<p>Professionals and researchers have developed a number of strategies aimed at improving the quality and safety of medication use. However, studies continue to demonstrate persistent problems. For instance, the first paper in this thesis reveals the prevalence of potentially harmful drug combinations among elderly people in Europe. The following four papers focus on two professional groups and how they have approached safety and quality issues related to medication use: 1) the Swedish drug and therapeutics committees (DTCs) and 2) pharmacist involved in pharmaceutical care, an international movement. Qualitative research approaches were applied.</p><p>Papers II and III focus on the DTCs: analyses indicate a development of the perception of the DTC role over time. The focus of the activities was broadened – from targeting prescribing physicians to incorporating decision-makers and patients. However, a clear patient-centered perspective was generally lacking. Moreover, the findings indicate a shift in focus from cost aspects of medication use to an increased focus on quality and safety aspects. </p><p>In the studies addressing pharmaceutical care (Papers IV and V), the findings propose that different classification systems for drug-related problems had different characteristics which reflected differences in goals in the pharmaceutical care process. It was also found that the concept of pharmaceutical care was understood in different ways and that the perceptions were based on at least two different understandings of health and illness. First, a patient-centered perspective characterized by a <i>holistic</i> understanding of health and illness, and, second, an “EBM perspective” primarily based on a <i>biomedical</i> understanding of health and illness. </p><p>This thesis has disclosed new aspects of how two groups of professionals perceive their work towards improved quality and safety of medication use. A patient-centered perspective among healthcare collectives is not obvious; therefore, efforts and comprehensive strategies supporting change are necessary. Strategies should focus on challenging the traditional thought patterns and care approaches among professionals and students. </p>

Professionals and researchers have developed a number of strategies aimed at improving the quality and safety of medication use. However, studies continue to demonstrate persistent problems. For instance, the first paper in this thesis reveals the prevalence of potentially harmful drug combinations among elderly people in Europe. The following four papers focus on two professional groups and how they have approached safety and quality issues related to medication use: 1) the Swedish drug and therapeutics committees (DTCs) and 2) pharmacist involved in pharmaceutical care, an international movement. Qualitative research approaches were applied. Papers II and III focus on the DTCs: analyses indicate a development of the perception of the DTC role over time. The focus of the activities was broadened – from targeting prescribing physicians to incorporating decision-makers and patients. However, a clear patient-centered perspective was generally lacking. Moreover, the findings indicate a shift in focus from cost aspects of medication use to an increased focus on quality and safety aspects. In the studies addressing pharmaceutical care (Papers IV and V), the findings propose that different classification systems for drug-related problems had different characteristics which reflected differences in goals in the pharmaceutical care process. It was also found that the concept of pharmaceutical care was understood in different ways and that the perceptions were based on at least two different understandings of health and illness. First, a patient-centered perspective characterized by a holistic understanding of health and illness, and, second, an “EBM perspective” primarily based on a biomedical understanding of health and illness. This thesis has disclosed new aspects of how two groups of professionals perceive their work towards improved quality and safety of medication use. A patient-centered perspective among healthcare collectives is not obvious; therefore, efforts and comprehensive strategies supporting change are necessary. Strategies should focus on challenging the traditional thought patterns and care approaches among professionals and students.

<p>Why do some anaesthetists perform a better job than others? Why do some trainees grow faster in their professional role than others? These are important questions when the education of anaesthetists is so topical. Research in work pedagogy has shown that competence is related to the way professionals understand their work; the two first interview studies of this thesis are about understanding work. <i>Study I</i> shows that specialist anaesthetists understand work in four different ways, representing four aspects of work. Some of them have a comprehensive understanding, seeing three or all four aspects of work, whereas others have more restricted understandings. In <i>Study II,</i> trainees expressed similar ways of understanding work, some comprehensive, some more restricted. It is important that trainees develop competence in all aspects of work. Therefore, trainees need not only to develop competence by <i>deepening their present understanding</i>, but also by <i>change of understanding</i>, an important but difficult step in competence development.</p><p>Reflection is important in professional training. The reflection process should encompass all aspects of work, to enable trainees to develop a broad competence. However, only anaesthetists with a comprehensive way of understanding work have the prerequisites for facilitating trainees’ reflection in all aspects of work.</p><p><i>Study III, </i>focussing on the learning environment,<i> </i>shows that two important principles of professional training are often violated for trainee anaesthetists: making use of the trainee’s curiosity and reducing trainees’ stress level. Trainees very much need support from well educated mentors. </p><p>Teachers should not only facilitate trainees’ development of competence but also support young trainees to develop into anaesthetists who enjoy work. <i>Study IV</i> shows that some experienced anaesthetists still enjoy work very much after years of practice. Their advice about how to get to terms with work should be shared with young trainees. </p>

Why do some anaesthetists perform a better job than others? Why do some trainees grow faster in their professional role than others? These are important questions when the education of anaesthetists is so topical. Research in work pedagogy has shown that competence is related to the way professionals understand their work; the two first interview studies of this thesis are about understanding work. Study I shows that specialist anaesthetists understand work in four different ways, representing four aspects of work. Some of them have a comprehensive understanding, seeing three or all four aspects of work, whereas others have more restricted understandings. In Study II, trainees expressed similar ways of understanding work, some comprehensive, some more restricted. It is important that trainees develop competence in all aspects of work. Therefore, trainees need not only to develop competence by deepening their present understanding, but also by change of understanding, an important but difficult step in competence development. Reflection is important in professional training. The reflection process should encompass all aspects of work, to enable trainees to develop a broad competence. However, only anaesthetists with a comprehensive way of understanding work have the prerequisites for facilitating trainees’ reflection in all aspects of work. Study III, focussing on the learning environment, shows that two important principles of professional training are often violated for trainee anaesthetists: making use of the trainee’s curiosity and reducing trainees’ stress level. Trainees very much need support from well educated mentors. Teachers should not only facilitate trainees’ development of competence but also support young trainees to develop into anaesthetists who enjoy work. Study IV shows that some experienced anaesthetists still enjoy work very much after years of practice. Their advice about how to get to terms with work should be shared with young trainees.

The general practitioner has a central position in the health care system, but demands have increased and there are signs of exhaustion in the corps. Patient-centredness is beneficial for the patients and probably for the outcome of health care. In Balint groups general practitioners study and gain further understanding of the physician-patient relationship by means of the participants’ own experiences. This thesis aims at studying experienced effects of Balint groups on the working life of general practitioners. General practitioners with and without Balint group experience are compared by means of a questionnaire, using statistical methods. General practitioners with Balint group experience are interviewed. Both these studies show positive experiences of Balint group participation in the physicians’ working life in terms of feeling of control and satisfaction, and on relations to patients, particularly patients with complex problems. A new instrument for measuring physicians’ degree of patient-centredness is presented. It can be used in groups of physicians to evaluate training programmes or by the individual physician to detect decline in patient-centredness as an early sign of burnout. Balint groups are viewed critically in interviews with Balint group leaders, focussed on difficulties and dropouts from the groups. Balint groups are found to fit into modern theories of small groups as complex systems, submitted to group dynamics that are sometimes malicious. Professionally conducted Balint groups seem to be a gentle, efficient method to train physicians, but with limits. Participation of a member demands a stable psychological condition and an open mind, and obligatory Balint groups are questioned. The thesis concludes that Balint groups are generally beneficial for general practitioners’ working life as a means to enable the physicians endure, even thrive in their job. The method facilitates development of new understanding of the physician-patient relationship with possible positive effects for the patient as well.

The major part of care in type 2 diabetes is in the hands of the patient so the focus of educational interventions should be on the person behind the disease. An experience-based group education programme that actively promotes participants’ reflection and understanding has been designed and implemented in cooperation with the Swedish Pharmacy. The regression model presented in Paper I revealed the importance of self-perceived role in diabetes management. Blood glucose control two years after baseline was improved for participants who described themselves as having an active role in their treatment, compared to those taking on a passive or a compliant role. Paper II described the resulting categories from content analysis of three open-ended questions about participants’ role, goal and support needs in diabetes management. The people taking care of diabetes most effectively and needing least support were called Disease Managers; those following the health professionals’ orders and depending on regular controls were categorised as Compliant, whereas the Disheartened had difficulties in achieving good metabolic control and often described both medical and social obstacles. These three self-management profiles were strongly correlated to metabolic outcomes. In Paper III perceptions of diabetes management were reassessed: perceptions were only stable in approximately half of participants, thus providing evidence for a dynamic model of learning self-management in diabetes. The three self-management profiles still correlated with metabolic outcomes. In paper IV the long-term metabolic outcome (HbA1c) of the study population was investigated. Metabolic control was stable up to seven years following the intervention, in contrast to the metabolic deterioration often present in diabetes. The main message of this thesis is that participants’ self-perceived role had a major influence on metabolic outcomes. Assessing self-management profiles both in diabetes and possibly other chronic conditions can help health care providers to tailor their educational efforts accordingly. Furthermore, this experience-based patient education programme outside the framework of routine diabetes care has the potential to stabilise metabolic control on the long run effectively.

<p>The settings investigated were departments of internal medicine (IM), orthopaedics and surgery in acute care hospitals in Sweden. The objective was to identify exogenous and endogenous determinants of accessibility of health care. Both qualitative and quantitative analysis of utilisation was performed on national and regional level of data aggregation. The study proposes that accessibility to acute health services is influenced by exogenous factors, partly outside the control of health care professionals, such as season, physical proximity and overall supply. Organisational properties such as availability of inpatient beds, hospital and physician specialisation and the degree of system integration between provides of emergency care have effects on the quality of care. The novel finding is the strong association between acute readmissions and remaining inpatient utilisation indicating effects of bed supply on global use within IM. These conclusions follow: </p><p>§</p><p>§</p><p>§</p><p>§</p><p>§</p><p>§</p><p>§</p><p>There are conflicts between accessibility, efficiency and appropriateness of settings calling for attention to capacity to benefit in addition to needs as priority criteria.</p> / <p>De studerade enheterna var kliniker för internmedicin, ortopedi och kirurgi vid akutsjukhus i Sverige. Studiernas syfte var att identifiera exogena och endogena determinanter av tillgänglighet till sjukvården. Kvalitativa och kvantitativa analyser av vårdutnyttjande utfördes på nationell och regional nivå av dataaggregering. Studierna utmynnar i slutsatsen att tillgängligheten till akutsjukvården påverkas av exogena faktorer, delvis utanför kontrollen för de professionella inom sjukvården, såsom säsong, fysiskt avstånd och totalt utbud. Organisatoriska egenskaper som tillgången till vårdplatser, sjukhusens och läkarnas specialisering och graden av systemintegration mellan producenter av akutvård har effekter på vårdens kvalitet. Det nya fyndet utgörs av upptäckten av en stark association mellan akuta återinskrivningar och övriga inskrivningar. Sambandet indikerar effekterna av vårdplatsutbudet på totalt slutenvårdsutnyttjande inom internmedicinen. Slutsatserna är som följer:</p><p>§</p><p>§</p><p>§</p><p>§</p><p>§</p><p>§</p><p>§</p><p>Det finns uppenbara konflikter mellan tillgänglighet, produktivitet och vårdgivarens ändamålsenlighet. Det fordras större uppmärksamhet på kapaciteten att tillgodogöra sig behandling utöver behov som ett kriterium för prioritering mellan patientgrupper.</p>

<p>Lengthy waiting times have been a problem in Swedish health services for many years. In 1992, Sweden implemented a national maximum waiting-time guarantee (MWG) through an agreement between the Swedish Government and the Federation of Swedish County Councils. The “guarantee” assured patients that the waiting time between the decision-to-treat and the treatment itself would not exceed three months. The national MWG covered twelve different treatments/interventions and remained in force for five years. This dissertation describes the genesis of the MWG, its implementation, and its effects.</p><p>Four papers serve as a foundation for the dissertation. Paper I describes how the guarantee was implemented during the first two years. Paper II studies the impact that the MWG had on cataract surgery. Paper III uses the results of two questionnaire surveys of department heads to explain why the MWG, although successfully launched, became increasingly difficult to maintain. Paper IV analyses data from the national cataract register to determine how production and waiting times in cataract surgery were affected by termination of the MWG.</p><p>This dissertation confirms that waiting time for health care is a complex phenomenon resulting from multiple causes. “Guarantees” are of particular interest because they define what constitutes too long in reference to waiting times. Beyond that, they are only a framework for developing a plan of action. The positive effects of the MWG were transient and based on rationalisation, introduction of new technology, and stricter prioritisation. The MWG contributed towards empowering patients and slowing the expansion of treatment indications, but it was unsuccessful in levelling out the wide regional variations in surgical rates.</p>

The aims of this licentiate thesis were to explore and describe female and male patients’ conceptions of integrity within health care and to illuminate the conceptions from a gender as well as a personal space boundary perspective. A qualitative design with a phenomenographic approach was used. The participants, 17 male (Study I) and 15 female patients (Study II), all of whom had undergone medical or surgical care, were strategically selected and interviewed. The identified conceptions were also analysed from a gender as well as a personal space boundary perspective. Three description categories emerged among the male patients (Study I); self-respect, dignity and confidence, while maintaining the self, dignity and confidence were the description categories found among the female patients (Study II). Male patients’ description of self-respect and female patients’ description of maintaining the self were for the most part similar although there were some differences. The conceptions revealed that integrity involves having the courage to set boundaries and having control over the private sphere, one’s self and one’s situation. While the male patients emphasised selfbelief and being alone, their female counterparts stressed that preserving one’s identity was essential in order to maintain the self. Dignity concerned being respected, and the male patients also described dignity as being seen as a trustworthy and whole person, while the women described it as not being exposed. Both male and female patients described confidence, which was related to handling patient information in a confidential way, trusting the professional caregivers, participating as well as balancing or changing the boundaries of integrity if necessary. The male patients also described confidence as being free. The personal space boundary perspective was useful for explaining the process of respecting the self by opening or closing outgoing and incoming boundaries around the self. The patients had to consider who, when and to what degree others should have access to their personal spaces. The way in which the professional caregivers interacted with the patient influenced the openness of the boundaries.

The settings investigated were departments of internal medicine (IM), orthopaedics and surgery in acute care hospitals in Sweden. The objective was to identify exogenous and endogenous determinants of accessibility of health care. Both qualitative and quantitative analysis of utilisation was performed on national and regional level of data aggregation. The study proposes that accessibility to acute health services is influenced by exogenous factors, partly outside the control of health care professionals, such as season, physical proximity and overall supply. Organisational properties such as availability of inpatient beds, hospital and physician specialisation and the degree of system integration between provides of emergency care have effects on the quality of care. The novel finding is the strong association between acute readmissions and remaining inpatient utilisation indicating effects of bed supply on global use within IM. These conclusions follow: § § § § § § § There are conflicts between accessibility, efficiency and appropriateness of settings calling for attention to capacity to benefit in addition to needs as priority criteria. / De studerade enheterna var kliniker för internmedicin, ortopedi och kirurgi vid akutsjukhus i Sverige. Studiernas syfte var att identifiera exogena och endogena determinanter av tillgänglighet till sjukvården. Kvalitativa och kvantitativa analyser av vårdutnyttjande utfördes på nationell och regional nivå av dataaggregering. Studierna utmynnar i slutsatsen att tillgängligheten till akutsjukvården påverkas av exogena faktorer, delvis utanför kontrollen för de professionella inom sjukvården, såsom säsong, fysiskt avstånd och totalt utbud. Organisatoriska egenskaper som tillgången till vårdplatser, sjukhusens och läkarnas specialisering och graden av systemintegration mellan producenter av akutvård har effekter på vårdens kvalitet. Det nya fyndet utgörs av upptäckten av en stark association mellan akuta återinskrivningar och övriga inskrivningar. Sambandet indikerar effekterna av vårdplatsutbudet på totalt slutenvårdsutnyttjande inom internmedicinen. Slutsatserna är som följer: § § § § § § § Det finns uppenbara konflikter mellan tillgänglighet, produktivitet och vårdgivarens ändamålsenlighet. Det fordras större uppmärksamhet på kapaciteten att tillgodogöra sig behandling utöver behov som ett kriterium för prioritering mellan patientgrupper.