Attitudes and beliefs about national guidelines for schizophrenia. A study among stakeholders.

The aim of this thesis was to investigate and synthesise the knowledge base concerning leadership and its influence on the implementation of evidence-based practice. A further aim was to investigate attitudes and beliefs among politicians, healthcare managers and mental healthcare professionals about the Swedish national guidelines for schizophrenia or schizophrenia-like conditions. Data was collected by means of a systematic literature search (Study I), a questionnaire distributed by e-mail to 592 Swedish decision-makers (Study II), five group interviews with 16 mental healthcare professionals (Study III) and interviews with 23 politicians and managers (Study IV). The results in Study I, extracted and synthesised from seven papers, indicated that leadership was vital for the process of implementing EBP in nursing and highlighted the importance of the organisation and the culture in which the leader operates. In Study II, data was analysed using descriptive and comparative techniques. The results showed that significantly more of the managers than politicians stated that they knew about the national guidelines for schizophrenia (i.e. their release and content) and they considered the guidelines to be a good source of support for planning and allocating resources. Data from the group interviews subjected to content analysis showed that the release of guidelines could be perceived as a challenge to the prevailing care and culture and also how staff expected the implementation process to flow from top to bottom. In Study IV, data was analysed deductively, to test how well the Promoting Action on Research Implementation in Health Services (PARIHS) reflected the empirical reality of a mental healthcare context, and inductively, through a qualitative content analysis. Together, the two analyses provided a rich description of an organisational culture that was highly unlikely to facilitate the implementation of the national guidelines, together with a distrust of the source behind such guidelines, which stands in clear contrast to the high confidence in the knowledge of experienced people in authority within the organisational context. In conclusion, more rigorous research is needed concerning the role of the leader however; the results indicate that leadership cannot be studied in isolation. Managers have a vital role to play in the implementation of national guidelines. However, the task could be virtually impossible without strategic government support and guidelines accompanied by an implementation plan. There is a need for decision-makers to assume responsibility in supporting the implementation of evidence-based practice. The results have highlighted that, regardless of who releases the guidelines, they are not likely to be utilized or implemented if those who are responsible for implementing them do not trust the source. This important aspect (i.e., contextual trust) is not covered by PARIHS or other implementation frameworks commonly used within health and social care organisations