Abstract
Culture change is common in healthcare organisations worldwide today, and change agents are key persons in the process of change. It is therefore of vital importance to deepen the knowledge about change agents’ experiences. The aim of the study was to illuminate meanings of being a change agent to improve home care services. Ten change agents were interviewed individually using open-ended questions. The interviews were analysed with phenomenological hermeneutics. The design of the study followed the COREQ guidelines. Three themes were revealed in the analysis: ‘Being confirmed by the opportunity to make quality improvements’; ‘Pushing oneself to transfer the message’; and ‘Being strengthened by achievements but wishing for better conditions’. In order to prepare co-workers, change agents need training before their mission begins and during the change process.
Introduction
In Europe, the ambitions to develop and expand home care services (HCS) are hampered by financial limits. Therefore, unconventional methods are needed to reduce the gap between growing needs and declining budgets. 1 In Sweden, municipal healthcare is extensive and growing as more and more older people are receiving health and social care in so-called ‘ordinary housing’. Older people often have complex care needs that require qualified healthcare interventions and care at all-day hours. The daily care is performed by HCS.2,3
In recent decades, organisational changes have swept like a wave across Sweden and other countries. 4 The pace of change has significantly increased in health and social care. 5 The goal of organisational change is organisational health, not employee health. 6 In HCS, organisational change has been found to be related to increased levels of stress and absenteeism rates, musculoskeletal problems, decreased job satisfaction, and intention to quit. 7 The organisational culture may be defined as an umbrella concept ‘for a way of thinking that takes a serious interest in cultural and symbolic phenomena or aspects in organizations’. 8 (p.14) To study an organisation's culture, it is important to understand its function. 9 A high functional culture is forceful and susceptible to change. 10
Research about change work in HCS is rare. However, change work in HCS has focused on adapting the organisation to the care recipients and the HCS, increased influence, autonomy, attractive work, 11 creating small autonomous workgroups, flattening the organisation, 12 flexible working hours, technological equipment, 13 improving organisation performance, 14 enhancing patient-centred care, 15 and implementing trust-based management. 16 A review shows that improvement work in HCS is focusing on changing specific behaviours or introducing new technology instead of dealing with complicated problems, such as sick leave, stress, gender inequality, 17 or musculoskeletal disorders. 18
A person who is going to carry through a change by getting others engaged in the change is called a ‘change agent’. 19 A change agent is defined as a person ‘who has the skill and power to stimulate, facilitate, and coordinate the change effort’. 20 (p.1) Research about experiences of being a change agent in HCS has not been found. However, a study about residential care for older people shows that the change agents felt appreciation for being chosen for the mission and they perceived the goals as good and meaningful; at the same time, they expressed difficulties in reaching out to co-workers. The researchers conclude that it is of great importance to prepare the change agents for their role. 21 The change agent plays an active role in shaping their role behaviour, and therefore it is crucial to understand how the role of a change agent is created in healthcare organisations. 22 The perspective of change agents has often been ignored in studies. 23 As culture change is common in healthcare organisations today, it is of vital importance to deepening the knowledge about change agents’ experiences as central individuals in the process of change. This knowledge could be used to plan and develop the change process in order to reach a stable and surviving change.
Aim
The study aimed to illuminate meanings of being a change agent to improve home care services.
Method and design
A qualitative study design was used to gain a deeper experience of the aim of the study. The Consolidated Criteria for Reporting Qualitative Research (COREQ) 24 was used for explicit and comprehensive reporting of qualitative studies.
The large project ‘Journey of learning’ took place in municipal home care in a small city in northern Sweden.cf. 21 The mission of the ‘Journey of learning’ was to implement a learning and changing process, which, through cultural change, aimed to contribute to a better life for sick older people in need of care, an improved work environment for healthcare personnel (including HCS), and more efficient working methods. Five areas were stipulated to ensure the following goals: coherent care; preventive and rehabilitating working methods; good dementia care; good medical treatment; and good end-of-life care. Together the goals were labelled ‘Living life best possible’, and stipulated that inhabitants shall grow old in safety and autonomy with access to good care. Quality councils (QC) were created to implement the culture change. The QCs were established in each HCS area as a part of the management system for systematic quality work in HCS. 25 The QCs were given the task of analyzing, planning, following up the results by measurements, encouraging, and showing possibilities in the work towards the goals in their area.cf. 21 The QCs should also have a coordinated function for the quality of home care with a focus on value creation for the recipients. The members of the QCs are entitled change agents.
Context/implementation
The cultural change was implemented in all HCS areas in the municipality in 2016. In HCS, care is provided out of the recipients’ needs in their own home environment. The care recipients can, after assessment of their needs, receive help with personal care, such as daily hygiene, showering, dressing, and food intake, as well as practical help, such as cleaning, laundry, and distribution of prepared food.
All change agents in two of 25 available randomly chosen HCS areas were asked to participate in the study through an information letter. The change agents were supposed to be highly committed and motivated in their work, and the managers of the HCS areas appointed them. All change agents had, at the time of the interviews, participated in three workshops. The workshops were carried out in a conference room in a city hotel and gathered all members of the QCs from all HCS areas and their managers. Between 150 and 200 change agents participated in the workshops in total. The initial workshop focused on the goals of the project in order to attain a culture wherein the care recipients could ‘Live life best possible’. The second and third workshops were adjusted to the change agents’ needs for information and knowledge. Knowledgeable persons provided them with lectures in the area of focus, for example how to manage fall risks and malnutrition, and group discussions about how to reach the goals were performed. During the workshops, the change agents had the possibility of meeting with other HC staff, reflect, discuss and co-create knowledge, support, and inspire each other. After the workshops, and together with the manager, the change agents should share the knowledge gained with their co-workers at their own workplace. All members of the QC met regularly, about once a month, at their workplace.
Settings
The staffing level at the two randomly chosen HCS areas was 20 enrolled nurses (ENs), respectively. All HCS staff worked shifts, that is, days, evenings, nights, and weekends. At weekends, staffing levels were lower. With the assistance assessment as a base, the daily work chores were estimated in minutes per visit according to the older person's needs. At the time of the study, 275 recipients in the two areas were granted home care for various needs.
Participants
Out of 14 change agents, 10 agreed to participate after information about the study. They had different occupations: two were registered nurses, one was a nursing aide, five were ENs, and two were managers. Four participants were men and six were women (age range = 33–54 years; median age = 47 years). The mean level of the participants’ work experience was 18 years in healthcare and 5 years at HCS.
Data collection
About 1 year after the culture change was implemented (2017), open-ended individual interviews were performed. An interview guide was established with a focus on the role of change agents and according to the aim of the project ‘Journey of learning’. The interviews were performed in the HCS office. The opening question was expressed as follows: Can you tell me about your role as a change agent? Follow-up questions about their work methods and about the possibilities and challenges they have met as a change agent were asked. Probing and follow-up questions were asked in order to clarify the narrations. The interviews were ongoing, in the range of 30–68 min (mean = 50 min). The interviews were recorded on a digital recorder and finally transcribed verbatim.
Interpretation
A phenomenological-hermeneutic method influenced by Ricoeur 26 and Lindseth and Norberg 27 was used to analyse the interviews. The objective of the method is to interpret, that is, explain and understand meanings of a phenomenon.28,29 The interpretation includes the dialectical movement between understanding the text as a whole and explaining its parts. The interpretation also consists of an approach to the text by bringing the text close to the interpreter and at the same time distancing it, and between what the text says and what understanding the text indicates. The process of interpretation includes three phases: naϊve reading; structural analysis; and critical interpretation.26,27 To uphold trustworthiness, the most expressive and descriptive citations from the interviews are presented. The participants are given numbers, e.g., P 1, P 2 etc.
Ethical approval
The study was ethically approved (Dnr 2015/179-31Ö). The Declaration of Helsinki 30 and General Data Protection Regulation 31 were used as an ethical base. The participants were given oral and written information about the study and gave their written consent before the interviews.
Naϊve understanding
The text was repeatedly read to grasp its whole meaning. A naϊve reading was formulated of the meanings of being a change agent in implementing a new organisational culture in home care, as follows: being a change agent is revealed as an ambiguous role. It means to be proud of being chosen to perform an important mission. It is to be motivated to participate in the QC and feel support but at the same time sometimes be disapproved of by co-workers. Feelings of both satisfaction and dissatisfaction as well as a struggle to motivate their co-workers in line with the decided changes are disclosed.
Structural analysis
A thematic structural analysis was performed to reveal the various parts of the text and to disclose if the naϊve understanding was supported or not. The structural analysis was performed in various steps. To begin, the text was divided into meaning units, that is, a part of any length that reveal meaning and relates to the research question. The meaning units were then compared and assorted to reveal meaningful connections. At last, the meaning content of the meaning units was condensed, abstracted, and grouped into sub-themes and themes. 27 An example from the structural analysis is provided (Table 1).
Examples of the structural analysis in one of the themes.
Interpretation and findings
Eight subthemes and three themes emerged from the text (Table 2).
Themes and subthemes.
Being confirmed by the opportunity to make quality improvements
Being a change agent means feeling chosen to make a difference, feeling stimulated and motivated during workshops, and feelings of belonging in a functioning QC.
Feeling chosen to make a difference
Getting the assignment as a change agent was described as an acknowledgement, it was interesting and great fun. Being able to participate in improving the care for the recipients was considered central and important. ‘Yes, at first it felt like but why me? But (the boss said) you are so good at saying and thinking and well okay (sounds proud) // then I got into it and it started to be … it's great fun.’ P 1
The journey of learning was described as a good initiative from an engaged top manager. To receive a set of clear relevant goals for the HCS was welcomed and longed for, even though the goals could sometimes be perceived as a dreamy vision. It felt a bit vague from the beginning what it would be about, but when being a part of the journey of learning, it cleared up as time went on. It was these goals change agents were selected to implement and realise. ‘I felt, anyway (we) who attended (in the workshops) perceive it as very positive // I’ve been working here for 20 years and something like this has not happened, like that we come together // and then actually can work together to make improvements.’ P 10
Feeling stimulated and motivated during workshops
The workshops were described as very positive. Besides listening to lectures from different relevant areas, e.g., about good palliative care, fall prevention, and malnutrition, they got to exchange experiences with other staff from different areas and got tips and ideas from how they worked. They also received confirmation that they were doing good things. Overall, it was a positive spirit during the workshops. At the same time, they were stimulated and motivated, and perhaps a little bit jealous when they realised that others had gone further in their work towards the goals. ‘You have met other groups and talked to each other and you have sort of heard, Oh! That was really smart! I will take that with me and then you have talked about it in the group at home (the quality council), so I heard this, what do you think about it? // we can test it … and at the workshops mostly good things, in some way or another, have been lifted.’ P 3
Feelings of belonging in a functioning quality council
The change agents’ work in the QC was generally described in positive ways. It created conditions for dialogue and cooperation between different professionals and a good team spirit arose that made them flourish. Although the QCs were in different phases in the work process, all change agents had met and gradually addressed various areas for improvements, e.g., continuity, prevention of risk of falling, and improved care plans. ‘We have got a great collaboration with nurses and other professionals in general, and we have started parts of the project.’ P 7
Some of them described that they now could discontinue the workshops but they wanted to keep the QCs because they now have their own driving force.
Pushing themselves to transfer the message
Being a change agent means striving to overcome the hardships to get all involved, perceiving acceptance versus dismissal from co-workers, and perceiving support from others.
Striving to overcome the hardships to get all involved and motivated
Change agents took part in the workshops and received inspiration and ideas that their co-workers did not get. It was difficult to convey everything they had learned. They knew that it was important to involve and motivate all co-workers in the improvement work as they wished to receive their co-workers’ ideas and suggestions on how this could be done. It was also difficult to get time for meeting places where dialogue with all the co-workers could take place. They described that they tried to squeeze some information into the scheduled workplace meetings that took place once a month but often they had to snap the opportunity to talk to their co-workers in their daily work. ‘We are such a large staff group and many times we have been between 20 and 30 at the workplace meetings// and if only a few have questions the time is over.’ P 2
Change agents had learned how difficult it could be with information and communication itself. For example, it was described that after a meeting where change agents described what was planned right now, i.e., to improve the continuity in the HCS, criticism came from the co-workers that they did not get any information about the journey of learning. The co-workers did not understand that improving continuity was part of the journey of learning. ‘Then I said, I interrupted as well, I said this is what we are doing on the journey of learning.’ P 4
It was a challenge to make the co-workers understand the goals of the journey of learning along with the measures planned. An attempt to communicate with the help of bulletin boards and written information was performed, but it became one-way communication that could easily be misunderstood and it counteracted dialogue. They emphasised that it was important that they transferred what should be done to their co-workers. ENs were described as having a lot of experience, spoke the same language as their co-workers, and therefore became more credible. ‘It is much better when an enrolled nurse explains their view of what's (to be done) they have perhaps worked for 10–15 years on the floor as well as they have a completely different language (to reach out).’ P 5
Perceiving acceptance versus dismissal from co-workers
When change agents should transfer the planned measures to be implemented, they were sometimes met by interest from co-workers who saw the potential of the improvement work for the recipients and wanted to be part of it. These co-workers were prone to change. The change agents described it as stimulating to be met with such a welcoming attitude, it gave prerequisites to do a good job together. It was their job now to keep the improvement work going and continue on the beaten path. ‘We now see to that we keep it (the improvement work) going in this well-functioning group … it is very good.’ P 6
However, they were sometimes met with resistance and dismissal when striving to transfer the planned measures to be launched. It was stressful to meet co-workers who were reluctant to change, even if they were not many. Change agents were confronted with schism, dissatisfaction, and slander. ‘We have actually become quite exposed, both me and XX // several in the group harbour a rancour and like anger specified against me and XX.’ P 4
In order to deal with resistance, change agents tried to understand what it was about. One understanding was that the co-workers were rooted and secure in the way they worked and they had themselves and not the recipients’ needs in the foreground. But it could also be about fear, uncertainty, and lack of knowledge and that they did not see the benefits of the improvement work. It was described that it probably did not matter what kind of changes were to be made, it was the change itself that was threatening. How much time they spent explaining did not matter either. ‘Because it does not matter if I explain the same thing for 2 hours, it is the same thing … it does not matter // they do not buy it (the changes to be made) anyway … so it sounds.’ P 1
Perceiving support from others
When change agents met resistance and it seemed impossible to bring about a change and when they were personally affected, they sought support from the manager. The manager supported them by saying that they did a good job and that it was their duty to try to reach out to their co-workers. The manager also talked to the ‘nay-sayers’, those who opposed working towards set goals. Change agents of different professions also supported each other. Change agents who were managers motivated the staff by telling them about new working methods and new measurement methods. They pep-talked the staff by emphasising how important it was for recipients to have, for example, continuity, a functioning care plan, and to keep track of results. They also put up a hard fight by demanding a willingness to change from the staff. It was also described that it was supportive to get the informal leaders on track in the improvement work. ‘I have also told the staff that if you want a manager who will not change, then you have to change jobs’ // ‘we had an informal leader and she was very strong, not always so positive. She said no (in the beginning) this will not work, but she was the first to change her mind. And when she had done that, it spread damn fast // then it was possible to do that (the changes planned).’ P 5
Being strengthened by achievements made but wishing for better conditions
Being a change agent means feeling contentment with the improvements at the same time feeling non-contentment by some prerequisites.
Feeling contentment with the improvements
The journey of learning became a catalyst for initiating quality improvements. Now there were clear goals to work for. They saw a clear benefit when working in line with the goals of the journey of learning. It has been an ‘eye opener’ to see opportunities for change. ‘The journey of learning became this catalyst to get everything started // instead of just talking about … oh, we should have done this and that … earlier nothing happened.’ P 4
The teamwork had improved between recipients, relatives, and various professions. Working towards a consensus about the goals and getting control of the quality of care through measurements and documentation had been useful and good for both the recipients and themselves. Improved continuity and the fact that recipients meet fewer care providers also benefitted the recipients, who were described as showing appreciation for that. ‘Well, I think it's good (to see results via measurements) // if we get red (figures that are no good), it becomes an incentive that now we get to sharpen up // and if good (figures), we feel confirmed and seen.’ P 6
Feeling non-contentment with some prerequisites
Change agents described the need for more rational administration; for example, if they could be able to document via the telephone, there would be better documentation opportunities. They wish they could document at the recipients instead of in the office. In addition to all documentation on the work done, everything that was measured must be documented and the administrative work had increased with the improvement work, and they narrated that time was taken from the residents. The lack of time was sometimes noticeable, as the time per recipient was limited. A lot can happen during a visit that leaves them behind at work. This was very stressful for all involved and the ‘paperwork’ connected to the journey of learning is de-prioritised at such times, which in turn adds additional stress and burden. ‘To be able to document … it is time that does not really exist … it is time that we have to invent.’ P 3
Another major obstacle to the opportunities to do a good job as a change agent is the lack of continuity among managers. The manager is central in the change work and if they quit or change employment several times a year, it swings worryingly. ‘If we had had a manager who had been a bit driven during this whole journey, then it could have accomplished much more // every workshop we had a new boss.’ P 9
Finally, more investment in the staff's health would be needed along the journey of learning. If the staff do not feel well and/or stressed, they cannot provide good care.
Comprehensive interpretation and reflections
The comprehensive interpretation is based on the naϊve reading, the subthemes, and themes and is reflected on in relation to the context of the study, the aim of the study, and applicable literature. It is formulated as follows: one meaning of being a change agent in HCS is to feel motivated and dedicated to receiving the mission to make quality improvements in the care of older people. However, it is a struggle to ‘get everybody on the train’ and the change agents are striving to find opportunities to discuss this with one another, i.e., to motivate, engage, and involve their co-workers. Feelings of contentedness to perceive improved care are disclosed along with feelings of burden.
The findings are discussed in light of Bridges and Bridges theory of managing organisational change 32 and empirical studies. Bridges and Bridges 32 argues that people are getting through change with a transition process. Bringing people through the transition is crucial if the change is going to succeed. Change is situational, for example, a reorganisation, while a transition is psychological, that is, the person needs to internalise and adapt to the new situation that the change creates. The process of transition may be described in three phases. First, the phase ‘ending’ means to, with support, dispose of old ways of working and the old identity of people. Second, the phase ‘neutral zone’ is an in-between time when the old way of working is gone but the new is not fully functioning. In this phase, repatterning is taken place. At last, the third phase may be labelled ‘the new beginning’, wherein people are experiencing new energy, evolving their new identity, and disclosing a new purpose, which makes the change begin to function. If the change is going to work, getting people through the transition is crucial. If a change occurs without people going through transition, ‘it is just a rearrangement of the chairs’. 32 (p.3)
The findings reveal that the change agents were confirmed by the opportunity to make quality improvements. During the workshops, they were able to discuss with other change agents. Logically, the change agents could start processing the first phase of ‘ending’, i.e disposing of old ways of working.cf. 32 The findings also reveal that the change agents were stimulated and motivated to attend the workshops. A study showed that appointing motivated change agents can create a useful grassroots approach for mitigating the negative effects of change. Change agents who were motivated were more likely to later experience meaning in the improvement work. 33 A reflection is that the change agents started the ‘ending’ phase at workshops while their co-workers ‘at home’ did not.cf. 32 In their monthly meetings in the QCs, change agents could continue the transition process and they felt support among each other. At the same time, some of their co-workers continued to work as they were used to, somehow reluctant to change.
The findings reveal that change agents were pushing themselves to transfer the message learnt from the workshops to their co-workers. However, it was hard to get all the co-workers ‘on the train’. One obstacle was the difficulty in finding enough time for meeting places where dialogue could take place. The change agents knew that it was essential to receive their co-workers’ ideas and suggestions. The lack of opportunities for dialogue also hindered the co-workers in disposing of old ways of working as it was hard for change agents to reach out.cf. 32 Motivation seems to be central in the change process, not only for change agents. Increased changeability in work-life enhances the demand for knowledge about how people may maintain motivation and commitment during changes. 34 To achieve a willingness to change or motivation in change processes, some conditions are contributory. A will and insight of the need to change is the engine in change processes as well as participation. Trust from the environment and confidence in one's own ability to change is important. Getting information and knowledge about the process and feeling security is also of vital importance. 35 A reflection is that the change agents were stimulated and motivated by the workshops and from their work in the QCs. However, they were sometimes met with criticism and questioning from some of their co-workers, who did not receive the stimulation and motivation or understood the need for change. While the change agents were on their way to dispose of old ways of working and enter the ‘neutral zone’, the co-workers were stuck in the ordinary ways of working, making it almost impossible to receive support to enter and participate in the ‘ending’ phase.cf. 32 We suggest that in order to facilitate the transition process, it would have made it easier if meetings were scheduled beforehand at the workplace to provide conditions for transmitting the message and discuss this with co-workers at the workplace. At these meetings, change agents could also show films from the workshops containing, for example, short lectures and ‘good examples’ of how to work with the change. In conclusion, a suggestion is to visualise the transition process to the co-workers, as they need support on their way to internalise the change and adapting to the new situation. Otherwise, no change is going to happen.cf. 32
Findings also revealed that the change agents perceived both acceptance and dismissal from their co-workers. Change agents were sometimes met with resistance when they tried to launch the planned measures. Resistance to change may be described as a person's behaviour as a reaction to a perceived or actual threat. 36 The resistance is a key barrier to culture change implementation 37 and may affect the sustainability and quality of change. 36 Factors contributing to resistance to change are an individual's extensive need for control, intolerance for vagueness, bad experiences of previous change attempts, unfavourable working climate in teams, and hierarchic organisations. 38 Resistance to change may arise if co-workers are not able to be involved in planning the change work. 35 A review of change work in home care shows that employee participation increased the likelihood of success. 17 If co-workers’ experiences and knowledge are requested, both resistance and inefficacy may be avoided. 35 An important task for change agents is to prepare their co-workers for change. 39 According to Bridges and Bridges, 32 it is destructive to attempt to defeat staff resistance to change without communicating the threat the change brings about to their existence. Resistance to change may prevent the change agents from getting into the neutral zone where repatterning takes place.cf. 32 A reflection is that extensive preparation has to be done to make all co-workers participative in the change process in order to prevent resistance. The change agents are getting through the initial phases in the transition process and to some extent reach the new beginning wherein they may experience new energy and new purposes, while some of their co-workers are not even reaching the ‘ending’ phase.cf. 32
Findings reveal that the change agents sought support from their managers when they met resistance from co-workers. The managers encouraged them to continue their work; at the same time, they underlined the importance of culture change to the co-workers. A functional relation between change agents and key decision-makers is of vital importance for the success of the change effort. 20 With an involved manager who acts like a driving force in the change work, the best chances to succeed is evident. 40 Healthcare staff expect leaders to concentrate on dialogue and consolidate the vision of the change process. 41 However, the findings of the present study revealed that change agents described a lack of continuity among managers, the managers often quit or changed employment, which was concerning in the change process. Findings in a doctoral thesis showed that delivery of important patient care may be influenced as well as declining quality of care when a manager quits their position. 42 A study showed that leadership turnover is often followed by declining organisational performance. 43 A reflection is that it is important that the change agents together with the co-workers and the manager are creating an opportunity to reflect on the perceived threat that the change poses. Of vital importance during the transition process is to create manager continuity in order to stabilise the process and build safety in the home care team.
Methodological considerations
Ricoeur 26 writes that you may argue for and against an interpretation and that a text may be understood in more than one way. We have presented what we found to be the most credible understanding of the text. To enhance trustworthiness, the interpretation procedure has carefully been described. This description allows the readers to follow the interpretation from raw text to a comprehensive understanding. In phenomenological hermeneutics, the participants narrate their lived experience in accordance to their pre-understanding, and the researcher understands the narrative according to his/her pre-understanding, a fact that may create a risk of misunderstanding. 27 Therefore, it was important to check our understanding of the narrative with probing follow-up questions during the interviews.cf. 27 The interview data in this study were gathered 6 years ago, which may be regarded as a long time. However, we do find that the meanings of being a change agent to improve HCS still are meaningful, relevant, and transferable in similar contexts.
Conclusions
An implication for practice is when planning to use change agents in order to achieve a culture change to improve care, change agents need training before their mission begins and during the change process. It is of vital importance to prepare them for their role and for resistance to change. It is also essential to provide good conditions for them to co-create the changes to be made with their co-workers. Extensive preparation has to be done to make all co-workers participative in the change process in order to succeed. To get through a change process, transition is crucial, a process that must be visualised to the change agents and co-workers in HCS. Change agents in HCS should have a close collaboration with the manager to create a functional team and work climate. It is important that the change agents together with the co-workers and the manager are creating opportunities to reflect on the perceived threat that the change poses. Turning resistance to change to becoming ready for change seems vital.
Footnotes
Acknowledgments
We would like to thank the participants in the study who narrated freely about their role as change agents.
Author contributions
EEL and GS designed the study, collected and analysed the data, and prepared and wrote the manuscript.
Author credentials
Eva Ericson Lidman (female) is RNT and PhD. Gunilla Strandberg (female) is RNT and PhD.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
This research received the following financial support for the research, authorship, and/or publication of this article: Stiftelsen Rönnbäret.
