How dislocation and professional anxiety influence readiness for change during the implementation of hospital-based home care for children newly diagnosed with diabetes – an ethnographic analysis of the logic of workplace change

Abstract

BackgroundIn 2013–14, the evidence based care model Hospital-based Home Care for children newly diagnosed with diabetes was implemented at a large paediatric diabetes care facility in the south of Sweden. The first step of the implementation was to promote readiness for change among the professionals within the diabetes team through regular meetings. The aim was to analyse the implicit facilitators and barriers evident on a cultural micro level in discussions during the course of these meetings. What conceptions, ideals and identities might complicate, or facilitate, implementation?MethodsA case study was conducted during the implementation process. This article draw on ethnographic observations carried out at team meetings (n = 6) during the introductory element of implementation. From a discourse theoretical perspective, the verbal negotiations during these meetings were analysed.ResultsThree aspects were significant in order to understand the dislocation during this element of implementation: an epistemological disagreement that challenged the function of information within care practice; a paradoxical understanding of the time-knowledge intersection; and expressions of professional anxiety. More concretely, the professionals exhibited an unwillingness to give up the opportunity to provide structured, age-independent information; a resistance against allowing early discharge; and a professional identity formed both by altruistic concern and occupational guardiancy. The findings suggest the necessity of increased awareness of the conceptions and ideals that constitute the basis of a certain professional practice; a deeper understanding of the cultural meaning that influences care practice within a specific logic in order to predict in what way these ideals might be challenged by the implemented evidence.ConclusionsOur main contribution is the argument that the implemented evidence in itself needs to be examined and problematized from a cultural analytical perspective before initiation in order to be able to actively counter negative connotations and resistance.

Implementation of discharge recommendations in type 1 diabetes depends on specialist nurse follow‐up

“…As implementation of interventions in clinical settings is known to be complex and seldom succeed , the implementation study was planned based on implementation literature recommendation . Still, our experience of the implementation process confirmed the difficulties described in the literature .…”

“…The educational time spent with families during the first month from the child's diagnosis was similar to that reported in the RCT , both in the hospital‐based group and in the RCT‐HBHC except for the support by the diabetes nurse, with median 5.0 (min‐max 2.0–10.0) in real‐life HBHC, 7.3 (4.2–13.6) hours in the hospital‐based care and 16.5 (9.5–29.0) in the RCT‐HBHC. The support after discharge by the diabetes nurse also decreased over time; in the real‐life HBHC there was median one school visit during (min‐max 0–2) the first month from diagnosis and thereafter totally one home and school visit during the two‐year follow‐up, in the RCT there were median 2.0 (min‐max 0–7) in the control group and 3 in the RCT‐HBHC of home and school visits during the two‐year follow‐up .…”

“…A multi‐centre study evaluating hospital‐based care and home‐based care at diagnosis of type 1 diabetes is ongoing and another two randomised controlled trials (RCT) have evaluated different models of care at diagnosis , indicating that home‐based care is a safe and effective way of caring for the child and the family. However, home‐based care involves increased responsibility for the family and the growing child and could create anxiety for healthcare professionals .…”

“…Therefore, the use of a theoretical base or framework that maps out the elements that need attention before, during and after the process of implementation is of great importance for a successful implementation . In the evaluation of the process of implementation, we have previously reported on the cultural understanding of barriers, facilitators and local leadership during the systematic implementation of HBHC . In this paper, the focus is on child and parent outcomes and healthcare resource use up to two years from diagnosis.…”

Implementation Science Methodologies for Complementary and Integrative Health Research

“…33 Types of approaches include in-depth interviews 35 ; qualitative pilot studies; qualitative semistructured interviews and focus groups; participant observation 33 ; and ethnography to capture implementation microprocesses, at the level of individual interactions. 36 The choice of methods depends on the research questions being addressed. 33 Quantitative methods.…”