Undersköterskans välbefinnande och hälsa kan påverkas av arbetsmiljön där inflytande och påverkan på arbetsinnehåll har betydelse. Tid för återhämtning kan vara svårt att få till stånd då undersköterskan arbetar oregelbundna arbetstider. Arbetsuppgifter som kan leda till en god hälsa och arbetsmiljö kan vara känslan av delaktighet och inflytande. Syftet med detta examensarbete var att beskriva undersköterskans erfarenheter av delaktighet och dess inverkan på hälsan. Examensarbetet genomfördes med en kvalitativ ansats och som metod för datainsamling användes semistrukturerade intervjuer. Individuella intervjuer genomfördes med sex undersköterskor som arbetar inom äldreomsorgen. Innehållsanalys användes som metod för att bearbeta data. Resultatet visar att tid för återhämtning och att kunna medverka och ta ansvar har betydelse sett ur individens perspektiv. Arbetsgruppen har betydelse för hälsa och delaktighet genom samspel, öppenhet och förmågan att lyssna på varandra. Ur ett organisatoriskt perspektiv är samspel med andra professioner och upplevelsen av en hälsosam arbetsmiljö viktigt. Chef för verksamhet bör tillsammans med undersköterskor skapa en miljö där välbefinnande råder genom delaktighet i en hälsosam och hållbar organisation. Genom detta förhållningssätt kan arbetsrelaterade problem förhindras vilket i sin tur kan bidra till en förbättrad hälsa hos den enskilde och att minska sjukfrånvaron.

Bakgrund. Att få en allvarlig bristning i samband med förlossning kan ge kvinnor smärta, lidande, och låg livskvalitet under lång tid. Syfte. Syftet med förbättringsarbetet har varit att förbättra eftervården genom att införa strukturerad uppföljning, öka kvalitén i bedömning och diagnostik, förbättra informationen till patienten och utveckla former för patientdelaktighet i förbättringsarbetet. Syftet med studien har varit att ur ett verksamhetsperspektiv beskriva erfarenheterna av patientdelaktigheten i förbättringsarbetet. Metod. Förbättringsarbetet har designats med hjälp av Förbättringstrappan och utgått från ett patientprocessorienterat perspektiv. Metod för studien var kvalitativ i form av en fallstudie. Resultat. Genom förbättringsarbetet följs kvinnorna upp via bristningsregistret, uppföljningsbesök med 3D- ultraljud görs på en specialinrättad mottagning. Vidare får kvinnorna individuell fysioterapeutinformation innan hemgång, en vårdkedja har införts och former för patientdelaktighet har utformats och använts. Dessa är frågeformulär, intervjuer, workshops och patientföreträdare i förbättringsnätverket. Resultatet från studien visar att formerna för patientdelaktighet ger skilda förutsättningar för delaktigheten. Resultatet visar på betydelsen av organisatoriska förutsättningar, värdet av patientdelaktighet, utmaningar vid införande och vilket reellt inflytande som patientdelaktigheten haft under processen och för resultaten av förbättringsarbetet. Slutsatser. Patientdelaktighet skapar värde i flera dimensioner. Patientdelaktighet behöver designas, anpassas till kontexten och förbättringsarbetets mål och dess syfte behöver vara tydligt uttryckt. / Background. Perineal tears during childbirth can lead to after-delivery complications that leads to great suffering and low quality of life for a long time. Purpose. The purpose has been to improve after-delivery care by systematic follow-up, increasing the quality of diagnostics and management of these women, improving the information for the patient and developing new ways of improving including patients in the improvement work. The purpose of the study has been to study the effect of patient participation in the improvement work. Method. "The improvement ramp" and patient process-oriented perspective has been used to design the improvement work. The method of the study was qualitative in the form of a case study. Results. Follow-up using 3D-ultrasound is introduced. A care chain has been introduced and ways of patient participation have been designed and used. These are questionnaires, interviews, workshops and patient representatives in the improvement network. The results of the study show that the ways of patient participation provide different conditions for participation. The result shows the importance of organizational conditions, the value of patient participation, challenges in the introduction and the real influence that patient participation has had during the process and on the results of the improvement work. Conclusions. Patient-participation in QI creates values in several dimensions. Patient-participation needs to be carefully designed in compliance with context, goals and purpose.

With an increasing migrant population there is a growing need to organize interpreting practices in healthcare in order to deliver equitable high-quality care. This thesis focuses on healthcare institutions’ organization of interpreting services. The aim of the study was to explore interpreting practices in a healthcare context by comparing two different healthcare areas – elderly and emergency healthcare. The study aimed to highlight the impact of the organizational and institutional context. This study was designed as an explorative and descriptive qualitative study including 79 healthcare professionals with experience of interpreting practices recruited via purposeful sampling in elderly and emergency healthcare. Data were collected through individual and focus-group interviews and analysed with inductive qualitative content analysis. The main findings show that the processes and structures around interpreting practices were complex and mainly linked to individual and interpersonal levels and, to a limited extent, to the institutional level. On the institutional level the Public Procurement Act was the only formal policy to follow. On individual and interpersonal level interpreting practices were structured by self-established informal workplace routines developed by the professional groups. The norms and routines used was determined by access to interpreters, time aspects, characteristics of the care given, health conditions and the person’s problem, expectations and requests from the person and also from healthcare professionals. There were wishes for improvement, with better flexibility in access to professional interpreters, training for users and interpreters, and also better technical solutions and equipment. In conclusion, the use of interpreters was rooted in the organizational environment of interpreting practice, including the availability of laws, policy and guidelines, and closely related to individuals’ language skills, cultural values and social factors. The use of professional interpreters was based on the nature of care in context and access to interpreters and determined by health professionals’ estimation of the person’s current health status in order to deliver fast and individualized care based on humanistic values. Thus, it is important to consider organizational framework and cultural awareness when formulating interpreting practices adapted to the context, and formal guidelines in order to achieve the aim of personcentered and equal health care.

The purpose of this thesis is to explore the institutionally shaped response to the introduction of the national guidelines on the Swedish regional health policy arena. The thesis consists of two case studies. Adapting a qualitative approach, the data is based on individual interviews and these were analysed thematically. The first paper explores the response by four Swedish regional health authorities to the introduction of the National Guidelines for Cardiac Care, while the second paper aims to broaden the understanding of how the national guidelines are used for strategic purposes among politicians. As illustrated in this thesis, organizations will respond, adjust and react to external pressure according to conditions shaped by the institutional context. Key findings here are that the national guidelines are a complex policy instrument that, beyond being able to be used in an instrumental fashion by the medical managment, can also serve a legitimizing function for political decision-makers. The goals of the national guidelines, i.e. equal and efficient care, and the uncertainty about who, among multiple stakeholders, is responsible for the guidelines in the regional health authority, is a source of ambiguity and potential conflict. Those who are potentially responsible represent different rationales – a political rationale and a scientific rationale. The dominating scientific rationale of the national guidelines can create instability, when pushing towards the use of explicit priority-setting. Priority-setting in the institutional setting of a regional health authority has strong elements of becoming “wicked problems” since the dilemma of prioritization remains regardless of ambitions to apply a “technocratic fix”. A wicked problem is characterized by high complexity and being persistently hard to solve (Williams et al. 2012). A recurring dilemma is that priority-setting still contains many wicked problems, as social values and political considerations remain important parts of the policy process. One weakness of the national guidelines, identified in this thesis, is that the guidelines discuss each service area separately, and thereby reinforce a silo mentality in the Swedish health policy arena. To sum up, the national guidelines create a multifaceted and complex response in the Swedish health policy arena where different rationalities collide, and where conflicts appear and are dealt with within the regional health authorities.

Sjuksköterskors praktiska kunskaper är avgörande för säker vård. Inom sjuksköterskeutbildningen kontrolleras färdigheter genom färdighetsexaminationer. Utifrån kartlagda brister i rättssäkerhet och arbetsmiljö vid färdighetsexaminationer initierades ett förbättringsarbete. Syftet med förbättringsarbetet var att förbättra processen för klinisk träning inom sjuksköterskeprogrammet genom att utveckla färdighetsexaminationer. En studie av förbättringsarbetet genomfördes i syfte att: Undersöka samsyn mellan lärare kring färdighetsexamination som pedagogisk aktivitet. Analysera och utveckla initial programteori utifrån intervjudata. Förbättringsarbete har utformats efter förbättringsmodellen, förbättringsrampen och programteoretisk ansats. Studie genomfördes med kvalitativa intervjuer och innehållsanalys utifrån en interaktiv och abduktiv ansats. Förbättringsarbetet resulterade i minskad variation mellan lärare i bedömningen av färdighetsexaminationer. Nya arbetssätt har lett till ökad samsyn mellan lärare och bättre arbetsmiljö. Programteorin reviderades utifrån intervjudata. Minskad variation visar på en ökad rättssäkerhet. Reviderad programteori har ökat möjligheten att dra lärdom av förbättringsarbetet såväl lokalt som generellt. Arbetet har bidragit till en utveckling av sjuksköterskeutbildningen och dess bidrag till en god och säker hälso- och sjukvård. / Nurses' practical knowledge is crucial for safe care. Within the nursing program skills are checked through clinical examinations. Based on identified deficiencies in terms of legal validity and working environment related to clinical examinations improvement work was initiated. The purpose of the improvement work was to improve the process of clinical training within the nursing program by developing the clinical examination. A study of the improvement work was conducted with the purpose of: Exploring teachers shared interpretations with clinical examinations as an educational activity. Analysing and developing initial program theory based on interview data. Improvement work was designed according to the model for improvement, improvement ramp, and a program theory approach. The study includes qualitative interviews with content analysis based on an interactive and abductive approach. The improvement work led to improved consensus between teachers and a better work environment. A reduction in variation between teachers’ assessments of clinical examinations was reached. The program theory was revised based on interview data. Reduced variation shows increased legal validity. Revised program theory has increased the possibility of learning from the improvement work both locally and in general. The work has developed the nursing education and its contribution to good and safe healthcare.

<p>Socioeconomic inequalities in health and disability are found in all countries where social gradients have been studied. Despite rapid economic growth and expanding health care systems, aiming at providing services to people according to need rather than according to wealth, persistent and even widening health inequalities are found in Europe after the second World War.</p><p>In this research project we wanted to establish a method for measuring socioeconomic status based on occupational groups and education in the HUNT Study, thereby providing tools for research in social medicine. A social gradient scale based on the occupational grouping from the HUNT study questionnaires had not been established. When this study was planned however, educational level, which might serve as a proxy for socioeconomic status, had been monitored in both HUNT I and HUNT II.</p><p>Disability pension has been a central element in social security legislation in Norway, established as a universal right for all citizens in 1967. This public income-maintenance program protects workers in case of disability, and comprises both universal and earningrelated programs. The main eligibility criterion has been permanent impaired earning ability by at least 50 % for reasons of illness or disease, injury or disability. Despite objective health improvement in the population the last decades, incidence of disability pension has increased.</p><p>In epidemiology, socioeconomic status is not only an important variable in itself. It is also a confounder that should be taken into consideration in discussing almost all causal relationships. Thus, in population based health studies, measures of socio-economic status are essential. Occupation, education and income together determine the socioeconomic status of a person. However, these factors are sufficiently distinct to require that they should also be studied separately in relation to health. To study them separately is often preferable since this can suggest hypotheses on causal relationships between exposure and disease.</p>

<p>The goals of this thesis are to evaluate quality of life (QoL) in adult patients with growth hormone deficiency (GHD) in relation to population normative data, to construct a preference-weighted index (utility) from a disease-specific QoL measure and to assess it in a clinical context.</p><p>The study included samples from the general population and patients with GHD from four European populations: England & Wales, the Netherlands, Spain and Sweden. The country-specific patient cohorts were retrieved from KIMS (Pfizer International Metabolic Database). </p><p>A questionnaire was developed that contained items from existing QoL questionnaires including, among others, Quality of Life Assessment in Growth Hormone Deficiency in Adults (QoL-AGHDA) and the EQ-5D. The QoL-AGHDA is a disease-specific measure for use in adults with GHD. The EQ-5D is a generic instrument which describes health states for which country-specific preference-based weights are available. Thus, it was possible to generate preference-weighted indices (utilities) based on data generated by both instruments. </p><p>This thesis reports QoL-AGHDA normative values for the populations of England & Wales, the Netherlands, Spain and Sweden, and confirms the extent of QoL impairment in patients with GHD in comparison with the general population. Long-term GH replacement resulted in sustained improvements in overall QoL towards normative country-specific values, as well in most of the dimensions that were impaired before treatment. </p><p>For use in health economic evaluations, models for generating utilities (QoL-AGHDA_utility) from QoL-AGHDA were developed. It is believed that these models may facilitate medical decision making, given that they provide a tool for obtaining utilities in the absence of directly collected preference-weighted indices.</p><p>QoL-AGHDA_utility effectively monitored treatment effects in patients with GHD. Moreover, this study confirmed a QoL-AGHDA_utility deficit before treatment and a gain after starting GH replacement. </p><p>The novel aspect of the present approach was to apply preference-weighted indices derived from a disease-specific measure to assess QoL in the clinical context, together with patient demographic and clinical characteristics. The robustness of this analysis is reinforced by the fact that utilities in both general and patient populations were generated using the same methodology. </p>

Socioeconomic inequalities in health and disability are found in all countries where social gradients have been studied. Despite rapid economic growth and expanding health care systems, aiming at providing services to people according to need rather than according to wealth, persistent and even widening health inequalities are found in Europe after the second World War. In this research project we wanted to establish a method for measuring socioeconomic status based on occupational groups and education in the HUNT Study, thereby providing tools for research in social medicine. A social gradient scale based on the occupational grouping from the HUNT study questionnaires had not been established. When this study was planned however, educational level, which might serve as a proxy for socioeconomic status, had been monitored in both HUNT I and HUNT II. Disability pension has been a central element in social security legislation in Norway, established as a universal right for all citizens in 1967. This public income-maintenance program protects workers in case of disability, and comprises both universal and earningrelated programs. The main eligibility criterion has been permanent impaired earning ability by at least 50 % for reasons of illness or disease, injury or disability. Despite objective health improvement in the population the last decades, incidence of disability pension has increased. In epidemiology, socioeconomic status is not only an important variable in itself. It is also a confounder that should be taken into consideration in discussing almost all causal relationships. Thus, in population based health studies, measures of socio-economic status are essential. Occupation, education and income together determine the socioeconomic status of a person. However, these factors are sufficiently distinct to require that they should also be studied separately in relation to health. To study them separately is often preferable since this can suggest hypotheses on causal relationships between exposure and disease.

The goals of this thesis are to evaluate quality of life (QoL) in adult patients with growth hormone deficiency (GHD) in relation to population normative data, to construct a preference-weighted index (utility) from a disease-specific QoL measure and to assess it in a clinical context. The study included samples from the general population and patients with GHD from four European populations: England &amp; Wales, the Netherlands, Spain and Sweden. The country-specific patient cohorts were retrieved from KIMS (Pfizer International Metabolic Database). A questionnaire was developed that contained items from existing QoL questionnaires including, among others, Quality of Life Assessment in Growth Hormone Deficiency in Adults (QoL-AGHDA) and the EQ-5D. The QoL-AGHDA is a disease-specific measure for use in adults with GHD. The EQ-5D is a generic instrument which describes health states for which country-specific preference-based weights are available. Thus, it was possible to generate preference-weighted indices (utilities) based on data generated by both instruments. This thesis reports QoL-AGHDA normative values for the populations of England &amp; Wales, the Netherlands, Spain and Sweden, and confirms the extent of QoL impairment in patients with GHD in comparison with the general population. Long-term GH replacement resulted in sustained improvements in overall QoL towards normative country-specific values, as well in most of the dimensions that were impaired before treatment. For use in health economic evaluations, models for generating utilities (QoL-AGHDAutility) from QoL-AGHDA were developed. It is believed that these models may facilitate medical decision making, given that they provide a tool for obtaining utilities in the absence of directly collected preference-weighted indices. QoL-AGHDAutility effectively monitored treatment effects in patients with GHD. Moreover, this study confirmed a QoL-AGHDAutility deficit before treatment and a gain after starting GH replacement. The novel aspect of the present approach was to apply preference-weighted indices derived from a disease-specific measure to assess QoL in the clinical context, together with patient demographic and clinical characteristics. The robustness of this analysis is reinforced by the fact that utilities in both general and patient populations were generated using the same methodology.

Bakgrund: Sjuksköterskeyrket beskrivs som komplext då sjuksköterskan måste ha kunskaper och färdigheter för att kunna ge patienten en god och säker vård. Första året i yrket beskrivs som en känslomässig och ansträngande period då sjuksköterskor upplever tung arbetsbelastning och en hög stressnivå. Nyutexaminerade sjuksköterskor upplever att tillräcklig introduktion och stöd från medarbetare är viktigt för att kunna utvecklas i yrkesrollen. Syfte: Att beskriva den nyutexaminerade sjuksköterskans upplevelse av första året i yrket. Metod: Studien genomfördes med en kvalitativ metod och en induktiv ansats. Datainsamlingen utfördes i form av sju semistrukturerade intervjuer. Kvalitativ innehållsanalys tillämpades för att analysera datamaterialet. Resultat: Vid analysen av datamaterialet framkom tolv underkategorier vilka bildar fyra kategorier; första tiden i yrket, att utöva yrket, arbetsklimatet påverkar och behov av kunskap och utveckling. Slutsats: Nyutexaminerade sjuksköterskor upplever ett behov av ytterligare kunskap då utbildningen inte förberett dem tillräckligt och beskriver första tiden som utmanande men också lärorik. Tillräcklig introduktion, ett trevligt bemötande och stöd från kollegor beskrivs som särskilt viktigt under första tiden. Möten med patienter och anhöriga beskrivs som givande och ger upphov till en känsla av att göra en skillnad.