Postoperative pain management in planned lumbar spine surgery: Implementing structural changes in a complex healthcare setting

Sammanfattning: BACKGROUND Poorly managed postoperative pain (POP) continues to cause suffering and prolong hospital care, affecting patients, individual health care professionals, and team strategies and attitudes. The impact on these strategies and attitudes needs greater understanding. Health care is currently shifting toward more person-centred care (PCC). One way of approaching changes in health care is by co-creation of interventions in order to more closely adapt these to specific contexts. Further, organizations in which change is to be implemented should be explored since resistance to change (RTC) and organizational culture (OC) are essential factors to consider in change management in health care settings. There is a lack of studies providing information on the impact of implementation of interventions in the challenging field of postoperative pain management (POPM) in a complex health care setting. AIM The overall aim of this thesis was to design and evaluate a change management intervention for postoperative pain and pain management for lumbar spine surgery patients. METHODS The overall research design was a multi-method design, drawing on several data sources and using various data collection and analytical methods. Studies I and II were interview studies of patients and health care practitioners (HCP)s to understand their underlying attitudes and strategies with regard to POPM in order to enhance knowledge of the persons in the patient-HCP relationship and to inform the intervention. Data analysis took the form of latent content analysis and thematic analysis. Studies III and IV were based on an intervention whereby PCC structures were implemented in the unit. The intervention was guided by the integrated Promoting Action on Research Implementation in Health Ser vices (i-PARIHS) framework (Harvey & Kitson, 2015). Both studies used data from questionnaires; in addition, multiple data (i.e. interviews, observations, and medical journal review) were analysed, using descriptive and inferential statistics. RESULTS The findings from Studies I and II demonstrate that the know-how, capability and vulnerability of both patients and HCPs comprise the basis for the patient-HCP relationship in a complex setting with the many-sided subject of POP. The goal was also to inform the change management intervention in the setting. Data from Studies III and IV affirm the intricacies of healthcare organizations. The meticulous bottom-up design of the intervention resulted in an essentially neutral result regarding patient-reported outcome measures (PROM), aside from patient participation in pain management which abated during the intervention. Moreover, while the organization initially presented agreeable prerequisite characteristics for change, during the actual change process the organization came under pressure due to the unrelated complete relocation of the units. CONCLUSION POPM was associated with both the complexity of pain management and the health care context. A multi-method design was chosen to broaden the possibility of explaining the phenomena. Qualitative interviews gave insight to patients’ and HCPs’ experiences, behaviours, attitudes and strategies. Experience and expertise were acquired by HCPs and patients and these competencies should be combined to achieve PCC. The impact of organizational strain, the partial implementation of PCC and lack of fidelity during the intervention are the most likely factors to explain the findings of decreased patient participation. This suggests that PCC needs to be implemented completely to achieve its potential.