Developing Leadership in Managers to Facilitate the Implementation of National Guideline Recommendations: A Process Evaluation of Feasibility and Usefulness

Background: Previous research supports the claim that managers are vital players in the implementation of clinical practice guidelines (CPGs), yet little is known about interventions aiming to develop managers’ leadership in facilitating implementation. In this pilot study, process evaluation was employed to study the feasibility and usefulness of a leadership intervention by exploring the intervention’s potential to support managers in the implementation of national guideline recommendations for stroke care in outpatient rehabilitation. Methods: Eleven senior and frontline managers from five outpatient stroke rehabilitation centers participated in a fourmonth leadership intervention that included workshops, seminars, and teleconferences. The focus was on developing knowledge and skills to enhance the implementation of CPG recommendations, with a particular focus on leadership behaviors. Each dyad of managers was assigned to develop a leadership plan with specific goals and leadership behaviors for implementing three rehabilitation recommendations. Feasibility and usefulness were explored through observations and interviews with the managers and staff members prior to the intervention, and then one month and one year after the intervention. Results: Managers considered the intervention beneficial, particularly the participation of both senior and frontline managers and the focus on leadership knowledge and skills for implementing CPG recommendations. All the managers developed a leadership plan, but only two units identified goals specific to implementing the three stroke rehabilitation recommendations. Of these, only one identified leadership behaviors that support implementation. Conclusion: Managers found that the intervention was delivered in a feasible way and appreciated the focus on leadership to facilitate implementation. However, the intervention appeared to have limited impact on managers’ behaviors or clinical practice at the units. Future interventions directed towards managers should have a stronger focus on developing leadership skills and behaviors to tailor implementation plans and support implementation of CPG recommendations

Perceived needs and satisfaction with care in people with multiple sclerosis: A two-year prospective study

<p>Abstract</p> <p>Background</p> <p>Considering the costs of multiple sclerosis (MS), it is crucial that the health-related services supplied are in accordance with needs as they are perceived by people with MS (PwMS). Satisfaction with care is related to quality of care and can provide health care providers with the means for improvement. The aim was to explore the perceived needs and satisfaction with care amongst PwMS over a two-year period, also taking sex and disease severity into consideration.</p> <p>Methods</p> <p>The sample consisted of 219 outpatients at a MS specialist clinic. Data on perceived needs and satisfaction with care were collected every six months using a questionnaire which included various dimensions of care. The data was analysed for the whole sample and on an individual level, as well as in subgroups with regard to sex and disease severity.</p> <p>Results</p> <p>There were no statistically significant variations in the proportion of PwMS with perceived needs concerning different health-related services during the study period. However, individual variations were found with regard to both perceived needs and satisfaction with care. Few PwMS perceived a continuous need for a specific service. However, the majority perceived a need for rehabilitation, assistive devices, transportation service for the disabled, psychosocial support/counselling and information on social insurance/vocational rehabilitation at least sometimes. Severe MS was associated with a greater perceived need for almost all the services studied and women experienced a need for psychosocial support/counselling to a greater extent than men. In relation to the different categories of health care staff, PwMS were most satisfied with nurses with regard to all dimensions of care. They were least satisfied with the availability of psychosocial support/counselling; and information about social insurance/vocational rehabilitation.</p> <p>Conclusion</p> <p>Despite the large proportion of individuals with mild disease severity in our sample, a considerable number of needs were identified of which many, on an individual level, varied over time. Key services demanded by PwMS were identified. Also the level of satisfaction with care varied and areas with a potential for improvement were identified such as the availability of rehabilitation services including an increase in the supply of psychosocial support and counselling.</p

Development and evaluation of rehabilitation at home after stroke in south-west Stockholm

In Sweden (population 8.8 million) the great majority of patients with acute stroke are admitted to hospital. Each year 10 000-12 000 patients develop persistent disability. This thesis consists of a set of consecutive studies on: 1) the estimated need for late stroke rehabilitation and the basis for such an intervention among non-institutionalized individuals in south-west Stockholm (SWS); 2) the feasibility and health-economic implications of rehabilitation at home after acute stroke; 3) an experimental evaluation of rehabilitation at home for moderately disabled stroke patients. On the basis of telephone interviews, we estimated the prevalent need for late stroke rehabilitation as being at least one per 1000 in SWS. The average duration of hospital stay for such patients was 95 days. Social and leisure activities were identified as the most promising goals for late rehabilitation programmes. We concluded that early rehabilitation in the community, linked to post-acute stroke care with reduction of hospital stay, would be functionally and socially advantageous and cost-effective for more than 25% of the incident stroke cases. A pilot study of rehabilitation at home after stroke at the Department of Neurology at Huddinge Hospital in SWS showed that the target group embraced patients who were independent in feeding and continent, had mental function within normal limits, and residual motor and/or speech dysfunction one week after acute stroke. The most important components of the rehabilitation programme were: I) training at home, consisting of task- specific activities, based on the patients' personal interests; 2) one therapist being selected as case-manager; 3) education and individual counselling being offered to all spouses; and 4) emphasis on adherence to structured training between therapy sessions. Home rehabilitation patients had a mean duration of hospital stay of 14 days and on average received 11 home visits. During the first year after stroke, the average per capita cost of health care for these patients was 127 730 SEK, broken down as follows: hospital care, 50%; family caregivers, 18%; rehabilitation at home, 10%; out-patient visits to physicians and nurses, 9%; home-help service, 7%; auxiliary equipment, 2%; medication, 2%; home adaptation, 1%; and transportation service, under 1%. Based on the results of the pilot study, we proposed and conducted a randomized controlled trial (on-going and currently at the 3-month follow-up stage) of rehabilitation at home for moderately disabled stroke patients. A total of 81 patients were followed-up at 3 months. Overall, there were no statistically significant differences in patient outcome. Multivariate logistic regression suggested a positive effect for the home rehabilitation group (HRG) in social activity, activities of daily living, motor capacity, manual dexterity and walking. A 52% reduction in bed-days was observed, from 29 days in the routine rehabilitation group to 14 days in the HRG, associated with a small increase (3 visits/patient) in total number of out-patient visits to physicians and nurses. After discharge, the mean number of home visits in the HRG was 10. No major differences in use of home help, impact on family caregivers in the form of time devoted to helping the patient or subjective well- being of spouses were found. Patient satisfaction favoured the HRG, with a significant difference in active participation in rehabilitation programme planning. The above led us to conclude that early supported discharge with continuity of rehabilitation at home could be the rehabilitation service of choice for the majority of moderately disabled stroke patients, provided that follow-up at 6 and 12 months confirm the suggested enhanced effectiveness, the considerable reduction in use of health care and low impact on family caregivers. Rehabilitation at home after stroke could become an important component of stroke units. This research strategy may be useful for developing stroke rehabilitation in Scandinavian and other populations. ISBN 91b28-2328-

Balancing everyday life two years after falling ill with Guillain-Barré syndrome: a qualitative study.

The aim was to describe experiences of disability in everyday life and managing the recovery process two years after falling ill with Guillain-Barré syndrome

Young individuals with stroke: a cross sectional study of long-term disability associated with self-rated global health

BACKGROUND: Perceived disability after stroke may persist long-term even among young individuals with mild stroke and may be related to age-related expectations of health and recovery. Thus, in order to appreciate the magnitude of perceived disability in a younger stroke population studies are needed to explore perceived health-related differences between young individuals with stroke and a matched general population. Further, to provide long-term measures by health care, relevant to the same young individuals with stroke, their perceived long-term functioning and disability associated with health need to be explored. METHODS: The generic questionnaire EQ-5D was used to compare ratings of global health and disability between young individuals living in the community up to 6 years after stroke (n = 150) and an age and geographically matched general population (n = 2661). Stroke related medical data were retrieved from medical records and the study specific questionnaire, the MYS-questionnaire, was used to assess self-rated disability associated with global health. RESULTS: Among the young individuals 79% had suffered a mild stroke, 45% rated a low global health compared to 15% of the matched general population and a higher proportion rated problems in mobility, self-care, usual activities and anxiety/depression. Among the young individuals with stroke, limitations and restrictions in leisure activities, work, reading as well as low level of physical activity, utilizing personal care provider or personal assistance and tiredness were negatively associated with self-rated global health (R square 0.60). CONCLUSION: The negative effects of stroke, on self-rated global health among young individuals living in the community, appear to be substantial, multi factorial and long-standing which call for interdisciplinary research collaborations and team measures by health care long-term

A population-based study of fall risk factors among people with multiple sclerosis in Stockholm county.

Objective: To identify factors associated with increased likelihood of reporting a recent fall among people with multiple sclerosis. This study was exploratory in its intent to examine sense of coherence as a contextual influence on fall risk. The study also sought to confirm that variables previously identified as fall risk factors for people with multiple sclerosis persist when tested in a population-based sample. Design: The study was cross-sectional and data was obtained in the context of a population-based study of people with multiple sclerosis living in Stockholm. Subjects: A total of 164 people with multiple sclerosis, age range 19–79 years. Methods: Data were gathered through established instruments. Key instruments utilized included the sense of coherence scale, the Lindmark Motor Capacity Assessment’s subscale for balance, and the 10-metre walking test. A logistic regression model examined factors associated with reporting a fall in the past 3 months. Results: Of the participants, 62 (38%) reported experiencing at least one fall in the past 3 months. Reduced walking speed, impaired balance, and weak sense of coherence were associated with falls in the past 3 months. Conclusion: These findings underscore the importance of examining diverse and modifiable influences on fall risk, including walking speed, balance and sense of coherence, in future studies involving people with multiple sclerosis

Developing Leadership in Managers to Facilitate the Implementation of National Guideline Recommendations: A Process Evaluation of Feasibility and Usefulness

Background: Previous research supports the claim that managers are vital players in the implementation of clinical practice guidelines (CPGs), yet little is known about interventions aiming to develop managers’ leadership in facilitating implementation. In this pilot study, process evaluation was employed to study the feasibility and usefulness of a leadership intervention by exploring the intervention’s potential to support managers in the implementation of national guideline recommendations for stroke care in outpatient rehabilitation. Methods: Eleven senior and frontline managers from five outpatient stroke rehabilitation centers participated in a fourmonth leadership intervention that included workshops, seminars, and teleconferences. The focus was on developing knowledge and skills to enhance the implementation of CPG recommendations, with a particular focus on leadership behaviors. Each dyad of managers was assigned to develop a leadership plan with specific goals and leadership behaviors for implementing three rehabilitation recommendations. Feasibility and usefulness were explored through observations and interviews with the managers and staff members prior to the intervention, and then one month and one year after the intervention. Results: Managers considered the intervention beneficial, particularly the participation of both senior and frontline managers and the focus on leadership knowledge and skills for implementing CPG recommendations. All the managers developed a leadership plan, but only two units identified goals specific to implementing the three stroke rehabilitation recommendations. Of these, only one identified leadership behaviors that support implementation. Conclusion: Managers found that the intervention was delivered in a feasible way and appreciated the focus on leadership to facilitate implementation. However, the intervention appeared to have limited impact on managers’ behaviors or clinical practice at the units. Future interventions directed towards managers should have a stronger focus on developing leadership skills and behaviors to tailor implementation plans and support implementation of CPG recommendations