Methodological considerations

This section presents methodological considerations of the strengths and weaknesses of the thesis.

Several researchers have participated during the entire research process (Aase et al., 2020) ensuring different perspectives in the design, planning, data collection, analysis, and dissemination. The researchers spent the first year in close collaboration in consortium workshops to design the leadership intervention. Monthly project meetings were organised with discussions and reflections about the intervention process and consistency of the intervention activities (such as experiences from workshops and activities and advice to ensure usefulness for the managers). This contributed to awareness and understanding of the research quality and organisational processes in all sites involved in the intervention program. It can be considered a major strength to have researchers, co-researchers and stakeholders involved, but it could also lead to information being lost in the shuffle. However, a strict meeting structure, continuous supervision meetings and close collaboration among researchers reduced this risk (Aase et al., 2020; Johannessen et al., 2021).

The data collection has the advantage of data from multiple sources to investigate a phenomenon. The use of several methods of data collection strengthens the interpretations and understanding of a phenomenon (Yin, 2018). The longitudinal insight into the nursing home and homecare services participating in the intervention for more than a year combined with the data collection from multiple sources was a strength of the thesis.

The thesis explored managers’ and employees’ perspectives and perceived challenges and how the leadership intervention influenced the quality and safety work processes. A detailed description and mapping of contextual settings enable others to assess the relevance of the study and to consider the transferability of the results. However, it is a small-scale study and intervention with only four sites, so future researchers should use larger samples and other contextual settings to establish stronger evidence for the leadership guide.

The changing nature of qualitative inquiry can make it difficult to replicate the findings (Yin, 2018). Implementation of context-sensitive intervention and healthcare improvement can be a challenge because what works in one setting does not need to be relevant in or easy to transfer to another setting (Coles et al., 2020). The municipalities and organisations differed in size and location and these differences can be considered a strength in the presentation of the results. However, it can be argued that some of the organisations had small management teams (n=3). This could limit the information perspectives and the transferability of the results (Malterud, 2018). At the same time, the Norwegian municipal context includes large, small, city and rural sites (NOU; 2018). Small management teams often work together on service provision. Hence, we argue that our sample reflects the context.

The observational data can be biased by researchers (Fangen, 2010). The thesis author’s background as a registered nurse and work in homecare could bias the interpretation of data collection and analysis of the data.

However, having several researchers involved in observation and data collection reduced the risk of bias and brought a range of perspectives to the notes. Moreover, all observations were conducted according to an agreed-upon observation guide (Appendix 8), that contributed to sound mapping and consistency among the researchers.

As described in the methods chapter, the study established intervention teams at the research sites. Data were analysed at sites where the thesis

author was not part of the intervention team (homecare service 1, nursing home 2). To ensure sound interpretation of results, Papers II and III included co-authors who assisted with the data collection in these sites, as a quality assurance to ensure that the managers’ quality challenges and implementation process were accurately described. All results were discussed among the author team and in project meetings.

Documents that were collected could have been used and interpreted more in the data analysis process in Paper III. There were variations in types and amount of collected documents from the organisations.

Therefore, collected documents received less attention in the analysis.

The documents complemented the other data (for example in the narrative of each case) but was not used in a systematic analysis in Paper III.

Directed content analysis can make the researcher more likely to find data that support theory (Hsieh & Shannon, 2005). Participants can also be guided to give specific answers when using a theoretical framework as basis for developing the interview guide. However, the thesis has not produced an exhaustive list of quality and safety challenges; the emphasis has been on understanding and describing the phenomenon.

Therefore, the OQ framework produced an overview of the quality and safety challenges and how they were connected for managers and employees in nursing homes and homecare services. We could then identify how context work was more prominent.

The thesis could have used other theories and methods that might have led to different results and perspectives. This thesis could have benefitted from the use of human factors theory that focuses on human beings and their capabilities in the work system (Carayon et al., 2006; Carayon et al., 2005). The Systems Engineering Initiative for Patient Safety (SEIPS) model builds on human factors and is concerned with complex processes in the work system (Carayon et al., 2006; Carayon et al., 2005). Holden et al. (2013) have included patient and next of kin in a revised version of

the SEIPS model. This could have been relevant for the thesis as patient and user are highlighted in the leadership guide and are the end-users of nursing homes and homecare services. The SEIPS model has been used in research on primary care (Johannessen, 2016; Odberg et al., 2020) to describe interaction and work processes in different organisations and their effect on patient outcomes. Moreover, Normalisation Process Theory (NPT) could also have been relevant for the thesis because it is concerned with social processes related to implementation and the implementation of the leadership guide and other tools in everyday work practice (May, 2013). NPT could have drawn increased attention to the workability of the leadership guide in its intended setting to evaluate the effects of the new practice (May 2013; Foss et al., 2016). Although other theories could have been useful, I believe the combination of the KTA and OQ frameworks in this thesis from start to completion is a major strength. This contributed to a consistent guidance and use of theory, reflection on theory, and further iteration and suggestions for theory development of both theories. This is important knowledge for further implementations and knowledge translation in practice.

The use of other methods in the data collection that could have supplemented or given other results. The SAFE-LEAD project collected quantitative data that could have been included in the thesis to complement the qualitative data. That could have contributed with data and analysis to support understanding of improvement in user-involvement or employee user-involvement and perception of patient safety culture (Ree, 2020; Ree & Wiig, 2019a; Ree & Wiig, 2019b). However, this thesis adopted a qualitative case study to explore the role of managers in improving quality and safety in nursing homes and homecare services as we were interested in the mechanisms that lead to successful quality and safety work. The purpose of this thesis was not to measure outcomes of quality and safety in the different organisations before or after the intervention, but rather to explore and understand how and why managers work on quality and safety and what happens in these

organisations before an intervention (Paper II) and when implementing a leadership guide (Paper III). The longitudinal data collection of interviews, observation and workshop was suitable to answer the research questions.

Quality and safety were explored from the viewpoints of managers and employees. What patients and their next of kin experience as good care and safety is beyond the scope of this thesis. It is therefore strongly recommended that further research investigate these perspectives.