Respondents in the individual interviews described, through illustrative examples, of how they identified, gathered, used, and disseminated knowledge before, during, and after the project period. The sources of knowledge mentioned in the statements were professional knowledge, both tacit and explicit, official documents such as the national guidelines and nationwide statistics, contextual documents such as procedures, budget, and follow-up, individual and summarized results of the rehabilitation and patient experiences, and knowledge obtained from actors at other hospitals. The statements also show that the use of knowledge can be described based on the questions why, what, and how.
Furthermore, the respondents’ statements revealed several examples of how they collaborated within the team, with colleagues, with the patient, and with external actors. While the statements of the team members and the managers mostly agreed with one another, the differences were visible in the details: the managers’ statements focused on planning and following up, while the team members’ statements described their roles in the team and the patient work in-depth. The group interview illuminated what happened after the project ended.
The overall analysis of the interviews is presented under four headings that represent different perspectives on how knowledge was handled: identifying sources of knowledge, gathering the identified knowledge, using the knowledge, and collaborating on knowledge. Representative examples of quotes illustrate the analysis.
Identifying sources of knowledge
A large part of the respondents’ statements focused on what knowledge they identified as important. All respondents were clear about the purpose and each person explained why the project was initiated using almost the exact same wording. A team member said: “We could see that in their home, it was completely different, and that the patient managed it [the rehabilitation] better than in the hospital.”
Statistics was an important impetus to the project. The respondents referred to follow-ups that showed that the population in the hospital area had a greater proportion of cardiovascular diseases than other hospitals. The respondents also mentioned that the hospital had shown good results in the quality register for stroke, but there had been shortcomings in the rehabilitation after discharge. The respondents highlighted that the management’s decision of how to organize home rehabilitation was based on the SBU report and the preliminary national guidelines. The first attempt to get permission to start a project about a year before the actual start was denied by the top management, partly due to a lack of funding; therefore, knowledge of budget and staffing was crucial before deciding on the organization. However, the postponed start was considered positive, as the project could start at a more appropriate time for the hospital without considering external stakeholder requirements.
The need for new procedures was expressed. Information from other hospitals working with home rehabilitation, together with local procedures, was identified as a starting point for administrative procedures, including assessment tools. In response to why home rehabilitation had not started earlier despite successful attempts from other hospitals, respondents said that old habits were difficult to change and that there were no official recommendations. However, the participants in the group interview thought that the project would have started soon anyway because the preparations had been going on for a long time.
Gathering the identified knowledge
The identified knowledge was gathered both before and during the project period and continued after the project ended. Team members’ own experiences can be described as tacit knowledge visible in the examples from everyday life before, during, and after the project period. The main knowledge sources for the decision to start the project were the report from SBU and the preliminary national guidelines. Another important knowledge source was a regional conference on geriatric care. As it was common knowledge that home rehabilitation had been performed for a long time at a hospital in the nearby region, employees from the hospital were invited to present their organization and procedures.
After the decision to start the project, team members visited a hospital to observe colleagues conducting the rehabilitation work. Team members also came in contact with another hospital and had an e-meeting with them. All documents received were adapted to local conditions by the team. When asked how they validated the information, the members clarified that they copied, tested, and changed the procedures as needed. Team meetings were held regularly to share experiences of the rehabilitation work and improve procedures. An important procedure was the use of assessment tools, and the results were compiled at the end of the project and presented to the management. A manager stated: “It is probably very important that we continue to follow up and measure and think about what we do.”
The team members’ work with the patients was based on their knowledge and experience of rehabilitation at the hospital and the rehabilitation, which was considered essentially the same when performed at home. To update personal knowledge of stroke, a skills improvement course, as well as opportunities to work with more experienced colleagues, were offered. In the group interview, participants expressed a need for increased opportunities to continue education, participate in temporary work at other hospitals, and search for new knowledge for inspiration.
Using the knowledge
The identified and gathered knowledge, as well as the tacit knowledge and the team members’ previous experience of rehabilitation, were used to manage the project and to share the knowledge with relevant actors. The respondents stated that the patient’s knowledge of their own situation and their goals for recovery were considered essential knowledge when planning the rehabilitation. This knowledge was transferred to the home environment and resulted in a rehabilitation plan. The individual assessment and follow-up during and after the rehabilitation period was used to plan the patient’s further rehabilitation and to improve the procedures. The respondents were pleased with the outcomes, which had reinforced their perception that rehabilitation at home was beneficial for the patients, but as a team member said, “when we started, the idea that patients would be discharged earlier was difficult to communicate with other professionals [involved in the care of the patient].”
On a question regarding the future, the team members stated that they wanted the team to continue and that the knowledge gained was important to preserve and disseminate, but the interviewed managers were vague in their comments and only referred to finances. In the group interview, it was mentioned that the reported outcomes were an important impetus for the management’s decision to introduce the method in regular work.
Dissemination of knowledge before, during, and after the project period was considered very important. Information was provided to hospital staff and employees in the municipalities on several occasions. However, the team members were self-critical, explaining that they could have devoted even more time to information activities before the project started to avoid misunderstandings and opposition, but were unable to do so partly due to the tight schedule. A team member thus recommended the following to other hospitals: “Inform everyone affected or who may be affected. Have information material for different target groups.”
Furthermore, the respondents were uncertain about the interest from other hospitals. As a manager said, “I wish they were a little more curious about what we are doing.” However, after the top management decided to introduce home rehabilitation at the other hospitals, the team members’ experiences were requested. Receiving the improvement scholarship also contributed to the increased attention. The respondents stated that the information they received from other hospitals was crucial in the planning phase, but they admitted that they did not repay the service.
In the group interview, participants were asked how the outcomes of the project could benefit evidence-based practice and person-centred rehabilitation in general, but they said they had not reflected on it. However, they believed the research projects were interesting. Participants were also asked if patients could be involved in improvement work, and they deemed it an interesting idea.
Collaborating on knowledge
The analysis of signs of collaboration revealed that it was obvious that many professionals were involved either in the project or in the rehabilitation work. The respondents described how they exchanged knowledge through contacts within the project, within the rehabilitation work, and with other partners.
Within the rehabilitation work
The patient was considered to be the most important person to collaborate with in order to achieve the patient’s goals. A manager reflected on this power relation in the interview, explaining that “You are the manager in your own home.” The respondents stated that because the hospital was small with short decision paths, collaboration with employees and managers in different departments and with the various health centres and municipalities was uncomplicated. A team member said: “I think it is easier to understand each other and use each other’s skills in a small hospital.” However, a need for improved collaboration on the patient’s rehabilitation plan before discharge was also mentioned.
For managing the project
The respondents were asked which persons they considered most important for the realisation of the project. The team mentioned the managers, while the managers’ opinion appeared in the following quote: “It was the commitment and enthusiasm of the staff that made it possible to start.” One factor for success mentioned by the managers was that the team members were handpicked based on their expressed interest. The managers pronounced the importance of involving the employees early on in change work, but since the top management rejected the project the first time, the employees’ commitment was put on hold.
The team members showed a great commitment to the work in the team and explained how the procedures and weekly meetings were crucial for knowledge sharing. As a team member mentioned: “We have a team meeting every week, but that is not true, we meet almost every day.” Over time, the respondents stated that their individual experiences had become common knowledge, which facilitated collaboration and the opportunity to replace each other when needed.
A physician acted as a medical expert to the team and administrative employees were consulted to some extent, but specially appointed facilitators did not participate in the project. One reason for this lack of participation was due to feelings of doubt about what skills the experts could provide. However, the collaboration with scholars was considered important to gain knowledge about evidence-based methods for evaluation. The immediate manager acted as a project manager and the other two managers were regularly informed of the project’s progress.
With external parties
Especially important were the contacts with another hospital’s employees who were already working with home rehabilitation, mediated by a former employee. Other information activities concerned, for example, actors in municipalities and politicians. A desire to collaborate with the other hospitals in the region was expressed. As a team member said: “Twice a year, all hospital social workers in the region meet in joint working groups. There you have the opportunity to talk about this [stroke rehabilitation].” The respondents also expressed the idea that knowledge gained could be translated to other hospitals and other patient groups.
Sources of knowledge and their use in health care change work
The project aimed to test how to organize the rehabilitation team and develop new procedures for the rehabilitation in the patient’s home. The analysis of the interviews showed that knowledge use played an important role in achieving the aim: (1) in evidence-based practice in the rehabilitation work, and (2) in change management when introducing the new method.
Evidence-based practice
The interviews showed that the care of the patients was based on a deep knowledge of what researchers consider to be effective rehabilitation after a stroke and based on the national guidelines, professional experiences of stroke rehabilitation, and the patient’s own knowledge and goals; that is, an evidence-based practice. Available resources provided the framework for the organization of rehabilitation. An assessment of the patient’s recovery provided knowledge for improvements in the rehabilitation work. The outcomes of the patient group gave impetus to future improvement efforts.
Change management
The analysis also showed how knowledge was identified, gathered, used, and disseminated in the project. The knowledge used for project management were contextual such as statistics, procedures, and resources, official documents, and information from other hospitals. The follow-up procedures and outcomes became important for the decision-makers and for disseminating knowledge to various stakeholders. After the project period, systematic improvement work was introduced. Thoughts of how to apply the knowledge gained to other contexts were expressed but not yet implemented. Figure 1 summarises how different sources of knowledge were used in the change work.