Bjurling-Sjöberg Petronella, Wadensten Barbro, Pöder Ulrika, Jansson Inger, Nordgren Lena
Department of Public Health and Caring Sciences, Caring Science, Uppsala University, Box 564, 751 22, Uppsala, Sweden.
Centre for Clinical Research Sörmland, Uppsala University, Kungsgatan 41, 631 88, Eskilstuna, Sweden.
BMC Health Serv Res. 2018 Nov 6;18(1):831. doi: 10.1186/s12913-018-3629-1.
Clinical pathways can enhance care quality, promote patient safety and optimize resource utilization. However, they are infrequently utilized in intensive care. This study aimed to explain the implementation process of a clinical pathway based on a bottom-up approach in an intensive care context.
The setting was an 11-bed general intensive care unit in Sweden. An action research project was conducted to implement a clinical pathway for patients on mechanical ventilation. The project was managed by a local interprofessional core group and was externally facilitated by two researchers. Grounded theory was used by the researchers to explain the implementation process. The sampling in the study was purposeful and theoretical and included registered nurses (n31), assistant nurses (n26), anesthesiologists (n11), a physiotherapist (n1), first- and second-line managers (n2), and health records from patients on mechanical ventilation (n136). Data were collected from 2011 to 2016 through questionnaires, repeated focus groups, individual interviews, logbooks/field notes and health records. Constant comparative analysis was conducted, including both qualitative data and descriptive statistics from the quantitative data.
A conceptual model of the clinical pathway implementation process emerged, and a central phenomenon, which was conceptualized as 'Struggling for a feasible tool,' was the core category that linked all categories. The phenomenon evolved from the 'Triggers' ('Perceiving suboptimal practice' and 'Receiving external inspiration and support'), pervaded the 'Implementation process' ('Contextual circumstances,' 'Processual circumstances' and 'Negotiating to achieve progress'), and led to the process 'Output' ('Varying utilization' and 'Improvements in understanding and practice'). The categories included both facilitating and impeding factors that made the implementation process tentative and prolonged but also educational.
The findings provide a novel understanding of a bottom-up implementation of a clinical pathway in an intensive care context. Despite resonating well with existing implementation frameworks/theories, the conceptual model further illuminates the complex interaction between different circumstances and negotiations and how this interplay has consequences for the implementation process and output. The findings advocate a bottom-up approach but also emphasize the need for strategic priority, interprofessional participation, skilled facilitators and further collaboration.
临床路径可提高护理质量、促进患者安全并优化资源利用。然而，它们在重症监护中很少被使用。本研究旨在解释在重症监护环境中基于自下而上方法的临床路径实施过程。
研究地点为瑞典一家拥有11张床位的综合重症监护病房。开展了一项行动研究项目，以实施针对机械通气患者的临床路径。该项目由当地跨专业核心小组管理，并由两名研究人员提供外部协助。研究人员运用扎根理论来解释实施过程。本研究中的抽样是有目的的理论抽样，包括注册护士（31名）、助理护士（26名）、麻醉师（11名）、一名物理治疗师、一线和二线管理人员（2名）以及机械通气患者的健康记录（136份）。2011年至2016年期间，通过问卷调查、多次焦点小组讨论、个人访谈、日志/现场记录和健康记录收集数据。进行了持续比较分析，包括定性数据和定量数据的描述性统计。
出现了临床路径实施过程的概念模型，一个被概念化为“为可行工具而努力”的核心现象是连接所有类别的核心类别。该现象从“触发因素”（“感知到实践欠佳”和“获得外部启发与支持”）演变而来，贯穿“实施过程”（“背景情况”、“过程情况”和“协商以取得进展”），并导致“结果”过程（“不同程度的利用”和“理解与实践的改进”）。这些类别包括促进和阻碍因素，这些因素使实施过程具有试探性和长期性，但也具有教育意义。
研究结果为重症监护环境中临床路径的自下而上实施提供了新的理解。尽管与现有的实施框架/理论有很好的共鸣，但该概念模型进一步阐明了不同情况与协商之间的复杂相互作用，以及这种相互作用如何对实施过程和结果产生影响。研究结果倡导自下而上的方法，但也强调战略重点、跨专业参与、熟练的协助者和进一步合作的必要性。
