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This thesis is anchored in improvement science, the research field of improvement. Improvement science describes and explores improvement in real-life contexts and "system of profound knowledge" (Deming, 2000) is a cornerstone. Performance measures, including their variation over time, are fundamental in the research and evaluation of outcomes of continuous quality improvement efforts (CQI efforts). However, the strong emphasis on operationalisations and measurements risks overshadowing other kinds of outcomes to which CQI efforts can lead. Research has shown that it is advantageous that those performing change have some kind of "sharedness", e.g. shared cognitions, understanding, knowledge, interpretations or frame of reference. Despite the diversity of concepts and scientific studies, "sharedness" is mainly described as a prerequisite for change. This thesis addresses the call to broaden the scientific approach in improvement science and to take advantage of knowledge developed since Deming's time. It has a point of departure in the presumption that CQI efforts also lead to intangible outcomes; qualitative effects that are not easily captured with traditional performance measures. The concept "Expressions of shared interpretations" is used to study "sharedness" as intangible outcomes. The overall aim with this thesis is to explore Expressions of shared interpretations as intangible outcomes of CQI efforts from the perspective of clinical microsystems and healthcare professionals. The specific aims are to examine and establish how Expressions of shared interpretations develop, influence CQI efforts and change over time. Using a qualitative approach, this thesis comprises four papers, based on three studies. The empirical context is healthcare and welfare organizations providing care: hospital clinics in county councils/regions and nursing homes in municipalities. The studies include time periods from one to three and a half years, totalling six years. Expressions of shared interpretations inherently mean that the methods for data analysis need to be based on commonalities or patterns in the data. In this thesis three methods are used: qualitative content analysis, thematic analysis and directed content analysis. To examine time-related changes, year-to-year comparative analyses of themes and categories are done. To explore Expressions of shared interpretations, different theoretical frameworks are used: team cognitions (Paper 1), sensemaking theory (Paper 2), cognitive shifts (Paper 3) and programme theories (Paper 4). A directed content analysis is applied in a meta-analysis of the results presented in the four papers. The results indicate that Expressions of shared interpretations develop as intangible outcomes of CQI efforts and a general programme theory of CQI efforts in health- and elderly care is developed, illuminating how Expressions of shared interpretations change and influence CQI efforts. The general programme theory incorporates the PDSA cycle and describes the complex, interconnected and continuous development of Expressions of shared interpretations. It also illuminates how Expressions of shared interpretations provide change performers with momentum to engage in forthcoming PDSA cycles and how sensemaking is a central activity. CQI efforts in health- and elderly care are characterised by a "just get on with it" attitude, while in this thesis, thoughtfulness is emphasized. Existing improvement tools support collaboration, creativity and analysis of critical aspects of the operations, yet none of the improvement tools help change performers gain understanding of the CQI effort as such. To address this, this thesis suggests that change performers complement the use of improvement tools with an inquiring mind, that they collaborate in thoughtful dialogues and that leaders function as inquirers. To support this posture, the widely used Model for improvement is complemented with a fourth question: What are our assumptions? The question pinpoints the need to be thoughtful in every step of the CQI effort, not just in the analysis of the problem at hand.

Two frames dominate present-day interpretations of sustainability and approaches to sustainability transformation in national and global policy arenas. One frame relates to transformation in global environmental governance that promotes goal-oriented agendas. The other frame relates to earth system sciences where sustainability transformation means breaking the devastating trends of the Anthropocene. In this paper, we examine the historical and cultural underpinnings of these two frames, each invoking particular relations and approaches to sustainability transformation. Our contribution is to discuss the role of the past in these frames and to illuminate how current outlooks toward the future still rely on principles that emerged in eighteenth- and nineteenth-century Europe and thus hinder alternative approaches to transformation in the present.

The concept of woodland key habitats is well-established in northern Europe, denoting sites in the forest landscape with particularly high biodiversity. In Sweden, woodland key habitats have been inventoried on individual forest owner's land by the Swedish Forest Agency since 1993. Recently, various actors have questioned the woodland key habitat concept and its policy implications. To investigate how framing of the concept has changed over time we conducted a media analysis based on theories of collective action frames. The analysis covered the period 1991–2018 and a total of 293 articles in daily newspapers. Our results showed that, over time, woodland key habitats have mostly been framed by government agencies, journalists and environmental organizations as suffering as a result of forestry practices and that nature conservation is the solution to this problem. Actors presenting other or conflicting frames are not as common and they occur mostly when the frequency of articles is high. However, it is noteworthy that individual forest owners sometimes framed themselves as suffering economically from the woodland key habitats, which contrasts with the dominant framing. There were no large differences between national and regional newspapers in the framing of woodland key habitats.

Rationale, aim, and objective: This study aimed to explore programme theories of a national quality register. A programme theory is a bundle of assumptions underpinning how and why an improvement initiative functions. The purpose was to examine and establish programme theories of a national quality register widely used in Sweden: Senior alert. The paper reports on how programme theories among change recipients emerge in relation to the established programme theory of the initiator. Methods: A qualitative approach and a longitudinal research design were used. To develop programme theories among change recipients, individual semistructured interviews were conducted. Three sets of interviews were conducted in the period of 2011 to 2013, totalling 22 interviews. In addition, 4 participant observations were made. To develop the initiator's programme theory, an iterative multistage collaboration process between the researchers and the initiator was used. A directed content analysis was used to analyse data. Findings: The initiator and change recipients described similar programme logics, but differing programme theories. With time, change recipients' programme theories emerged. Their programme theories converged and became more like the programme theory of the initiator. Conclusions: This study has demonstrated the importance of making both the initiator's and change recipients' programme theories explicit. To learn about conditions for improvement initiatives, comparisons between their programme theories are valuable. Differences in programme theories provide information on how initiators can customize support for their improvement initiatives. Similar programme logics can be underpinned by different programme theories, which can be deceptive. Programme theories emerge over time and need to be understood as dynamic phenomena.

AbstractChildren with intellectual disability receiving residential support, according to the Swedish Disability Act, need substantial support to cope with everyday life. These children have cognitive and communicative limitations, entailing difficulties for staff in consulting the children regarding their support arrangements. In addition, due to lack of research there are knowledge gaps and uncertainties concerning how staff can provide the children's support. To deliver high qualitative support, research suggests that disability organisations should (1) continuously work with quality improvement, (2) adopt a multi‐dimensional framework that explains human functioning and disability as a basis for understanding individual support needs, and (3) use person‐centred approaches. Based on these principles, this study has applied a realist evaluation to identify enablers and barriers during the implementation of an improvement programme aimed at improving staff's ability to provide support to children living in special residences.

Abstract
Background and purpose: The use of quality registers has increased rapidly in Sweden and they are identified as beneficial for health care competitiveness. A quality register is a structured gathering of patient information, to improve health care. However, the introduction of quality registers in health care organisations presupposes that employees know how to use them in quality improvement. Disconnections, or knowledge gaps, concerning quality registers hamper the possibilities to take advantage of them. Taking departure in professional health care educations, the purpose with the paper is to identify and explore knowledge gaps concerning quality registers. A second purpose is to propose actions to bridge the gaps.
Methodology/Approach: In 2012 50 semi-structured telephone interviews were completed and the material analysed in the search for knowledge gaps.
Results: Five knowledge gaps were found. Some professional health care educations teach improvement knowledge, but they have difficulties integrating quality registers as a resource in teaching. Quality registers do not sufficiently cooperate with professional health care educations and county councils do not generally include learning of quality registers in clinical placements/practicums.
Conclusion: Professional health care educations need forums where they can collaborate with others to jointly explore how learning of quality registers can be integrated. There are promising approaches.

The term woodland key habitat (WKH) was launched in Sweden in 1990. Definitions for the concept have changed over the years, and today the WKH concept and its application are issues of debate in Sweden. Consequently, the Swedish Forestry Agency (SFA) initiated a collaborative process including forest stakeholders with the purpose to clarify the application and develop the inventory methodology of WKH. We have studied, by means of interviews and observations, participant perceptions of how endogenous and exogenous factors affect the collaborative process. During our research, we identified three game changers: the pause in WKH registration in northwestern Sweden that caused several participants to drop out of the process; budget allocations for new nationwide WKH inventories that put the process on hold; and formal instructions from the government that came nine months later and essentially re-initiated the collaborative process. Altogether, this not only affected the participants' abilities, understanding and willingness to participate, but also the overall legitimacy of the process – indicating the difficulty of conducting policy development in collaborative form, especially when it is highly politicized since it impact on the participants' anticipation of the process and its end results. ; Future Forests

Background Clinical practice improvements based on quality-register data are influenced by multiple factors. Although there is agreement that information from quality registers is valuable for quality improvement, practical ways of organising register use have been notoriously difficult to realise. The present study sought to investigate the mechanisms that lead various clinicians to use quality registers for improvement. Methods This research involves studying individuals' decisions in response to a Swedish programme focusing on increasing the use of quality registers. Through a case study, we focused on heart failure care and its corresponding register: the Swedish Heart Failure Register. The empirical data consisted of a purposive sample collected longitudinally by qualitative methods between 2013 and 2015. In total, 18 semi-structured interviews were carried out. We used realist evaluation to identify contexts, mechanisms, and outcomes. Results We identified four contexts – registration, use of output data, governance, and improvement projects – that provide conditions for the initiation of specific mechanisms. Given a professional theoretical perspective, we further showed that mechanisms are based on the logics of either organisational improvement or clinical practice. The two logics offer insights into the ways in which clinicians choose to embrace or reject certain registers' initiatives. Conclusions We identified a strong path dependence, as registers have historically been tightly linked to the medical profession's competence. Few new initiatives in the studied programme reach the clinical context. We explain this through the lack of an organisational improvement logic and its corresponding mechanisms in the context of the medical profession. Implementation programmes must understand the logic of clinical practice; that is, be integrated with the ways in which work is carried out in everyday practice. Programmes need to be better at helping core health professionals to reach the highest standards of patient care. ; Funding Agencies|Swedish Association of Local Authorities and Regions (SALAR); Jonkoping University

The new European Union Forest Strategy for 2030 aims to plant an additional 3 billion trees on non-forest land to mitigate climate change. However, the choice of tree species for afforestation to achieve the maximum climate benefit is unclear. We compared the climate benefit of six different species in terms of carbon (C) sequestration in biomass and the harvested wood substitution in products to avoid carbon dioxide (CO2) emissions from fossil-based materials over the 100-year period by afforesting about 1/4 of the available area in northern Europe. The highest climate benefit was observed for larch, both at a stand scale (1626 Mg CO2 eqv. ha(-1)) and at the landscape level for the studied scenario (579 million Mg CO2 eqv.). Larch was followed by Norway spruce, poplar, hybrid aspen and birch, showing a climate benefit about 40-50% lower than that for larch. The climate benefit of willow was about 70% lower than larch. Willow showed 6-14-fold lower C stocks at the landscape level after 100 years than other tree species. The major climate benefit over the 100-year period comes from wood substitution and avoided emissions, but C stock buildup at the landscape level also removes significant amounts of CO2 already present in the atmosphere. The choice of tree species is important to maximize climate change mitigation.

Conflicting perspectives on forests has for a long time challenged forest policy development in Sweden. Disagreements about forest futures create intractable deadlocks when stakeholders talk past each other. The purpose of this study is to move beyond this situation through the application of participatory backcasting. By comparing visions of the future forest among stakeholder groups, we highlight contemporary trajectories and identify changes that were conceived as desirable. We worked with four groups: the Biomass and Bioenergy group, the Conservation group, the Sami Livelihood group and the Recreation and Rural Development group; in total representatives from 40 organizations participated in workshops articulating the groups' visions. Our results show well-known tensions such as intrinsic versus instrumental values but also new ones concerning forests' social values. Identified synergies include prioritization of rural development, new valued-added forest products and diversified forest management. The results may feed directly into forest policy processes facilitating the process and break current deadlocks. ; Supplement: 2

Riparian buffers are the primary tool in forest management for protecting the habitat structure and function of streams. They help protect against biogeochemical perturbation, filter sediments and nutrients, prevent erosion, contribute food to aquatic organisms, regulate light and hence water temperature, contribute deadwood, and preserve biodiversity. However, in production forests of Sweden and Finland, many headwater streams have been straightened, ditched, and/or channelized, resulting in altered hydrology and reduced natural disturbance by floods, which in turn affects important riparian functions. Furthermore, in even-aged management systems as practiced in much of Fennoscandia, understory trees have usually been cleared right up to the stream's edge during thinning operations, especially around small, headwater streams. Fire suppression has further favored succession towards shade tolerant species. In the regions within Fennoscandia that have experienced this combination of intensive management and lack of natural disturbance, riparian zones are now dominated by single-storied, native Norway spruce. When the adjacent forest is cut, thin (5 - 15m) conifer-dominated riparian buffers are typically left. These buffers do not provide the protection and subsidies, in terms of leaf litter quality, needed to maintain water quality or support riparian or aquatic biodiversity. Based on a literature review, we found compelling evidence that the ecological benefits of multi-layered, mixed-species riparian forest with a large component of broadleaved species are higher than what is now commonly found in the managed stands of Fennoscandia. To improve the functionality of riparian zones, and hence the protection of streams in managed forest landscapes, we present some basic principles that could be used to enhance the ecological function of these interfaces. These management actions should be prioritized on streams and streamside stands that have been affected by simplification either through forest management or hydrological modification. Key to these principles is the planning and managing of buffer zones as early as possible in the rotation to ensure improved function throughout the rotation cycle and not only at final felling. This is well in line with EU and national legislation which can be interpreted as requiring landscape planning at all forest ages to meet biodiversity and other environmental goals. However, it is still rare that planning for conservation is done other than at the final felling stage. Implementing this new strategy is likely to have long-term positive effects and improve the protection of surface waters from negative forestry effects and a history of fire suppression. By following these suggested management principles, there will be a longer time period with high function and greater future management flexibility in addition to the benefits provided by leaving riparian buffers at the final felling stage.

Planting new forests has received scientific and political attention as a measure to mitigate climate change. Large, new forests have been planted in places like China and Ethiopia and, over time, a billion hectares could become available globally for planting new forests. Sustainable management of forests, which are available to wood production, has received less attention despite these forests covering at least two billion hectares globally. Better management of existing forests would improve forest growth and help mitigate climate change by increasing the forest carbon (C) stock, by storing C in forest products, and by generating wood-based materials substituting fossil C based materials or other CO2-emission-intensive materials. Some published research assumes a trade-off between the timber harvested from existing forests and the stock of C in those forest ecosystems, asserting that both cannot increase simultaneously. We tested this assumption using the uniquely detailed forest inventory data available from Finland, Norway and Sweden, hereafter denoted northern Europe. We focused on the period 1960 - 2017, that saw little change in the total area covered by forests in northern Europe. At the start of the period, rotational forestry practices began to diffuse, eventually replacing selective felling management systems as the most common management practice. Looking at data over the period we find that despite significant increases in timber and pulp wood harvests, the growth of the forest C stock accelerated. Over the study period, the C stock of the forest ecosystems in northern Europe increased by nearly 70%, while annual timber harvests increased at the about 40% over the same period. This increase in the forest C stock was close to on par with the CO2-emissions from the region (other greenhouse gases not included). Our results suggest that the important effects of management on forest growth allows the forest C stock and timber harvests to increase simultaneously. The development in northern Europe raises ...