Sissel Steihaug

Mangelfullt samarbeid innen helsevesenet er velkjent, og samarbeidsutfordringer som organisatoriske rammebetingelser, faglig uenighet og individuelle faktorer trekkes fram. • Her beskrives slike samarbeidsutfordringers betydning for klinisk arbeid. Pasientene opplevde oppsplittede tjenester som følge av uheldig organisering og faglig uenighet. Ulike faglige perspektiver og ulik rolleforståelse vanskeliggjorde tverrfaglig samarbeid.

This article summarizes and synthesizes the findings of four separate but inter-linked empirical projects which explored challenges of collaboration in the Norwegian health system from the perspectives of providers and patients. The results of the four projects are summarised in eight articles. The eight articles constituted our empirical material. Meta-ethnography was used as a method to integrate, translate, and synthesize the themes and concepts contained in the articles in order to understand how challenges related to collaboration impact on clinical work. Providers' collaboration across all contexts was hampered by organizational and individual factors, including, differences in professional power, knowledge bases, and professional culture. The lack of appropriate collaboration between providers impeded clinical work. Mental health service users experienced fragmented services leading to insecurity and frustration. The lack of collaboration resulted in inadequate rehabilitation services and lengthened the institutional stay for older patients. Focusing on the different perspectives and the inequality in power between patients and healthcare providers and between different providers might contribute to a better environment for achieving appropriate collaboration. Organizational systems need to be redesigned to better nurture collaborative relationships and information sharing and support integrated working between providers, health care professionals and patients.

The growing elderly population and the rising number of people with chronic diseases indicate an increasing need for rehabilitation. Norwegian municipalities are required by law to offer rehabilitation. The aim of this study was to investigate how rehabilitation work is perceived and carried out by first-line service providers compared with the guidelines issued by Norway’s health authorities. In this action research project, qualitative data were collected through 24 individual interviews and seven group interviews with employees – service providers and managers – in the home-based service of two boroughs in Oslo, Norway. The data were analysed using a systematic text-condensation method. The results show that rehabilitation receives little attention in the boroughs and that patients are seldom rehabilitated at home. There is disagreement among professional staff as to what rehabilitation is and should be. The purchaser–provider organization, high speed of service delivery, and scarcity of resources are reported to hamper rehabilitation work. A discrepancy exists between the high level of ambitious goals of Norwegian health authorities and the possibilities that practitioners have to achieve them. This situation results in healthcare staff being squeezed by the increasing expectations and demands of the population and the promises and statutory rights coming from politicians and administrators. For the employees in the municipalities to place rehabilitation on the agenda, it is a requirement that authorities understand the clinical aspect of rehabilitation and provide the municipalities with adequate framework conditions for successful rehabilitation work. Key points Home-based rehabilitation is documented to be effective, and access to rehabilitation has been established in Norwegian law.The purchaser–provider organization, high rate of speed, and a scarcity of resources in home-based services hamper rehabilitation work.Healthcare providers find themselves squeezed between the health authorities’ overarching guidelines and requirements and the possibilities of achieving them.Rehabilitation must be placed on the agenda on the condition that authorities understand the clinical aspect of rehabilitation.

To use general policy guidelines and staff experience of rehabilitation work in two boroughs in Oslo to develop a model for organisation and cooperation in home-based rehabilitation. The project was conducted as a collaboration between researchers and employees in the two boroughs. It was a practice-oriented study designed as an action research project combining knowledge generation and improvement of practice. Data were collected at seven meetings, and individual, qualitative interviews with a total of 24 persons were conducted in the period February 2010 to June 2011. Home-based rehabilitation occurred rarely in the boroughs, and this field received little attention. However, this project provided a broad discussion of rehabilitation involving all parts of the organisation of both boroughs. In the course of the project, researchers and borough staff together developed a model for the organisation of and cooperation on rehabilitation including a coordinating unit assigned the paramount responsibility for the rehabilitation and an interdisciplinary team organising the collaboration on the practical level. When implementing a model like this in primary health services, we recommend involving several levels and service locations of the borough staff in order to legitimise the model in the organisation. An increasing number of older people with chronic diseases in the Western world have caused increasing emphasis on rehabilitation in primary health care in patients' homes. This study has elucidated challenging framework conditions for rehabilitation work in two Norwegian boroughs. To reduce municipal challenges we propose a rehabilitation model with a coordinating unit with the paramount responsibility for rehabilitation, and an interdisciplinary team constituting a suitable structure for collaboration.

To explore experiences from a process of change for women with chronic pain. A group-based treatment programme was intended to increase the awareness of how attitudes, habits and bodily practices are established, developed, and can be transformed, and thereby probably reduce pain. A single case story from this treatment programme is presented. A semi-structured interview was conducted with all participants about their experiences after completion of the programme. All eight women reported that they had benefited from participation. From these interviews a single case was chosen to represent the study's findings. A narrative analysis was conducted, focusing this patient's story from a phenomenological understanding of the body. The patient's story illuminates how events and experiences can be connected, and how she interprets her contemporary situation in the light of previous experiences. In this way, she alters her understanding and develops a new approach to her situation. Her story demonstrated how symptoms can be understood as the result of stressful habits that the body has developed as a reaction to demands from the surroundings. Reflection on how the body functions may lead to a new realization of how phenomena are interconnected, thus making changes possible.

Medicine lacks good models for understanding and treating chronic muscle pain. The aim of this study was to explore whether participation in a treatment group for women with chronic muscle pain can help the participants to develop strategies to handle their chronic muscle pain. The study was carried out as a qualitative research project. Eight women completed a treatment programme consisting of movement training and group discussions. The qualitative data consisted of transcriptions from audio-taped individual interviews. The data material was analysed by systematic text condensation inspired by Giorgi. All the women describe participation in the treatment group as useful. Their experiences could be categorized as follows: To know oneself, to negotiate with oneself and others, to be able to choose, and to be able to act. The participants developed strategies for handling their chronic muscle pain. Both the women's new understanding of their chronic muscle pain and increased confidence in themselves were important. These phenomena can help women in their encounters with their surroundings, for example when consulting doctors. The doctor's awareness of the women's resources and their own mastering strategies may contribute to a new understanding of the disposing, triggering, and maintaining factors, and of the curative and health-promoting forces at work in those with chronic muscle pain.

Each person develops their own posture and patterns of movement; our bodies are marked by the life we live. Our ways of being imply that the body is used and strained in different ways, and these habits are decisive for what kind of functional problems we may develop. A group-based treatment programme for women with chronic muscular pain includes movement training and group discussions once a week over the course of ten months, aimed at changing straining bodily habits. The study explores what the participants appreciate as meaningful and beneficial effects of this programme. A treatment group of ten women with long-lasting chronic muscular pain was organised at the start of the 21st century. Seven of them completed the programme. Transcriptions from individual interviews with the participants were analysed using a phenomenological analysis. The participants made new bodily experiences, changed their bodily habits and developed strategies for handling stress and pain in daily life. Group treatment may be a beneficial offer in primary care to women with chronic muscular pain.

Chronic muscular pain is often regarded as incomprehensible or indefinable when the doctor ``can't find anything'' on examination. However, the physiotherapist often detects physical signs in these patients: changes in posture, holding breath, tense and hard musculature, and poor balance. The findings are dependent on what is being sought. The view of the body as ambiguous, as something a person has and is, can shed light on the way life has left its traces in the body, such as changes in posture and poor balance. In this article it will be argued that combining a physiotherapeutic, a phenomenological, and a biological perspective can make chronic muscular pain more comprehensible. Chronic muscular pain can be perceived not as a sign representing a symbol of underlying factors but rather as a sign understood as an expression of the bodily state.