title: The complexity in the implementation process of empowerment-based chronic kidney care: a case study.
abstract: BACKGROUND
  This study is part of an interactive improvement intervention aimed to facilitate empowerment-based chronic kidney care using data from persons with CKD and their family members. There are many challenges to implementing empowerment-based care, and it is therefore necessary to study the implementation process. The aim of this study was to generate knowledge regarding the implementation process of an improvement intervention of empowerment for those who require chronic kidney care.
  
  
  METHODS
  A prospective single qualitative case study was chosen to follow the process of the implementation over a two year period. Twelve health care professionals were selected based on their various role(s) in the implementation of the improvement intervention. Data collection comprised of digitally recorded project group meetings, field notes of the meetings, and individual interviews before and after the improvement project. These multiple data were analyzed using qualitative latent content analysis.
  
  
  RESULTS
  TWO FACILITATOR THEMES EMERGED: Moving spirit and Encouragement. The healthcare professionals described a willingness to individualize care and to increase their professional development in the field of chronic kidney care. The implementation process was strongly reinforced by both the researchers working interactively with the staff, and the project group. One theme emerged as a barrier: the Limitations of the organization. Changes in the organization hindered the implementation of the intervention throughout the study period, and the lack of interplay in the organization most impeded the process.
  
  
  CONCLUSIONS
  The findings indicated the complexity of maintaining a sustainable and lasting implementation over a period of two years. Implementing empowerment-based care was found to be facilitated by the cooperation between all involved healthcare professionals. Furthermore, long-term improvement interventions need strong encouragement from all levels of the organization to maintain engagement, even when it is initiated by the health care professionals themselves.
authors.affiliation: School of Health Sciences, Jönköping University, P.O. Box 1026, Jönköping SE-551 11, Sweden.
authors.forename: Annette
authors.initials: A
authors.lastname: Nygårdh
authors.affiliation: School of Health Sciences, Jönköping University, P.O. Box 1026, Jönköping SE-551 11, Sweden ; Department of Internal Medicine, County Hospital Ryhov, Jönköping SE-55185, Sweden.
authors.forename: Dan
authors.initials: D
authors.lastname: Malm
authors.affiliation: Linneus University, Växjö SE- 351 95, Sweden.
authors.forename: Kerstin
authors.initials: K
authors.lastname: Wikby
authors.affiliation: Department of Health Sciences, Faculty of Medicine, Lund University, P.O. Box 187, Lund SE-221 00, Sweden.
authors.forename: Gerd
authors.initials: G
authors.lastname: Ahlström
keywords: Case study; Empowerment; Healthcare professionals; Implementation process; Improvement intervention; Individualized care; Interactive research; Qualitative research; Quality of care
references.citation: BMC Med Inform Decis Mak. 2008 Sep 12;8:38
references.pmid: 18789150
references.citation: J Clin Nurs. 2008 Feb;17(4):539-48
references.pmid: 18205684
references.citation: Implement Sci. 2010 Jul 01;5:52
references.pmid: 20594312
references.citation: BMJ Qual Saf. 2012 Oct;21(10):876-84
references.pmid: 22543475
references.citation: Implement Sci. 2006 Oct 18;1:23
references.pmid: 17049080
references.citation: Implement Sci. 2011 Oct 24;6:119
references.pmid: 22024188
references.citation: Implement Sci. 2009 Aug 12;4:54
references.pmid: 19674440
references.citation: Implement Sci. 2012 Mar 14;7:17
references.pmid: 22417162
references.citation: J Contin Educ Health Prof. 2007 Spring;27(2):94-102
references.pmid: 17576625
references.citation: Worldviews Evid Based Nurs. 2012 Feb;9(1):1
references.pmid: 22295997
references.citation: BMJ Qual Saf. 2011 Apr;20 Suppl 1:i18-23
references.pmid: 21450764
references.citation: Diabetes Educ. 2005 Jan-Feb;31(1):53, 55-6, 61
references.pmid: 15779247
references.citation: Cancer. 2004 Sep 1;101(5 Suppl):1165-87
references.pmid: 15329892
references.citation: Worldviews Evid Based Nurs. 2013 May;10(2):95-103
references.pmid: 22730957
references.citation: J Clin Nurs. 2012 Mar;21(5-6):897-904
references.pmid: 22081948
references.citation: BMJ Qual Saf. 2011 Jul;20(7):604-10
references.pmid: 21493589
references.citation: Jt Comm J Qual Patient Saf. 2005 May;31(5):275-85
references.pmid: 15960018
references.citation: J Nurs Manag. 2008 May;16(4):404-8
references.pmid: 18405256
references.citation: Patient Educ Couns. 2010 Jun;79(3):277-82
references.pmid: 19682830
references.citation: BMC Nurs. 2011 Oct 28;10:21
references.pmid: 22035275
references.citation: Nephrol Nurs J. 2012 Jul-Aug;39(4):285-93; quiz 294
references.pmid: 23061113
references.citation: Nurse Educ Today. 2004 Feb;24(2):105-12
references.pmid: 14769454
references.citation: J Clin Nurs. 2006 May;15(5):588-98
references.pmid: 16629968
references.citation: BMJ Qual Saf. 2013 Mar;22(3):233-41
references.pmid: 23362504
references.citation: Qual Saf Health Care. 2003 Feb;12(1):40-6
references.pmid: 12571344
references.citation: Milbank Q. 2004;82(4):581-629
references.pmid: 15595944
references.citation: J Adv Nurs. 1991 Mar;16(3):354-61
references.pmid: 2037742
references.citation: J Nurs Care Qual. 2004 Oct-Dec;19(4):297-304
references.pmid: 15535533
references.citation: J Interprof Care. 2008 Mar;22(2):191-203
references.pmid: 18320453