Promoting a sense of security in everyday life—A case study of patients and professionals moving towards co‐production in an atrial fibrillation “learning café”

Abstract Background An improvement initiative sought to improve care for atrial fibrillation (AF) patients; many felt insecure about how to cope with AF. Objective To reveal AF patients' and professionals' experiences of pilot‐testing a Learning Café group education programme, aimed at increasing the patients' sense of security in everyday life. Design Using an organizational case study design, we combined quantitative data (patients' sense of security) and qualitative data (project documentation; focus group interviews with five patients and five professionals) analysed using inductive qualitative content analysis. Setting AF patients and a multiprofessional team at a cardiac care unit in a Swedish district hospital. Improvement activities Two registered nurses invited AF patients and partners to four 2.5‐hour Learning Café sessions. In the first session, they solicited participants' questions about life with AF. A physician, a registered nurse and a physiotherapist were invited to address these questions in the remaining sessions. Results AF patients reported gaining a greater sense of security in everyday life and anticipating a future shift from emergency care to planned care. Professionals reported enhanced professional development, learning more about person‐centredness and gaining greater control of their own work situation. The organization gained knowledge about patient and family involvement. Conclusions The Learning Café pilot test—exemplifying movement towards co‐production through patient‐professional collaboration—generated positive outcomes for patients (sense of security), professionals (work satisfaction; learning) and the organization (better care) in line with contemporary models for quality improvement and with Self‐Determination Theory. This approach merits further testing and evaluation in other contexts.


| Problem description
It was just as if they were leaving you alone on the doorstep, saying: now we are done, now you have to take care of yourself. This article reports on that improvement project and is formatted according to the Standards for QUality Improvement Reporting Excellence (SQUIRE) guidelines. 1

| Available knowledge
Atrial fibrillation is a common heart arrhythmia associated with an irregular heart rhythm, chest discomfort, an increased risk of stroke due to formation of thrombi inside the heart, and even of premature death. Arrhythmias in general are also associated with lowered quality of life and uncertainty, causing low patient confidence in decision making concerning treatment options and self-care. [2][3][4] To support persons living with AF, (hereafter referred to as patients with AF), clinical guidelines promote an integrated care approach with multidisciplinary teams providing easy access to appropriate care and patient support. 5 This includes empowerment for self-management, counselling on lifestyle changes, and risk factor management to promote coping. Coping with disease is essential for long-term adaptation and self-care for patients with heart disease. 6 Problem-focused coping strategies, that is the ability to seek information, plan and solve problems, can support decision making, decrease uncertainty due to an illness, and improve clinical outcomes and patients' quality of life. [5][6][7] Inadequate patient and family support for coping with AF is common, due to insufficient disease knowledge and inadequate support in dealing with symptoms, which cause emotional distress. [8][9][10][11] Fear and uncertainty can be reduced when health-care providers have time to explain AF and to help patients self-manage their AF. 12 Persons with a good understanding of their AF report fewer symptoms and fewer AF-related negative emotions. 13 Although various structured approaches to AF care have been tried worldwide, it is still unclear what design to use in different health-care settings for integrated AF care, including patient support and education. 5,[14][15][16][17] A key design idea in such support initiatives is to enable fruitful interactions between fellow persons living with the same condition, family members and health-care professionals. These interactions, using a non-hierarchical structure by valuing and giving weight to each team member's views, can provide both experiential and formal disease knowledge that underpin the development of useful coping strategies. 18-20

| Rationale
The Learning Café is a health group education model designed on such principles to provide patients with opportunities to interact with fellow patients, family members and health-care professionals. 21 To improve their sense of security in everyday life, the Learning Café starts by identifying the patients' and their family members' questions and concerns. This is done to focus on what matters to them, to increase their knowledge, and to support effective coping. The Learning Café model exemplifies patient-professional health-care collaboration and facilitates mutual learning among patients, family members and professionals about how to live with a chronic condition.

| Specific aim
The aim of the Learning Café initiative was to increase AF patients' sense of security in everyday life. The organizational case study reported here aimed to reveal experiences from pilot-testing the Learning Café among participating patients and health-care professionals.

| Context
The Learning Café programme was designed and pilot-tested between September 2016 and January 2017, in the cardiac care K E Y W O R D S atrial fibrillation, coping behaviours, co-production, health-care quality improvement, patient education, Self-Determination Theory services at the Highland district hospital in Region Jönköping County, Sweden. Serving 115 000 inhabitants in the surrounding small towns and rural areas, the cardiac services are among the hospital's largest, staffed by cardiologists, resident and intern physicians, registered and assistant nurses and a physiotherapist, an occupational therapist and administrative assistants. Each year, 300 patients with AF are admitted from the emergency department, making AF a leading cause of emergency admission at the hospital. The cardiac services operate with limited resources, which make it necessary to perform improvement initiatives within existing resource constraints.
In this particular context, there are several contextual factors that might influence quality improvement (QI) success. [22][23][24] One of these factors is physician involvement (QI team leader with two additional physicians included in the improvement team). Another contextual factor promoting QI success is a high microsystem motivation to change due to an important quality gap in care identified by both patients and professionals, that is the need for improvement of AF management. The health system also has a long tradition of quality improvement work with top management leaders dedicated to constantly improve health care. 25

| Improvement activities
The physician leader of the cardiac care services (the first author) formed an improvement team with two additional physicians, two registered nurses specializing in cardiac care and an administrative assistant. Another nurse supported the team as Improvement After each session and before leaving the Learning Café room, the improvement team asked the patients to rate their sense of security in everyday life with AF and their satisfaction with the Learning Café programme. The ratings were done on a scale of 0-10, 10 representing "completely secure" and "completely satisfied", respectively (ie self-assessment by patients, using a nonvalidated form developed by the professionals and piloted with patients). The improvement team noted that the term "sense of security in everyday life" could concern different aspects of life for different patients. The main purpose of using the ratings was to assess the patients' subjective sense of being secure despite living with AF. These ratings were reviewed by the improvement team after each session and discussed with the participants during the following sessions. Since the sense of security scale was completed anonymously at each session, no linked individual data were collected. After each session, the improvement team also reflected on the strengths of the programme and opportunities to improve it by adjusting subsequent sessions using Plan-Do-Study-Act (PDSA) cycles. 26 The introduction of the Learning Café group education programme was the team's main quality improvement intervention to improve care for patients with AF. In addition, although not further elaborated here for the sake of brevity, the team developed a checklist to guide clinicians in managing AF (ie guidance on the diagnostic workup and medical treatment) and mapped patients' care processes in co-operation with the Learning Café participants.
The checklist was only used by clinicians during patient care prior to participation of the Learning Café; therefore, it did not affect the patients' or the professionals' experience of the Learning Café initiative.

| Study of the improvement activities, data collection and analysis
To understand the stakeholders' experiences of the Learning Café' group education programme, the authors undertook an organizational case study, using both quantitative and qualitative data. 27 Quantitative data included patients' ratings of their sense of security in everyday life and their satisfaction with the Learning Café group education programme. These ratings were visualized graphically in chronological order. Qualitative data included documents (the project plan, notes from project meetings and field notes reflecting the improvement efforts) and transcripts from two semi-structured focus group interviews.
All patients and professionals in the Learning Café programme were invited to the focus group interviews, scheduled a few weeks after the concluding café session. The first invitation to join the focus group interviews was made orally by the first author at the end of the last Learning Café session. The individuals interested in participating received a letter with written information about the study.
Five patients and five professionals accepted the invitation to participate and formed the two interview groups, one for patients and one for professionals. Five individuals is an appropriate number of individuals to include in focus group interviews for data collection. 28 Informed written consent was obtained from all participants. In her role as a master's student, the first author (AMS) conducted both interviews, with her master's thesis advisor (author JT) as an observer, to explore participants' experiences of the Learning Café programme. The interviews were audio-recorded, transcribed verbatim and anonymized. The interviews were transcribed by an administrative assistant who was not part of the improvement team. Using content analysis, 29 the main author undertook qualitative analysis according to Lundman & Hällgren Graneheim (Table 1). 30 Since there was no pre-existing framework expected to fit the results, she took TA B L E 1 An example of a meaning unit, code, subcategory, category and theme as postulated by Lundman   an inductive approach to the content analysis. 31 The draft analysis was reviewed with the advisor (JT) and finalized by reaching consensus as a form of investigator triangulation. The validity of the case study was strengthened by using data and informant triangulation, combining quantitative and qualitative data, and by illustrating interview themes with quotes from both patients and professionals to reveal different perspectives. 27

| Ethical considerations
Written informed consent was obtained from all participants prior to data collection. The study was vetted by the Regional Research Ethics Review Board in Linköping, Sweden (Dnr 2016/493-31).

| Patients' ratings
The patients' sense of security in everyday life increased (median rating increasing from 7 to 9) with successive sessions (Figure 1).
The patients' satisfaction with the Learning Café sessions was high throughout the programme (median rating increasing from 9 to 10).
Some quantitative data concerning the patients' sense of security and satisfaction were missing since some patients could not participate in all four sessions. No new participants joined after the first session.

| The health-care professionals: working environment
The expectation was that improving care through the Learning We've had the chance to see them not as patients, but as persons. [FGS] It has felt like an energy boost also for us, it is like you're reminded of why you chose to work with this in the first place [--] but you get so incredibly much back from the patients and you really have the time to see them as individuals. So that's like a reward too. [FGS] You don't just stand still but you do something about an existing problem, you work with others who want things to get better too instead of just complaining about what is working poorly.
[FGS] and it is not always the patient's real problem that is in focus.

| The organization: delivery of health care
[FGS] We were a bit worried that they [the patients and fam- ily members] would not ask for certain things since we wanted to get across a particular type of information.
But I think we actually did here. [FGS] Both patients and professionals reported that participating in the "Learning Café" created a sense of security in everyday life that could change patients' patterns of future health-care utilization in a welcome way, shifting from unplanned emergency care to planned care: When you experience the reassurance from getting answers to a lot of questions, you don´t need to make emergency calls so often.
[ And I also think that when the patients' sense of security increases, they might choose to wait a little bit and follow the recommendations instead of getting in touch with the emergency department immediately. [FGS] Applying existing quality improvement models 32,33 on this case study, the next section synthesizes the pilot test experiences into a conceptual model. The model illustrates and summarizes the improvement efforts and the findings of the Learning Café case study ( Figure 2).

| D ISCUSS I ON
The context-and culture-specific results from this study indicate that the Learning Café pilot test-exemplifying collaboration be- Reflecting on the findings after the conclusion of the data analysis, we found that innate psychological intrinsic motivators included in Self-Determination Theory (SDT) 34,35 -autonomy, competence and relatedness-can link the execution of the Learning Café programme to its results. Autonomy represents peoples' need to feel that they have choices and that their behaviours are self-endorsed. 35 Competence refers to peoples' need to develop mastery and to operate effectively within their own lives. 35 Relatedness concerns peoples' need to care about, and be cared for by, others. 35 SDT posits that people, in this case patients with AF and professionals, will naturally engage in interesting, challenging and enjoyable activities, which help satisfy these innate psychological needs. 36  and, thereby, to promote self-management, well-being and work satisfaction. 34,35 Applying the components of SDT retrospectively to the results thus helps us make sense of our research findings. 38

| Learning Café strengthening coping strategies
One explanation for the increase in patients' overall sense of security in everyday life with successive Learning Café sessions ( Figure 1)

| Learning Café enhancing working experience
The is learning about how to co-produce effectively and how lessons from co-production could be used for service improvement. Building on these statements, co-production of health care is understood in this paper as when patients, family members and professionals collaborate along the health-care process and learn together to further improve health-care services.
The professionals participating in the study context lacked previous experience of how to involve patients in co-producing improvement efforts. Therefore, the initial planning phase involved only professionals, who thereafter invited patients to join the Learning Thus, although not including every possible aspect of co-production of health care, the Learning Café-involving patients and family members, starting with what matters to them, using a person-centred approach-exemplifies movement towards co-production of healthcare services in the present context through patient-professional collaboration. [51][52][53][54] We suggest that this initiative promoted the patients' and professionals' autonomy, competence and relatedness. Previous research implies that the drive to satisfy these fundamental human needs greatly influences if and how patients participate in service development in health care. 37

| Methodological considerations
This is a single case study of a pilot test in one particular setting. We were not able to collect follow-up data on the programme from participants after its conclusion; therefore, we cannot report on the sustainability of its favourable effects. Future research could include such longer-term follow-up to assess both patients' sense of security and their actual demand for emergency services over time.

| CON CLUS IONS
The pilot test of the Learning Café group education programme exemplifies movement towards co-production through patientprofessional collaboration with enhanced stakeholder autonomy, competence and relatedness. The pilot test generated positive outcomes for patients (sense of security), professionals (work satisfaction; learning) and the organization (better care) in a Swedish district hospital setting. The improvement initiative was conducted within existing resource constraints. Since the completion of our pilot test, top management in the health system has promoted Learning Cafés with additional patient groups and in different contexts, that is not only within specialized care but also within primary care contexts.

ACK N OWLED G EM ENTS
The authors thank the patients and professionals who participated in the study. Dr Suutari's work was conducted as part of her employment at the Highland Hospital, Region Jönköping County, initially while a master's student in Quality Improvement and Leadership in Health

CO N FLI C T O F I NTE R E S T
The authors declare that they have no conflicts of interest in publishing this work.

DATA AVA I L A B I L I T Y S TAT E M E N T
Research data at the School of Health and Welfare, Jönköping

PATI E NT CO N S E NT
Informed consent was obtained from the participants prior to data collection.

E TH I C A L A PPROVA L
The study was vetted by the Regional Research Ethics Review Board