceived CPG adherence (activities consistent with the CPG recommendations). These were staff, policy and role expectation knowledge reservoirs. There was variation in the adherence to the eight CPG recommendations with greater adherence to recommendations that were mandatory. Additionally, findings showed that the relationship between staff knowledge reservoir and CPG adherence was the only relationship moderated by the practices that helped to prevent/address knowledge loss through various activities designed for reviewing and updating practice knowledge. Interestingly, although CPG adherence was reported significantly greater in LTC resident care units, its association with patient outcomes was much weaker than in hospital patient care units. Hospital units had significantly greater correlation between perceived CPG adherence and all four of the falls prevention outcomes reported by study participants. Lastly, quality management culture as managed by senior leaders in the organization was also found to be a significant predicator of adherence to the CPG. The research study validated key assumptions made in the theoretical model while helping to clarify the distinct influence of different knowledge reservoirs. The SIM model provided an alternate perspective within which to study knowledge transfer and sustainability of clinical practices and has potential to apply to other change initiatives. This study answered the call for greater theoretically driven studies of CPG implementation as well as attention on the organizational influences of CPG implementation and sustainability.

Postoperative urinary retention (PUR) is a common problem seen after surgery, particularly after orthopedic surgery. There has been a great deal of research done surrounding the causes of PUR and the optimal treatment for PUR, all with conflicting results. Little research has been done with orthopedic nurses to find out how they actually treat PUR, and on what information they base those treatment decisions. Evidence-based practice has been gaining popularity recently and highlights the need for nurses to make treatment decisions based on sound research, patient preferences, clinical expertise, and taking into consideration health care resources and the clinical setting (DiCenso, Ciliska, & Guyatt, 2005). This study investigated nurses' views on the definition of PUR, how they assessed for PUR, how they treated PUR and what they based their treatment decisions on. Ten nurses who worked on orthopedic units were interviewed using a semi-structured format consisting of four questions. The interviews were recorded and then transcribed verbatim by the student researcher. Qualitative description, as described by Sandelowski (2000), was used to analyze data. All nurses defined PUR fairly similarly. Various contributing factors for PUR were mentioned, some that were studied in the literature, and some that were not. Each nurse had a slightly different way of treating PUR, and 'ward routine' was also described differently. Study results point to a need for more research and education in the area of PUR so that all nurses are treating PUR in the same manner based on the same sound knowledge base.

Purpose & Objectives: To foster improved client care and the continued professionalization of Massage Therapy (MT), it is important that MT practitioners research utilization is more clearly understood. The purpose of the study was to explore Massage Therapists (MTs) perceptions of research and their self-reported research utilization. Specifically, to 1) describe MTs perceptions of research and their appraised self-efficacy in research literacy and capacity; 2) better understand the nature of MTs research utilization; 3) identify what practitioner characteristics are associated with research utilization.<p> Methods: Using a sequential explanatory mixed methods design, the study was conducted in two phases. In the first phase, all (815) registered members of the Massage Therapist Association of Saskatchewan (MTAS) were invited to participate in a mail-out survey. In the second phase, semi-structured qualitative interviews using a critical incident framework explored the nature of practitioners use of research. Univariate and logistic regression analysis were conducted using SPSS.<p> Results: In total, 333 questionnaires were returned for a 41% response rate. MTAS members reported overall positive perceptions of research as indicated by high endorsement of its value in adding credibility to MT and by majority agreement that MT practice should be based on research. Reported self-efficacy in various research literacy and capacity skills revealed low levels of knowledge and experience. Reported reference to online research databases, reference to peer-reviewed journals, the belief that MT practice should be based on research, and working more than 20 hours per week were all predictive of research utilization. Case study participants described specific events regarding challenges and successes in utilizing research in their practices and key factors underpinning research utilization were issues of access, issues related to the practitioner, issues of the research itself, and issues of impact on care.<p> Conclusion & Implications: While members of the MTAS perceive research positively, a gap exists between research and practice. Challenges to the diffusion of research appear to be occurring at the stages of research awareness and understanding. Curriculum in MT schools should include more critical appraisal training and more research-based resources. Provincial regulatory status may be the first step to quality training and service delivery.

Purpose & Objectives: To foster improved client care and the continued professionalization of Massage Therapy (MT), it is important that MT practitioners research utilization is more clearly understood. The purpose of the study was to explore Massage Therapists (MTs) perceptions of research and their self-reported research utilization. Specifically, to 1) describe MTs perceptions of research and their appraised self-efficacy in research literacy and capacity; 2) better understand the nature of MTs research utilization; 3) identify what practitioner characteristics are associated with research utilization.<p> Methods: Using a sequential explanatory mixed methods design, the study was conducted in two phases. In the first phase, all (815) registered members of the Massage Therapist Association of Saskatchewan (MTAS) were invited to participate in a mail-out survey. In the second phase, semi-structured qualitative interviews using a critical incident framework explored the nature of practitioners use of research. Univariate and logistic regression analysis were conducted using SPSS.<p> Results: In total, 333 questionnaires were returned for a 41% response rate. MTAS members reported overall positive perceptions of research as indicated by high endorsement of its value in adding credibility to MT and by majority agreement that MT practice should be based on research. Reported self-efficacy in various research literacy and capacity skills revealed low levels of knowledge and experience. Reported reference to online research databases, reference to peer-reviewed journals, the belief that MT practice should be based on research, and working more than 20 hours per week were all predictive of research utilization. Case study participants described specific events regarding challenges and successes in utilizing research in their practices and key factors underpinning research utilization were issues of access, issues related to the practitioner, issues of the research itself, and issues of impact on care.<p> Conclusion & Implications: While members of the MTAS perceive research positively, a gap exists between research and practice. Challenges to the diffusion of research appear to be occurring at the stages of research awareness and understanding. Curriculum in MT schools should include more critical appraisal training and more research-based resources. Provincial regulatory status may be the first step to quality training and service delivery.

Medical decisions should be based on good evidence. But this does not mean that health care professionals should practice evidence-based medicine. This dissertation explores how these two positions come apart, why they come apart, and what we should do about it. I begin by answering the descriptive question, what are current standards of evidence in medicine? I then provide a detailed critique of these standards. Finally, I address the more difficult normative question, how should we determine standards of evidence in medicine? In medicine, standards of evidence have been established by the pervasive evidence-based medicine (EBM) movement. Until now, these standards have not been subjected to comprehensive philosophical scrutiny. I outline and defend a theory of knowledge – a version of Helen Longino’s Critical Contextual Empiricism (CCE) – which enables me to critically evaluate EBM. My version of CCE emphasizes the critical evaluation of background assumptions. In accordance with this, I identify and critically evaluate the three substantive assumptions underlying EBM. First, I argue that medicine should not be held to the restrictive definition of science assumed by proponents of EBM. Second, I argue that epidemiological evidence should not be the only “base” of medical decisions. Third, I argue that not only is the particular hierarchy of evidence assumed by EBM unjustified, but that any attempt to hierarchically rank research methods is incoherent and unjustifiably restricts medical knowledge. Current standards of evidence divert attention from many legitimate sources of evidence. This distorts medical research and practice. In the remainder of the dissertation I propose means for improving not only current standards of medical evidence but also the process of producing and defending future standards. On the basis of four CCE norms, I argue that we have reason to protect and promote those features of the medical community that facilitate diversity, transparency, and critical interaction. Only then can we ensure that the medical community retains its ability to produce evidence that is both rigorous and relevant to practice.

Organizational theory can assist in better understanding how changes made in clinical practice can be sustained in healthcare organizations. Organizational learning and knowledge transfer theories were used to develop and test a theoretical model, “Sustaining in Memory” (SIM) model, to explore how organizations disperse or distribute newly transferred knowledge in knowledge reservoirs situated in the organization. Three hypotheses were generated from the theoretical model and tested with data from a cross sectional postal survey of 148 patient/resident care units in one large Canadian province where a CPG on prevention of falls was widely disseminated. Findings confirmed that fall prevention practice knowledge was transferred and embedded in all six knowledge reservoirs; however, there were three specific knowledge reservoirs that were found to be significant predictors of perceived CPG adherence (activities consistent with the CPG recommendations). These were staff, policy and role expectation knowledge reservoirs. There was variation in the adherence to the eight CPG recommendations with greater adherence to recommendations that were mandatory. Additionally, findings showed that the relationship between staff knowledge reservoir and CPG adherence was the only relationship moderated by the practices that helped to prevent/address knowledge loss through various activities designed for reviewing and updating practice knowledge. Interestingly, although CPG adherence was reported significantly greater in LTC resident care units, its association with patient outcomes was much weaker than in hospital patient care units. Hospital units had significantly greater correlation between perceived CPG adherence and all four of the falls prevention outcomes reported by study participants. Lastly, quality management culture as managed by senior leaders in the organization was also found to be a significant predicator of adherence to the CPG. The research study validated key assumptions made in the theoretical model while helping to clarify the distinct influence of different knowledge reservoirs. The SIM model provided an alternate perspective within which to study knowledge transfer and sustainability of clinical practices and has potential to apply to other change initiatives. This study answered the call for greater theoretically driven studies of CPG implementation as well as attention on the organizational influences of CPG implementation and sustainability.

Knowledge is a critical element for the provision of quality health care. Optimal clinical decision making incorporates multiple types of knowledge including patient knowledge, clinical experiential knowledge and research knowledge. Understanding how knowledge is shared and used in best practice is challenging as a number of factors can facilitate or impede the process. Several authors have highlighted the value of using a theoretical framework when examining knowledge in health care. A theoretical framework provides direction for the generation and testing of hypotheses which can contribute to building a comprehensive body of knowledge in a field of study. Although the majority of knowledge exchanged in practice settings occurs between clinicians, current knowledge exchange and utilization models in health care generally focus specifically on the exchange of research knowledge between the scientific community and the practice community. Acknowledging and understanding the knowledge seeking and sharing behaviours of clinicians is a key element in the larger knowledge translation puzzle. Emergency medicine is a clinical speciality where there is evidence of a knowledge to practice gap, however, there is limited understanding of the factors that contribute to the gap. Emergency practitioners must make decisions in a busy and often chaotic environment that is prone to multiple interruptions and distractions. The challenge for consistent and quality care is also more pronounced in rural and some suburban areas where emergency care needs are similar but resources are limited. The purpose of this program of research is to identify factors relevant to knowledge exchange and utilization in rural and urban emergency departments with the aim of developing a Model for Knowledge Exchange and Utilization in Emergency Practice. A series of studies were carried out using a mixed method research design to further develop and describe 3 key dimensions (individual, context of practice, knowledge) which were identified through a review of the literature. Data was collected using surveys, participant observations and interviews with nurses and physicians working in rural and urban emergency departments in Nova Scotia. Triangulation of results across the studies contributed to developing a comprehensive and rigorous description of the 3 dimensions of interest.

Postoperative urinary retention (PUR) is a common problem seen after surgery, particularly after orthopedic surgery. There has been a great deal of research done surrounding the causes of PUR and the optimal treatment for PUR, all with conflicting results. Little research has been done with orthopedic nurses to find out how they actually treat PUR, and on what information they base those treatment decisions. Evidence-based practice has been gaining popularity recently and highlights the need for nurses to make treatment decisions based on sound research, patient preferences, clinical expertise, and taking into consideration health care resources and the clinical setting (DiCenso, Ciliska, & Guyatt, 2005). This study investigated nurses' views on the definition of PUR, how they assessed for PUR, how they treated PUR and what they based their treatment decisions on. Ten nurses who worked on orthopedic units were interviewed using a semi-structured format consisting of four questions. The interviews were recorded and then transcribed verbatim by the student researcher. Qualitative description, as described by Sandelowski (2000), was used to analyze data. All nurses defined PUR fairly similarly. Various contributing factors for PUR were mentioned, some that were studied in the literature, and some that were not. Each nurse had a slightly different way of treating PUR, and 'ward routine' was also described differently. Study results point to a need for more research and education in the area of PUR so that all nurses are treating PUR in the same manner based on the same sound knowledge base.