Bo Strangert

1. Inducing holistic healthcare strategies for elderly 

and long-term patients

This project was motivated by widespread complaints in Swedish society during the late 1970s about a lack of empathy and individualized healthcare. Also, the trade unions for nurses and nursing assistants called attention to unsatisfactory work conditions and the need for in-service training for the personnel. Our extensive prestudy 1978-80 confirmed the predicament and the restricted focus on certain physical conditions at the expense of concern with inpatients’ backgrounds, wishes, and psychosocial needs. The demand for a radical organizational change at nursing homes was obvious.

The crucial task was about handling the feelings of hopelessness and incapability among personnel who daily had to face fragile patients, many with chronic illness or suffering from dementia. There were definite grounds for low job satisfaction and bad care. Repeated attempts by management to improve work motivation and care conditions had failed.

From our cognitive perspective, it seemed necessary to make the care process more meaningful for the personnel, improving the patient’s quality of care. We assumed that the sense of meaning could be strengthened by understanding more about a patient's background, personal needs, thoughts, and reactions. Consequently,, the goal of our project in 1980 was to develop a holistic healthcare strategy for each member of the nursing team as well as for the unit as a whole.³

Cognitively, with  'holistic strategy' we mean understanding by compounding mental patterns, linked with judgment and behavior to treat patients respectfully and comprehensively. In brief, each staff member ought to develop empathic and functional skills adapted to each patient’s wishes and needs. Satisfying that objective would also make healthcare more sensitive to patient diversity.  Theoretically, a 'holistic perspective' on each patient was assumed to be necessary for good treatment.

Therefore we constructed nursing schemas to characterize individual patients configurationally by collecting information about healthcare actions and experiences (including patient interviews) that would reinforce a holistic strategy as time goes by. Different forms were tested experimentally to find ones that allowed reliable perception and retention of complex information. The information should also be easy to communicate and validate.

Formally, a schema included a conjuncture of specific events and care operations Ea, Eb, Ec … to be documented in the individual healthcare plan (IHCP), where a, b, c … represent inclusive sources of information about a patient’s biography, somatic functions, ADL, psychological, social and communicative functions. The configuration of the five grand functions is a multifunctional description of a patient’s state at a certain time in the healthcare process. IIHCP was assumed to strengthen understanding and possible compassion. ⁴ 

Besides satisfying the need for reliable written documentation, an individual healthcare plan should advance the holistic perception and treatment of a patient by assembling and integrating essential information during care work. The purpose was to make everybody in a nursing team comprehend the complex interplay between different healthcare operations and a patient’s conditions and reactions. 

To make the IHCP functional in the activities and structure interpersonal communication, it was necessary to design a control system of information transaction, judgment, and action. That was an essential complementary condition for the holistic strategy. The normative control system should structure the set of specific healthcare procedures and roles for all staff members. It is outlined in Figure 1 (from Strangert, 1983).

Figure 1. Control model of IHCP-processes.

It represents the formal normative network of events and healthcare operations to start or revise an individual plan of the healthcare process for a patient p. In brief, it is a recurrent cycle of decisions (d_p) on diagnostic events (O_b, O_s), and conclusions on conditions c_s, which precede goal generation and formulation (g_g, c_g). These operations include both individual meetings with the patient and recurrent IHCP-conferences with the whole nursing staff. Decisions are followed up during daily conferences with each nursing team, which decides on action planning (d_a, g_a), care procedures (a), observation, and conclusion on effects (O_e,c_e), leading either to a repeated action cycle or to inclusive feedback (c_f). Thus, the individual plan is shaped, evaluated, and revised cyclically during the whole healthcare process.

To implement the corresponding healthcare process involved qualified individual and organizational learning. Professional thinking and role expectations needed to be changed using extensive training of employees and recurrent follow-up of staff activities. The OD intervention was supported by off-line training of registered nurses to be efficient team leaders. The nursing teams were introduced to new work procedures through extensive instruction and practice. A core condition was to ensure that goal-directed acting would result from continued vital work experiences in the network of care events.

The progress with the new organization was followed up and assessed for a sample of nine nursing homes with a total of 36 nursing teams (for more than 300 patients). The research team used qualitative methodology and recorded data from recurrent visits to each nursing home during the whole OD period. Data included analysis of all healthcare plans, conference observations, interviews with patients or relatives, nursing teams, managers, and single employees. Support and specific feedback about progress were given at each occasion and visit.

Eventually, the detailed evaluations confirmed positively that the undertaken care operations would, in general, be sufficient to attain the project goal of holistic care strategies in the pilot set of seven nursing homes (Strangert, 1983; Strangert, Andersson, Brännström & Sandberg, 1983).

In connection with quality management, the question is how administration and cost-effectiveness are handled in managerial operational planning (Strangert & Wågman, 1987). A follow-up project in three regions investigated whether local nursing homes and other healthcare units could develop towards more self-governed administration (Strangert, Brännström & Wågman, 1988). However, four years later a national political decision transferred the government of elderly care from regional (medical service) to municipal (social service) authority by a reform,  ”Ädelreformen, 1992”. That led to an organizational decline which possibly made the situation worse for the handling of elderly and long-term care for years to come.⁴

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¹ See References for detailed project descriptions. 

² Some theoretical explications are given in On concept development and modeling in healthcare contexts.

³  'Holistic’ can be a fuzzy concept. The hypothesis about a possible ”holistic understanding”, based on conjectures of information from a patient, is explicated in On concept development and modeling in contexts of healthcare.

⁴ See a report from a work environment inspection of nursing homes and an independent evaluation of a TQM-project in a municipality (Strangert, 2000a, pp.29-53).

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References in chronological order

Strangert, B. Försöksverksamhet med nya arbetsformer inom sjukvården. (Experimentation with new work models in healthcare). Rapport 1/1978, Forskargruppen för kommunikationspsykologi, Umeå Universitet..

Strangert, B. (1978). Vård- och organisationsplanering i arbetsgrupper. (Healthcare and organizational planning). Rapport 2/1978. Forskargruppen för kommunikationspsykologi, Umeå Universitet.

Strangert, B. (1980). Gruppvård i långvården. Ett åtgärdsprogram. (Team nursing in long-term care. An action program.) Rapport 1/1980, Forskargruppen för kommunikationspsykologi, Umeå Universitet.

Strangert, B., Andersson, B., Brännström & L. Sandberg, L. (1982). Utbildning i gruppvård. (Training in team nursing.) Rapport 1/1982, Forskargruppen för kommunikationspsykologi, Umeå Universitet.

Strangert, B. (1983). Organisationsutveckling i långvården. (Organization development in long-term care.) Forskargruppen för kommunikationspsykologi, Umeå Universitet.

Strangert, B., Andersson, B., Brännström & L. Sandberg, L. (1983). Utveckla gruppvården. (Develop team nursing). Forskargruppen för kommunikationspsykologi, Umeå Universitet.

Lind, T. (1985). Förändringar i sjuksköterskans rolluppfattning vid införandet av gruppvård i långvården. (Changes in the nurse's role perception at the introduction of team-nursing in long-term care.) C-uppsats 1985, Psykologiska institutionen, Umeå Universitet.

Strangert, B., Andersson, B., & Brännström, L. (1986, 2.uppl.). Utbildning i gruppvård med individuell vårdplanering. (Training in team nursing with individual healthcare planning.) Forskargruppen för kommunikationspsykologi, Umeå Universitet.

Strangert, B. (1987). Ledningsfunktioner och personalinflytande vid verksamhetsvärdering. I Ledning, personalinflytande och verksamhetsvärdering i sjukvården. (Management, employee involvement and service evaluation). Forskargruppen för kommunikationspsykologi, Umeå Universitet.

Wågman, L. (1987). Kartläggning av verksamhetsplaneringen vid sjukvårdens basenheter. (Survey of operational planning at healthcare base units.) I Ledning, personalinflytande och verksamhetsvärdering i sjukvården. (Management, employee involvement and service evaluation.) Forskargruppen för kommunikationspsykologi, Umeå Universitet.

Strangert, B., Brännström, L. & Wågman, L. (1988). Självstyrande vårdorganisation. (Self-governing healthcare organization.) Rapport 1/1988, Forskargruppen för kommunikationspsykologi, Umeå Universitet.

Strangert, B. (2000a). Studier av yrkesinspektionens metodik vid systeminspektion av internkontroll. (Studies of the labour inspection’s methodology at system inspection of internal control.) Rapport 1/2000. Forskargruppen för kommunikationspsykologi, Umeå Universitet.

Strangert, B. (2000b, 2.uppl.). Att utveckla ledarskap. Exempel från vård och omsorg. (Developing leadership. Examples from healthcare.) Forskargruppen för kommunikationspsykologi, Enheten för arbets- och organisationspsykologi, Umeå Universitet.

Participants in the project (1978-1988)

Björn Andersson, Per Asplund, Vivan Brännström (regional administrator and acting member of the R&D team), Lauritz Brännström, Gösta Bucht, Birgitta Engström, Helén Eriksson, Lotten Höglund, Siv Jungebjörk, Tord Lind, Margaretha Lindberg, Gertrud Locatelli, Margreth Reiniusson, Johan Runnman, Lennart Sandberg, Per-Olov Sandman, Bo Strangert (project leader), Ann-Louise Söderlund, Mona Wiklund, Leif Wågman. The nursing staffs at nine districts: Anderstorp (Skellefteå), Boliden, Skelleftehamn, Dorotea, Malå, Bjurholm, Teg (Umeå), Avd 15 Hedgården (Bollnäs), Avd. 35 Sollefteå sjukhus.

R&D funding

Arbetarskyddsfonden

Arbetsmiljöfonden

Socialdepartementet genom delegationen för social forskning

Västerbottens läns landsting