– STUDY I AND STUDY II
Study I and II were conducted in the social care context. The data collection for these studies was part of a project that aimed to explore the kinds of support line managers working in the social care setting, including social services and older people care, need to implement EBP. The National Board of Health and Welfare (NBHW) assigned the project to the PROCOME research group at the Medical Management Centre, Karolinska Institutet. The starting point was the identified knowledge gaps in how line managers implement EBP and in the support they need in leading implementation of EBP.
5.2.1 Social care in Sweden
The social care system in Sweden is tax-funded. At the local level, 290 local authorities (municipalities) fund and deliver social care, which broadly includes support and care for the elderly, and social services, which supports families, children, people with substance abuse problems, and people with functional disabilities (Holosko et al., 2009). Before the 1990s, older people care was the responsibility of the regional authorities. However, a transfer of that responsibility, including a mandate for older people care from regional to the local authorities, was enacted in 1992 as a result of the ÄDEL reform (Anell et al., 2012). The care and support offered in the social services area is broad and includes a vast range of services that support children, families, and individuals with disabilities, whereas older people care is usually either provided in the home or in special housing facilities. It is common that employees in social services have a university degree in social work or similar qualifications, whereas relatively few employees in older people care have a university degree (National Board of Health and Welfare, 2014).
The Social Services Act (2001:453), which is the legislative foundation of Swedish social care services, states that the overall aim of this Act is to foster economic and social security, equal living conditions, and active participation in society (older people care is regulated by this law as well as by the Medical Services Act (2017:30)). Moreover, this legislation promotes self- governance and allows considerable freedom for local authorities to work according to their specific needs, which results in differences in how social care services and older people care are organized and delivered throughout Sweden.
The national government is responsible for overall policy in health and social care services through the Ministry of Health and Social Affairs (MHSA). The NBHW is a government agency under MHSA and has a key role at the national level in collecting and evaluating information and in developing national guidelines based on evidence for health and social care in Sweden (Anell et al., 2012). The Swedish Association of Local Authorities and Regions (SALAR) is a politically governed interest organization that represents all regional and local authorities and offers support and service to these organizations at the national level in order to improve conditions for self-government (Swedish Association of Local Authorities and Regions, 2016). Since 2010, the MHSA and SALAR have established yearly agreements to foster EBP within social care to ensure good quality support in this sector (Swedish Association of Local Authorities and Regions, 2015)
In the 1990s, the NBHW established Research and Development (R&D) units (FoU enheter) to support practices in social care services and older people care. These R&D units have been argued as crucial to strengthening the use of EBP in social care (Alexanderson et al., 2009; Soydan, 2010). The development of these units is a result of the growing emphasis by government agencies and other stakeholders on improving and supporting the implementation of EBP in social care services and older people care. Thus, the focus on the development of knowledge should be long-term and should take a national perspective. However, this work should be practically driven at the regional and local levels since this is where the responsibility
and mandate lie to provide care and support. This results in higher expectations on the senior management and a more central role for the line managers in driving this work because these managers’ interpretations and priorities guide the service and support provided to the clients (Thylefors, 2016). To implement EBP, therefore, line managers require knowledge, skills and support.
5.2.2 Setting for Study I and Study II
Data for Study I and II were collected at seven Swedish local authorities. Purposive sampling (Patton, 2015) of local authorities was conducted in order to obtain representation by various local authorities on the line managers’ experiences. A representation of local authorities was sought due to a lack of previous knowledge of how line managers in social care work with EBP implementation and of the support they need, and because of a large variation in how care and support are organized in Sweden. The project aimed to include local authorities that differed in geographic location (north, central, and south Sweden, including urban and rural areas), size (number of inhabitants), and their experiences of working with EBP to get an overview of the country. Twenty-eight of the 290 local authorities were initially selected based on their geographic location and size.
The webpages of these local authorities were then reviewed, and information was gathered on the extent that they appeared to work according with EBP. Search terms included “evidence- based practice”, “research and development”, “practice guidelines”, among others. Information about the local authorities’ work with EBP was also gathered from the R&D association and from the opinions of experts in the area. Based on advice from experts, two additional local authorities were included as they were known for having extensive experience of working according to EBP (i.e. being in the forefront with implementing EBP). After the data from these 30 local authorities were discussed in the project group, it was decided to use seven local authorities in the project. An overview of the local authorities selected for the studies is presented in Table 2.
5.2.3 Participants and data collection
Twenty-eight semi-structured interviews with line managers were performed in October and November, 2012. Five to six managers at each of the seven local authorities were randomly selected from a list of managers obtained from each local authority’s website. Each manager was invited to participate in an interview. Of the forty managers invited, 32 agreed to participate although four managers cancelled at the last minute. The managers worked in both the social services area, including areas providing support for children, youths, families, and people with addictions, and in older people care where managers’ were mainly employed in nursing homes. Twenty of the interviews were conducted with managers in social services and eight with
managers in older people care. This was because more managers in the local authorities work in the social services area than in older people care.
The semi-structured interview guide was founded on broad dimensions based thematization (Kvale, 2008) with each dimension having a number of questions. For example, some questions asked the managers about their role in implementing EBP, how they described their practical work with implementation (i.e., what they do/their actions), and which factors support and/or influence their implementation leadership, among others. Follow-up and probing questions were also asked when required throughout the interviews to encourage further descriptions (Kvale, 2008). These one-to-one interviews were conducted at each manager’s workplace (with between two and six managers from each of the seven local authorities). The interviews lasted 60-80 minutes and were recorded and transcribed verbatim.
Table 2. Overview of the seven local authorities included in Study I and Study II.
Local authority
Geographic location Size, approximate inhabitants Level of apparent experience of working with EBPa I Central (close to a metropolitan city) 10 000 Low
II North 85 000 High – identified as
being in the forefront
III North 5 000 Low
IV South (close to a
metropolitan city)
37 000 Medium
V South 330 000 High – identified as
being in the forefront
VI Central 62 000 Medium
VII Central 16 000 Medium
a Based on information from each local authority’s website, the National Research and Development
Association website, and advice from experts in relevant governmental agencies.
5.2.3.1 Participants included in Study I and Study II
All the interviewed line managers (N=28) were included in both Study I and II. There were 20 female (13 in social services and seven in older people care) and eight male (seven in social services and one in older people care) managers. They had been managers for an average of 14 years and been in their present managerial position for an average of seven years. The managers had between nine and 55 employees. Most managers in social services held a university degree in social work, whilst only one manager in older people care had a university degree.