The qualitative research interview

Critical dialogue method of ethics consultation: making clinical ethics facilitation visible and accessible

In clinical ethics consultations, clinical ethicists bring moral reasoning to bear on concrete and complex clinical ethical problems by undertaking ethical deliberation in collaboration with others. The reasoning process involves identifying and clarifying ethical values which are at stake or contested, and guiding clinicians, and sometimes patients and families, to think through ethically justifiable and available courses of action in clinical situations. There is, however, ongoing discussion about the various methods ethicists use to do this ethical deliberation work. In this paper, we make visible and accessible seven steps of facilitation used in the critical dialogue method of ethics consultation.We describe how the facilitation techniques serve two overall purposes. First, to identify ethically justified responses to ethical questions. Second, to assist participants to gain greater moral clarity, understanding and confidence to respond to ethical challenges as independent moral agents.By describing in detail facilitation steps for clinical ethics consultation, we aim to advance the scholarship of 'clinical ethics facilitation methods' and to demystify the ethical deliberation work undertaken by clinical ethicists.

Barriers and facilitators of healthcare access for long COVID-19 patients in a universal healthcare system: qualitative evidence from Austria

BACKGROUND

Long COVID-19 challenges health and social systems globally. International research finds major inequalities in prevalence and healthcare utilization as patients describe difficulties with accessing health care. In order to improve long-term outcomes it is vital to understand any underlying access barriers, for which relevant evidence on long COVID-19 is thus far lacking in a universal healthcare system like Austria. This study aims to comprehensively identify access barriers and facilitators faced by long COVID-19 patients in Austria and explore potential socioeconomic and demographic drivers in health and social care access.

METHODS

Applying an exploratory qualitative approach, we conducted semi-structured interviews with 15 experts including medical professionals and senior health officials as well as focus groups with 18 patients with confirmed long COVID-19 diagnosis reflecting varying participant characteristics (age, gender, urbanicity, occupation, education, insurance status) (July-Nov 2023). Data were analysed following a thematic framework approach, drawing on a comprehensive 'access to health care' model.

RESULTS

Based on expert and patient experiences, several access barriers and facilitators emerged along all dimensions of the model. Main themes included scepticism and stigma by medical professionals, difficulties in finding knowledgeable doctors, limited specialist capacities in the ambulatory care sector, long waiting times for specialist care, and limited statutory health insurance coverage of treatments resulting in high out-of-pocket payments. Patients experienced constant self-organization of their patient pathway as stressful, emphasizing the need for multidisciplinary care and centralized coordination. Facilitators included supportive social environments, telemedicine, and informal information provided by a nationwide patient-led support group. Differences in patient experiences emerged, among others, as women and younger patients faced gender- and age-based stigmatization. Complementary health insurance reduced the financial strain, however, did not ease capacity constraints, which were particularly challenging for those living in rural areas.

CONCLUSIONS

The findings of this study indicate a call for action to improve the long COVID-19 situation in Austria by empowering both providers and patients via increased information offerings, strengthened interdisciplinary treatment structures and telemedicine offerings as well as research funding. Our insights on potentially relevant socioeconomic and demographic drivers in access barriers lay the necessary foundation for future quantitative inequality research.

People at Risk of, or with Cardiovascular Diseases' Perspectives and Perceptions of Physiotherapist-Led Health Promotion in Cameroon: A Mixed-Methods Study

Cardiovascular diseases (CVDs) and their risk factors are a major cause of illness and death worldwide, especially in low- and middle-income countries like Cameroon. Physiotherapist-led health promotion (PLHP) has proven effective in improving health and reducing CVD risks. Understanding patient perspectives is crucial for designing effective, context-specific PLHP interventions. This study explored patients' views, experiences, perceived usefulness, acceptability, and preferred methods of PLHP, through a sequential explanatory mixed-methods approach. The quantitative data highlights a significant burden of CVD conditions and risk factors among patients seen in physiotherapy services. Qualitatively, three themes were identified and included: (1) perspectives and experiences of people at risk or with CVDs (pwCVDs) on PLHP; (2) perceived usefulness and acceptability of PLHP; (3) preferred delivery methods of PLHP. Participants reported positive feedback on PLHP and physiotherapy services. Barriers to effective PLHP included high workloads for physiotherapists, limited service access in rural areas, and prohibitive costs. Despite these challenges, participants expressed strong confidence in physiotherapists' competence, though they also called for improved regulation and ongoing professional development. PLHP components, especially physical treatment and dietary advice, were deemed highly useful and acceptable. Patients suggested various delivery methods, including peer support groups, home visits, and mass media interventions. This study highlights the need to improve the scope of practice, competence of physiotherapists, and accessibility of physiotherapy services in Cameroon for pwCVDs. It is necessary to adopt multidisciplinary approaches to achieve better outcomes for risk factors like diabetes and hypertension in context.

Disclosure of true medical information: the case of Bangladesh

BACKGROUND

Truth-telling in health care is about providing patients with accurate information about their diagnoses and prognoses to enable them to make decisions that can benefit their overall health. Physicians worldwide, especially in the United Kingdom (U.K.) and the United States (U.S.), openly share such medical information. Bangladesh, however, is a Muslim-majority society with different social norms than Western societies. Therefore, we examined whether Muslim culture supports truth disclosure for patients, particularly how and to what extent medical information about life-threatening diseases is provided to patients in Bangladesh.

METHODS

This was a phenomenological qualitative study. We conducted thirty in-depth interviews with clinicians, nurses, patients and their relatives at Shaheed Suhrawardy Medical College Hospital in Dhaka, Bangladesh. We also used observations to explore interactions between patients, families and healthcare professionals regarding their involvement in medical decisions and truth disclosure issues. NVivo software was used to identify common themes, and a thematic analysis method was utilised to analyse the datasets.

RESULTS

This study identified three recurring themes relevant to the ethics and practice of truth disclosure: best interest rather than autonomy, the ambivalent value of deception and who understands what. The participants revealed that physicians often withhold fatal medical prognoses from terminally ill patients to ensure the best healthcare outcomes. The results indicate that deception towards patients is commonly accepted as a means of reducing burden and providing comfort. The participants opined that true medical information should be withheld from some patients, assuming that such disclosures may create a severe burden on them. Whether or to what extent medical information is disclosed primarily depends on a family's wishes and preferences.

CONCLUSIONS

While truth disclosure to patients is considered an ethical norm in many cultures, such as in the U.K. and the U.S., the practice of concealing or partially revealing severe medical prognoses to patients is an actual medical practice in Bangladeshi society. This study emphasises the importance of recognising a patient's active involvement and respecting the cultural values that shape family involvement in medical decision-making. These findings may have significant policy and practical implications for promoting patient autonomy within Bangladeshi family dynamics and religious-based cultural values.

Chartered Accountants' perception of the Fourth Industrial Revolution

The Fourth Industrial Revolution (4IR) is an era of enormous technical progress that has impacted professionals across industries, including Chartered Accountants (CAs). This study explored how CAs view the impact of the 4IR on their profession, focusing on the shifting roles, competencies, and challenges they face during this transitional period. The research adopted a qualitative approach to data collecting, including 14 semi-structured interviews with participants from various CA backgrounds. This research provides a thorough knowledge of the 4IR's consequences for the profession and the perceptions of CA's of the 4IR. Rapid task automation via technologies such as AI is posing a challenge to traditional CA roles, forcing a change towards more analytical thinking and strategic insight. CAs need to develop critical thinking abilities and data analysis ability. Older generations might need support to adapt to the technological changes. Despite fears about job loss due to technology, members were largely optimistic about the 4IR's professional development potential. Conclusions are drawn and recommendations are given.

Occupational well-being of diplomatic personnel: a qualitative study

BACKGROUND

Diplomatic personnel face unique job demands due to their frequent relocations. There is some evidence that occupational stress contributes to poor well-being in this occupational group, but little research on the aspects of the job that are perceived to be particularly challenging.

AIMS

This study aimed to explore diplomatic personnel's perceptions of their organization and their roles and to identify aspects of the job, which could cause stress and potentially affect well-being.

METHODS

Semi-structured interviews were carried out with 24 employees of the Foreign, Commonwealth and Development Office between September 2021 and February 2022. Participants were asked to reflect on their experiences before the coronavirus disease 2019 pandemic. Thematic analysis was used to analyse data.

RESULTS

Participants enjoyed many aspects of their work including the variety, travel opportunities and feeling that they made a difference. They also identified several stressors relating to job demands, overseas postings, family needs, frequent relocation, hardship posts, workplace relationships, (lack of) appreciation and acknowledgement, and organizational culture. Good relationships with colleagues and managers were perceived to be very important.

CONCLUSIONS

Findings suggest various ways in which diplomatic organizations can better support their personnel, highlighting workload management; cross-cultural training; providing appropriate support to both accompanying families and unaccompanied staff members; practical and psychological preparation for those in high-risk locations; encouraging positive workplace relationships; good management; increased autonomy and increased recognition for good work.

The Attitudes, Beliefs and Perspectives of Registered Nurses on Sleep Health Management in Residential Aged Care Facilities: A Qualitative Study

AIM

To explore the attitudes, beliefs and perspectives of registered nurses (RNs) regarding sleep health and sleep health management of residents living in aged care settings in Australia.

DESIGN

Qualitative inductive thematic analysis of semi-structured interviews.

METHODS

Semi-structured interviews were conducted with RNs working in residential aged care facilities using a topic guide between August 2021 and April 2022. Participants were recruited using a convenience-based and snowball sampling approach. Interviews were audio-recorded, transcribed verbatim and inductively analysed for emergent themes.

RESULTS

Eighteen interviews were conducted with RNs working in aged care. Thematic analysis of the data derived three main themes: (i) Awareness and observations of sleep health, (ii) assessment and management of sleep disturbances and (iii) barriers to implementing evidence-based sleep health management. It was found that the most common barrier to providing evidence-based sleep health practices was related to workplace constraints. Participants detailed the limitations of the RN's professional role and ability to work autonomously in sleep health practices.

CONCLUSION

Despite the intentions of RNs to implement evidence-based non-pharmacological strategies for sleep health management, pharmacological interventions prevail. Systemic efforts to address organisational constraints in aged care may improve sleep disturbance management and assist with shifting the current attitudes around sleep health in aged care facilities.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

This study highlights that current sleep health management of residents in residential aged care is inadequate. Upskilling nurses in sleep health care techniques and improving organisational commitment to such care provision are issues urgently required to enhance the sleep health of residents.

IMPACT

Current sleep health practices are not evidence-based in residential aged care. Optimising sleep practices in residential aged care that are person-centred is likely to improve quality of life and healthy ageing.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Navigating transitions: a qualitative study of nursing teams' experiences of educational and cultural transitions in Germany

BACKGROUND

The global migration of health professionals in general and nurses in particular, has led to nursing shortages and socioeconomic impacts on health systems in both source and destination countries. Adding to the complexity of the situation is the fact that the nursing profession itself is evolving from a vocational to an academic one. Although nursing migration and academization have been studied from either an institutional or an individual perspective, there is a gap in the literature regarding how nursing teams experience these transitions. This study aims to explore how nursing teams navigate through the transitions of academization and internationalization of the current dynamic nursing landscape in Germany.

METHODS

Based on social constructivism epistemology this qualitative study involved face-to-face focus group discussions conducted at several hospital sites in Germany from September 2021 to May 2023. The focus group discussions were audio-recorded, transcribed, and analysed using content analysis; the four dimensions of transition theory according to Schlossberg's Four S (4 S) framework (self, situation, support, and strategy) were used as a priori items to construct the coding framework.

RESULTS

Nine focus group discussions were conducted with a total of 40 nurses from different educational and migrant backgrounds. The analysis showed that the transition experiences of the nursing teams were heterogeneous, with educational and national backgrounds playing an important role in how realistic their expectations of their professional roles and identities were. The dynamic situation characterized by a shortage of qualified nursing staff, increases the pressure on nursing teams and underscores the importance of employer-provided and peer support. Onboarding and communication are key strategies used depending on the duration of the employee turnover.

CONCLUSION

This study provides insights into the challenges and coping strategies of nursing teams in the current dynamic scene of migration, academicization and professional socialisation in Germany. Extending the Schlossberg 4 S framework from the individual to the team perspective provides a comprehensive view of the transitional experiences of nursing teams. Within each domain of the framework, the experiences of nursing teams are remarkably diverse. Educational background (vocational or academic) and origin (German or foreign trained) play an important role in shaping the transitional experiences of nursing teams.

"It's not just about you": International students' vulnerabilities and capacities during the first phase of the COVID-19 pandemic in Canada

In Canada, the COVID-19 pandemic was initially characterized by emergency government responses that disrupted daily life, especially for marginalized groups. This study explored the vulnerabilities and capacities of international students studying at a university in Calgary, Canada during the first phase of the pandemic. Guided by the Capacities and Vulnerabilities Analysis framework, we thematically analyzed 11 semi-structured interviews with international students. We found that material vulnerabilities included balancing finances, housing conditions, lack of information, food inaccessibility, reliance on public transport, and poor mental health, social vulnerabilities included lack of social support, culture shock, and racism, and attitudinal vulnerabilities included "nowhere to go", feeling like a burden, and perception of Canada as safe. Material capacities included financial support, knowledge about pandemic, and mental health supports, social capacities included local social support and multilingualism, and attitudinal capacities included resilience, religious and spiritual beliefs, "it's not just about you", and reflexivity. We found overlapping and complex relationships between vulnerabilities and capacities, indicating that while international students' vulnerabilities were exacerbated and introduced challenges during the pandemic, students uniquely leveraged their capacities to offset and recover from challenges. Findings from this study may be informative for stakeholders involved in disaster responses, especially universities and governments, to support international students' capacities and address their vulnerabilities.

Social media shaping autism perception and identity

LAY ABSTRACT

This study suggested that social media can provide important information about autism to autistic people. We interviewed 12 autistic adults (aged 18-49 years) and talked to them about the use of social media to find both general information and content specifically about autism, autism identity and online autistic communities. There is little research exploring how autistic people find information about autism on social media and how that makes them feel. Therefore, it is important to ask autistic people about their experiences with using social media to obtain content about autism. The 12 participants explained that when they searched for information about autism on the official health pages, they often felt that the information they found was insufficient and could not answer their questions. In addition, they searched on social media platforms for information about autism despite that they perceived social media as an unreliable source. On the social media platforms, many found content that was positive in relation to their autistic identities. The participants also found comfort in some of the forums and social media groups and received helpful advice. Nevertheless, some of the discussions were aggressive and the participants felt alienated, which did not provide a sense of community online. The findings from the study may advice on what is missing in the official pages about autism, and highlight the need to involve the autistic community in writing the content on such platforms.

"I Do Not Believe We Should Disclose Everything to an Older Patient": Challenges and Ethical Concerns in Clinical Decision-Making in Old-Age Care in Ethiopia

Clinical decision-making in old-age care is a complex and ethically sensitive process. Despite its importance, research addressing the challenges of clinical decision-making in old-age care within this cultural context is limited. This study aimed to explore the challenges and ethical concerns in clinical decision-making in old-age care in Ethiopia. This qualitative study employed an inductive approach with data collected via semi-structured interviews with 20 older patients and 26 health professionals recruited from healthcare facilities in Ethiopia. Data were analysed using reflexive thematic analysis. Our analysis identified three key themes. First, participants highlighted perceptions that older patients' religious beliefs interfere with the clinical decisions both older patients and health professionals make. Second, older patients often receive limited information from health professionals about their diagnosis and treatment. Third, families of older patients appear to strongly influence clinical decisions made by older patients or health professionals. This research enhances the understanding of clinical decision-making in old-age care within Ethiopia, a context where such research is scarce. As a result, this study contributes towards advancing the deliberation of ethical dilemmas that health professionals who work with older patients in Ethiopia might face. A key implication of the study is that there is a need for more ethics and cultural competence training for health professionals working with older patients in Ethiopia.

The equity road ahead for financing non-national immunization program vaccines in China: challenges and opportunities from a qualitative study

BACKGROUND

In China, national immunization program (NIP) vaccines benefit from robust financial support and have achieved high coverage. Non-NIP vaccines rely on fragmented funding sources, mostly out-of-pocket payment, and face sub-optimal and inequitable coverage. Sustainable financing needs to be secured for addressing equity in non-NIP vaccine delivery. However, discussion and understanding of this issue remain limited. This study aims to analyze the current situation, comprehensively identify challenges and opportunities in non-NIP vaccine financing, and offer suggestions to enhance vaccine uptake and improve public health.

METHODS

Between July and December 2023, we conducted a series of semi-structured, in-person interviews with 55 stakeholders from the Health Bureau, Centers for Disease Control and Prevention, Medical Insurance Bureau, and Finance Bureau across five provinces in China. Participants were selected through stratified sampling, and the interviews mainly included their involvement in non-NIP vaccine financing, challenges faced, and strategies for improvement to enhance financing performance. Informed consent was obtained, and thematic analysis was used to analyze the data.

RESULTS

Non-NIP vaccine financing sources include out-of-pocket payments, government fiscal, health insurance and other external funds. These four channels differ in vaccine types covered, costs, and target populations, each with unique challenges and opportunities. High out-of-pocket costs remain a significant barrier to equitable vaccine uptake, while market competition has lowered the vaccine price and improved accessibility. Local fiscal support for free vaccination programs faces challenges related to sustainability and regional disparity, though governmental commitment to vaccination is growing. Nevertheless, centralized procurement organized by the government has lowered the price and reduced the financial burden. Despite legal restrictions on using basic health insurance for vaccinations and limited commercial insurance options, private medical savings accounts and mutual-aid mechanisms present new opportunities. Although the scope and impact of external support are limited, it has successfully increased awareness and social attention to vaccination.

CONCLUSION

Relying on individual payments as the main financing channel for non-NIP vaccines is unsustainable and inadequate for ensuring universal vaccine access. A concerted and synergistic approach is essential to ensure sufficient, sustainable resources and enhance public financial management to improve equity in the non-NIP vaccines.

Professional identity formation of medical students in relation to older persons' healthcare: exploring the views of older persons living in the Netherlands - a qualitative study

OBJECTIVES

Given the growing population of older persons, medical students need to develop an appropriate professional identity to comply with older persons' healthcare needs. In this study, we explored the needs and expectations of older persons regarding their doctor to gain more insight into the characteristics of this professional identity.

DESIGN

A qualitative study based on a constructivist research paradigm was conducted, based on individual semistructured, in-depth interviews using a letter as a prompt, and focus groups. Thematic analysis was applied to structure and interpret the data.

SETTING AND PARTICIPANTS

Our study population consisted of older persons, aged 65 years and above, living at home in the South-West of the Netherlands, with no apparent cognitive or hearing problems and sufficient understanding of the Dutch language to participate in writing, talking and reflecting. The in-depth interviews took place at the participant's home or the Leiden University Medical Center (LUMC), and the focus groups were held at the LUMC.

RESULTS

The older persons shared and reflected on what they need and expect from the doctor who takes care of them. Four major themes were identified: (1) personal attention, (2) equality, (3) clarity and (4) reasons why.

CONCLUSION

Increasing complexity, dependency and vulnerability that arise at an older age, make it essential that a doctor is familiar with the older person's social context, interacts respectfully and on the basis of equality, provides continuity of care and gives clarity and perspective. To this end, the doctor has to be caring, involved, patient, honest and self-aware. Participation in a community of practice that provides the context of older persons' healthcare may help medical students develop a professional identity that is appropriate for this care.

Enhancing older Veterans' care: Insights from medication reviews and deprescribing interventions

BACKGROUND

Patient experience during and after health care is a critical indicator of quality of care that encompasses effective communication, respect, dignity, and emotional support. However, qualitative studies exploring the experiences of older adults after deprescribing interventions are sparse, highlighting a knowledge gap. This project seeks to address this gap by exploring Veterans' experiences during and after a deprescribing intervention provided by a pharmacist. This study aims to: 1. Assess Veteran's experience of the process of their Comprehensive Medication Review and deprescribing intervention visit; 2. Assess the Veteran's experience with the outcomes of their Comprehensive Medication Review and deprescribing intervention.

METHOD

Data was collected from 17 Veterans through semi-structured interviews using an interview guide. The Veteran Affairs study site utilizes the VIONE polypharmacy risk calculator to identify high-risk Veterans; the majority of these Veterans were on at least 10 medications. The interview transcripts were analyzed using inductive content analysis. Two research team members independently coded the data for categories and themes. Similarities were identified, and any divergence was discussed and resolved. To enhance the validity of the findings, member checking was performed with Veterans to confirm the results.

RESULT AND DISCUSSION

Most Veterans viewed the process of the pharmacists' visits and recommendations positively. They expressed confidence in pharmacists' knowledge and instructions. They appreciated the clarity of information pharmacists provided about the purpose, proper administration, and interactions of their medications. These enhanced the Veterans' ability to manage their medication regime. They also desired an increased frequency of interactions with their pharmacist due to these positive interactions. Veterans appreciated interprofessional collaboration between pharmacists, physicians, and other providers. Veterans expressed how pivotal lab test results were for evaluating medication recommendations and effectiveness. Most Veterans reported positive outcomes and/or indicated there were no negative effects as a result of their recent medication changes. Some reported seeking additional information from their providers regarding suggested medication changes to validate recommendations. There was some uncertainty about whether there would be follow-up visits with the professional after the medication change and who should initiate this. A minority indicated problems associated with prior medication discontinuation before the deprescribing intervention and how this limited their openness to future opportunities of deprescribing.

CONCLUSION

This exploration of Veterans' experiences with the process and outcomes of a deprescribing service affirms its importance and overall success in this site as part of the unique publicly funded Veteran healthcare system in the US. Equally important, the positive Veteran response suggests the value of exploring its potential to benefit patients experiencing polypharmacy across a range of other sites and systems.

"Staying connected": Speech-language pathologists' perspectives on the communication needs of people with primary progressive aphasia and their family members

PURPOSE

The research objectives were to explore the communication needs pertaining to (a) people with primary progressive aphasia (PwPPA); (b) family members of PwPPA; and (c) the different variants of primary progressive aphasia (PPA), from the perspectives of speech-language pathologists (SLPs).

METHOD

This investigation used a qualitatively driven concurrent mixed methods research design. Data collection involved semi-structured interviews and mixed methods questionnaires with 14 SLPs. Qualitative content analysis of interview and questionnaire data was used to identify codes and categories related to the research objectives. Quantitative analysis of questionnaire data involved single item summaries and cross item tabulations.

RESULT

Analysis revealed eight categories of communication need pertaining to PwPPA and six pertaining to their family members. Results regarding communication needs according to variant of PPA revealed limited findings.

CONCLUSION

SLPs perceived several important areas of communication need for PwPPA and their family members, highlighting key clinical implications for proactive communication care across the continuum of care. Future research can build on the current findings and integrate the perspectives of PwPPA and their family members on this topic, to develop interventions and explore models of service delivery to meet their progressive and complex communication needs.

Internship and postgraduate entrance examination: A qualitative study on the psychological experience of undergraduate nursing students under dual pressure in China

Background

With the development of nursing positions and nursing disciplines in China's tertiary hospitals, the number of people applying for the master's degree in nursing is also increasing year by year. Postgraduate examinations are held during internship, so nursing students face the dual pressure of testing and internship, which brings varying degrees of negative experiences and emotional fluctuations.

Objective

To explore the psychological experiences and influencing factors of undergraduate nursing students under the dual pressures of clinical nursing internships and postgraduate examination preparations.

Design

Descriptive qualitative study.

Method

Purposeful sampling was used to recruit 18 participants from eight tertiary hospitals in China between October and December 2023. Semi-structured in-depth interviews were conducted, with interview recordings transcribed verbatim. Thematic analysis was then applied to the data.

Results

Four themes were identified: negative experiences under dual pressures, coping mechanisms for negative experiences, motivational effects under dual pressures, and evaluations of significant individuals. Nursing students improved their overall abilities through internships and exam preparations, gaining a clear understanding of themselves and certain hospital roles. However, at this stage, students also experienced adverse psychological experiences for various reasons. Thus, they employed several methods to alleviate their psychological stress, aiming for a better state to face internships and exam preparations.

Conclusion

Schools and hospitals should pay more attention to the needs of nursing students under dual pressures, monitoring their emotional states, and providing psychological support to enhance their stress-coping abilities. It is important to ensure the overall well-being of students while strengthening the motivational effects of internships and learning experiences.

Stakeholder perspectives on managing the adolescent sleep crisis using a transdiagnostic self-management app for sleep disturbances: A qualitative follow-up study

Sleep problems are diverse and pervasive among the adolescent population. Current sleep health interventions are ill-equipped to address the sleep crisis. We developed DOZE (Delivering Online Zzz's with Empirical Support), which is a self-management evidence-based app for sleep disturbances. In an initial study, we found that DOZE was perceived as an acceptable and effective support for teen sleep. In a qualitative follow-up study, we engaged with students and other stakeholders to understand their experiences with implementing, disseminating, and using DOZE. The study employed a combination of qualitative surveys and semi-structured interviews to students (n = 21) and stakeholders (teachers, social workers, and researchers; n = 5), respectively. Reflexive thematic analysis was used to identify themes related to experiences implementing and engaging with the app. Students reported increased sleep regularity and sleep duration after using DOZE. Facilitators included greater integration of the app with school curriculum, timing of implementation, and researcher involvement in supporting knowledge dissemination and engagement. Barriers included worries about phone use at night and normalized poor sleep patterns among adolescents. There is need to identify ways to support implementation and engagement in different communities. Researchers continue to engage with stakeholders to support timely access to sleep health interventions for adolescents.

What does 'safe care' mean in the context of community-based mental health services? A qualitative exploration of the perspectives of service users, carers, and healthcare providers in England

BACKGROUND

Having traditionally received limited attention in empirical research and safety improvement agendas, issues of patient safety in mental healthcare increasingly feature in healthcare quality improvement discourses. Dominant approaches to safety stem from narrow clinical risk management perspectives, yet existing evidence points to the limitations of this characterisation. Although mental healthcare is increasingly delivered in community-based settings, narratives of safety pertain primarily to hospital-based mental healthcare. Therefore, through exploratory qualitative interviews and one focus group, we aimed to examine how service users, carers, and healthcare providers conceptualise 'patient safety' in community-based mental healthcare.

METHODS

Semi-structured interviews and a single focus group were conducted with users of UK community-based mental healthcare provision for adults (n = 13), their carers (n = 12), and providers (n = 18), who were diverse in characteristics and experiences. Study data were analysed in accordance with a reflexive approach to thematic analysis.

FINDINGS

Four key themes were developed, reflecting contrasting conceptualisations of safety in this care context, where participant thinking evolved throughout discussions. 'Systemic inertia: threats to safety' characterises the entrenched, systemic challenges which rendered participants powerless to advocate for or deliver safe care. 'Managing the risks service users present' equates 'safe care' to the mitigation of risks service users may pose to themselves or others when unwell, or risks from those around them. 'More than responding to risks: everyone plays a role in creating safety' recognises providers' agency in causing or proactively preventing patient harm. Finally, 'The goals of 'safety': our destination is not yet in sight' positions safety as a work in progress, calling for ambitious safety agendas, giving primacy to goals which meaningfully improve service users' lives.

CONCLUSIONS

Our findings have implications for the understanding and improvement of patient safety in community-based mental healthcare settings, where improvement objectives should transcend beyond management of risks and preventing deterioration to address patient and carer-centred concerns, including practices that make people feel unsafe.

Perspectives of stakeholders on the implementation of a dietary and exercise intervention for postpartum mothers with a history of gestational diabetes mellitus (GDM): a community-based qualitative study

Women with a history of Gestational diabetes mellitus (GDM) have a high risk of developing Type 2 diabetes mellitus (T2DM) in their future life. Lifestyle interventions are known to reduce this progression. The success of a lifestyle intervention mainly depends on its feasibility. Therefore, this study aimed to evaluate the feasibility of a lifestyle intervention programme aimed to attenuate the development of T2DM in mothers with a history of GDM. This qualitative phenomenological study was carried out in selected Medical offices of Health (MOH) areas in Sri Lanka. Postpartum mothers with a history of GDM who have undergone a comprehensive, supervised lifestyle intervention program for 1 year, their family members, and public health midwives (PHM) were recruited for this study. Focus group discussions (FGD) were carried out with mothers and PHM while In-depth interviews (IDI) were conducted with family members. Framework analysis was used for the analysis of data. A total of 94 participants (45 mothers, 40 healthcare workers, and 9 family members) participated in FGDs and IDIs to provide feedback regarding the lifestyle intervention. Sixteen sub-themes emerged under the following four domains; (1) Feelings and experiences about the lifestyle intervention programme for postpartum mothers with a history of GDM (2) Facilitating factors (3) Barriers to implementation and (4) Suggestions for improvement. Spouse support and continued follow-up were major facilitating factors. The negative influence of healthcare workers was identified as a major barrier to appropriate implementation. All participants suggested introducing continuing education programmes to healthcare workers to update their knowledge. The spouse's support and follow-ups played a pivotal role in terms of the success of the programme. Enhancing awareness of the healthcare workers is also essential to enhance the effectiveness of the programme. It is imperative to introduce a formal intervention programme for the postpartum management of mothers with a history of GDM. It is recommended that the GDM mothers should be followed up in the postpartum period and this should be included in the national postpartum care guidelines.

Unveiling the burden of COPD: perspectives on a patient-reported outcome measure to support communication in outpatient consultations-an interview study among patients

Introduction

Chronic Obstructive Pulmonary Disease (COPD) profoundly affects physical, psychological, and social aspects of life, yet these issues often remain unaddressed. Patient-Reported Outcomes Measures (PROM) have the potential to address these issues by promoting person-centered communication. However, their impact in COPD practice remains uncertain. This study aimed to investigate how patients with COPD perceive the usefulness of a new holistic PROM for general palliative care (PRO-Pall) before and during outpatient consultations.

Methods

Semi-structured telephone interviews were conducted with patients diagnosed with moderate to very severe COPD, 2-5 days after consultation at a respiratory outpatient clinic in Denmark. Interviews were transcribed verbatim and analyzed inductively using qualitative content analysis.

Results

Nine patients (five males; mean age: 66 years) participated in the study with four themes emerging: (1) Unlocking thoughts: Completing PRO-Pall stimulated patients' self-reflection, which revealed previously overlooked COPD-related issues, particularly psychosocial challenges. (2) Unmasking concerns: Patients felt encouraged to be honest, rather than concealing their concerns. (3) Breaking the ice: PRO-Pall responses enabled direct questioning by healthcare professionals during consultations, initiating discussions on patients' sensitive yet vital COPD-related matters. (4) Deepening the dialogue: Healthcare professionals' targeted and attentive approach fostered more holistic and meaningful discussions, providing most patients with a deeper understanding of psychosocial issues affecting their well-being.

Conclusion

Completing PRO-Pall prior to outpatient consultations prompted most patients with COPD to unveil previously unacknowledged psychosocial challenges. During consultations, addressing these challenges initiated open discussions on individual concerns, enhancing most patients' understanding of the multifaceted burden of COPD.

Impact of disability-based discrimination in healthcare on parents of children with medical complexity

AIM

To qualitatively assess the impact of disability-based discrimination in healthcare on the parents of children with medical complexity (CMC).

METHOD

In this qualitative study, we conducted in-depth, semi-structured interviews with the parents of CMC. Data collection and analysis occurred iteratively; constant comparison methods were used to identify themes describing the impact of disability-based discrimination in pediatric healthcare on the parents of CMC.

RESULTS

Thirty participants from 15 US states were interviewed. Four themes were developed regarding the impact of disability-based discrimination in healthcare on parents. The themes were: (1) discrimination leads to a loss of trust in healthcare providers; (2) discrimination increases the burden of caregiving; (3) discrimination impacts parental well-being; and (4) racism and poverty-based discrimination amplifies disability-based discrimination.

INTERPRETATION

The experience of discrimination toward their child results in loss of trust and therapeutic relationship between provider and parent, causes increased burden to the family, and contributes to decreased parental well-being. These experiences are magnified in minoritized families and in families perceived to have a lower socioeconomic status based on insurance type.

Patient perceptions of advanced practice radiation therapists prescribing medication in radiation therapy

INTRODUCTION

The purpose of this study was to determine patient perceptions of an advanced practice radiation therapist (APRT) prescribing medication for radiation therapy treatment-related side effects. By comprehending patient perceptions, it is important to implement change in order to improve patients' quality of life.

METHODS

A literature review was conducted on advanced practice (AP) roles in Canada and world-wide; the roles searched were: APRT, nurse practitioner and pharmacist. The search focused on evidence demonstrating improvements made to patient care due to the implementation of these roles. Based on this review and input from a team of experts a qualitative semi-structured interview survey was designed, and pilot tested. The survey consisted of five open-ended questions, which were designed to determine patient satisfaction of an APRT prescribing medication over the course of their radiation therapy treatments. Patients undergoing head and neck radiation therapy treatments at a large, academic cancer centre were invited to participate. Six patients who had a head and neck APRT involved in their treatment were interviewed. A comprehensive thematic analysis was then conducted using the transcripts created from these interviews, which was followed by two independent blinded analyses to ensure validity of the results.

DISCUSSION

The thematic analysis produced four salient themes which were: side effect management, care provided by the APRT in comparison to other healthcare workers, patients' access to care, and overall patient satisfaction. Common medications for head and neck radiation therapy treatment related side effects were discussed and these were: Magic Mouthwash, Xylocaine, Nystatin, Benadryl, Advil, Tylenol, Dexamethasone, Tantum, Biotene, Mucaine, Flamazine, Hydrocortisone, Ondansetron, Senokot, and narcotics.

CONCLUSION

This study was valuable to understand patient experiences and provide evidence to change processes in order to improve quality of patient centered care. The study revealed that although patients were happy with the process of prescribing medication, they all agreed that having an advanced practice radiation therapist prescribe would improve care. Patient responses further demonstrated the need for future research in regards to side effect management as a whole by APRTs as well as how role clarification can impact patient perceptions of APRTs.

Life-Threatening Clinical Simulations for Nursing Students: Promoting Critical Thinking and Satisfaction

BACKGROUND

Integrating life-threatening clinical simulations improves learning outcomes. This study assessed nursing students' critical thinking factors before and after simulation, evaluated nursing clinical reasoning ability and learning satisfaction at two time points, and explored relationships and predictions among critical thinking, clinical reasoning, and satisfaction before and after simulation.

METHOD

Surveys and focus groups were used for this mixed-methods study.

RESULTS

Quantitative findings revealed increased critical thinking scores for curiosity, skepticism, and systematicity; clinical reasoning; and satisfaction after simulation. Qualitative results supported these improvements and indicated enhanced curiosity for clinical knowledge and iterative phases of clinical reasoning. Students expressed satisfaction with the simulations. Objectivity significantly influenced clinical reasoning and satisfaction in nursing students following life-threatening simulations.

CONCLUSION

Fostering a culture of critical thinking in life-threatening simulations is crucial. Educators must teach the importance of objectivity in clinical practice, encourage critical evaluation, and foster self-reflection in simulations. [J Nurs Educ. 2024;63(9):595-603.].

Human errors in emergency medical services: a qualitative analysis of contributing factors

BACKGROUND

The dynamic and challenging work environment of the prehospital emergency care settings creates many challenges for paramedics. Previous studies have examined adverse events and patient safety activities, but studies focusing on paramedics' perspectives of factors contributing to human error are lacking. In this study, we investigated paramedics' opinions of the factors contributing to human errors.

METHOD

Data was collected through semi-structured individual interviews (n = 15) with paramedics and emergency medical field supervisors in Finland. The data was analyzed using inductive content analysis. Consolidated criteria for reporting qualitative research were used.

RESULTS

Contributing factors to human errors were divided into three main categories. The first main category, Changing work environment, consisted of two generic categories: The nature of the work and Factors linked to missions. The second main category, Organization of work, was divided into three generic categories: Inadequate care guidelines, Interaction challenges and Challenges related to technological systems. The third main category, Paramedics themselves, consisted of four generic categories: Issues that complicate cognitive processing, Individual strains and needs, Attitude problems and Impact of work experience.

CONCLUSION

Various factors contributing to human errors in emergency medical services (EMS) settings were identified. Although many of them were related to individual factors or to the paramedics themselves, system-level factors were also found to affect paramedics' work and may therefore negatively impact patient safety. The findings provide insights for organizations to use this knowledge proactively to develop their procedures and to improve patient safety.

Adapting an Online Guided Self-Help CBT Programme Targeting Disordered Eating for Students in Aotearoa New Zealand: A Qualitative Study

Disordered eating is a significant issue in university student populations. Currently, access to interventions is limited. Online interventions present an innovative way to increase accessibility to treatment for those in need. The current study explored how an online intervention for disordered eating (everyBody) could be modified to suit the needs of university students in Aotearoa New Zealand. Aotearoa New Zealand is a unique cultural context, with an indigenous population that has a high incidence rate of disordered eating, highlighting the need to adapt everyBody to the local context. Individual interviews were conducted with nine students currently at university in Aotearoa New Zealand, aged between 18 and 33 years old (five females, four males). Three first-order themes were identified using template analysis. The themes indicate that participants perceived the programme as acceptable and feasible for use with Aotearoa New Zealand's university student population. Furthermore, the themes provide insight into potential adaptions to the programme to facilitate engagement and uptake. The suggested changes were largely consistent with previous research on E-therapy design (e.g., content length, therapeutic alliance), and also highlight changes specific to fit Aotearoa New Zealand's cultural context. The findings have implications for universities and other funders deciding on services for students with disordered eating and eating disorders.

Negotiating grey areas: an interview-based analysis of paramedic uncertainty and decision-making in cardiac arrest events

BACKGROUND

Paramedics are responsible for critical resuscitation decisions when attending Out of Hospital Cardiac Arrests (OHCA). Existing research indicates that a range of clinical and non-clinical factors moderate their decision-making. Within the United Kingdom (UK), there is little evidence on how and why paramedics make their decisions at actual OHCA events.

METHODS

We explored the experiences of UK paramedics using individually recalled OHCA events as catalysts for discussion. Pen portraits developed from semi-structured interviews with 31 paramedics across two UK ambulance services were thematically analysed, enabling cross-participant comparisons whilst retaining depth and context.

RESULTS

We identified four themes: uncertainties encountered in resuscitation guidelines, influences on decision-making, holistic perspectives, and indirect moderators. We found that paramedics experienced uncertainty at all stages of the resuscitation process. Uncertainties arose from indeterminate, ambiguous or complex information and were described as having both clinical and ethical dimensions. Whilst guidelines drove paramedics' decisions, non-clinical personal, practical and relational factors moderated their assessments of survivability and decision-making, with attitudes to interactions between patient age, frailty and quality of life playing a substantial role. Coping strategies such as uncertainty reduction, assumption-based reasoning and weighing pros and cons were evident from interviews.

CONCLUSIONS

The complexity of interactions between clinical and non-clinical factors points to an element of variability in paramedics' responses to uncertainty. Exploring UK paramedics' uncertainties and decision-making during specific OHCA events can help acknowledge and address uncertainties in resuscitation guidelines and paramedic training, providing paramedics with the tools to manage uncertainty in a consistent and transparent way.

Decision-making in action: How international-level professional football players gain an advantage

Understanding how both visual and contextual in-game information influences player's attempts to gain an advantage over their opponent is key to understanding skilled decision-making in fast-ball sports. In the present study, we conducted semi-structured interviews with 15 male professional football players to explore their reported behaviours and perspectives on their in-game decision-making and the ways in which they adapt to gain an advantage over their opponent. Professional players who have competed internationally at either Under 17, Under 19, Under 21, or senior level took part in semi-structured interviews. The data were analysed using reflexive thematic analysis which generated four higher-order themes about players reported behaviours and perspectives on their decision-making and ways of gaining an advantage: (i) being "unpredictable"; (ii) option generation and invitation, comprising two sub-themes: (iia) generating and realising options in action; and (iib) act on what invites you in the moment; (iii) anticipation and awareness; and (iv) dictating and controlling the game. A key finding was that players attempts to gain an advantage were largely grounded in the aim of 'being unpredictable' through the use of deception and disguise, as well as deliberate manipulation of action sequences in order to make their actions 'hard to read'. A further important finding was that players do not always seek a universal optimal decision, as their individual action capabilities influence their available options. These findings have important implications for the assessment of decision-making performance in future empirical research.

Dispatcher nurses' experiences of handling drones equipped with automated external defibrillators in suspected out-of-hospital cardiac arrest - a qualitative study

BACKGROUND

Reducing the time to treatment by means of cardiopulmonary resuscitation (CPR) and defibrillation is essential to increasing survival after cardiac arrest. A novel method of dispatching drones for delivery of automated external defibrillators (AEDs) to the site of a suspected out-of-hospital cardiac arrest (OHCA) has been shown to be feasible, with the potential to shorten response times compared with the emergency medical services. However, little is known of dispatchers' experiences of using this novel methodology.

METHODS

A qualitative semi-structured interview study with a phenomenological approach was used. Ten registered nurses employed at an emergency medical dispatch centre in Gothenburg, Sweden, were interviewed and the data was analysed by qualitative content analysis. The purpose was to explore dispatcher nurses' experiences of deliveries of AEDs by drones in cases of suspected OHCA.

RESULTS

Three categories were formed. Nurses expressed varying compliance to the telephone-assisted protocol for dispatch of AED-equipped drones. They experienced uncertainty as to how long would be an acceptable interruption from the CPR protocol in order to retrieve a drone-delivered AED. The majority experienced that collegial support was important. Technical support, routines and training need to be improved to further optimise action in cases of drone-delivered AEDs handled by dispatcher nurses.

CONCLUSIONS

Although telephone-assisted routines for drone dispatch in cases of OHCA were available, their use was rare. Registered nurses showed variable degrees of understanding of how to comply with these protocols. Collegial and technical support was considered important, alongside routines and training, which need to be improved to further support bystander use of drone-delivered AEDs. As the possibilities of using drones to deliver AEDs in cases of OHCA are explored more extensively globally, there is a good possibility that this study could be of benefit to other nations implementing similar methods. We present concrete aspects that are important to take into consideration when implementing this kind of methodology at dispatch centres.

In search of the pleasure of moving through bodily re-explorations and interactions with the surroundings: a qualitative study on changed perceptions of physical activity in people with mild multiple sclerosis

INTRODUCTION

Reduced physical activity (PA) among people with multiple sclerosis (pwMS) with low disability is a significant concern. Developing healthcare to promote PA requires a comprehensive understanding of pwMS's perspectives.

PURPOSE

To explore how pwMS with mild disability perceive PA and the impact of individual, professional, social, and environmental aspects on their PA engagement.

METHODS

Qualitative, in-depth interviews with 27 pwMS (21 women, 6 men; aged 31-66; EDSS ≤ 3.5) were analyzed via systematic text condensation and informed by enactive theory.

RESULTS

Three categories were formed: Perception Shifts after Diagnosis: Participants adapted their perceptions to PA throughout their disease journey. Initial uncertainty concerning bodily capacities, prospects and safety reduced PA. Moving "correctly" during activities was emphasized to facilitate PA levels. Affective Experiences Drive Behavior: Pleasure associated with movement was a highlighted motivator, however, some experienced PA less rewarding after diagnosis. Discomfort and fear were barriers to PA engagement. The Surroundings Influence Perceptions: Participants sought social interactions and outdoor-environments to improve PA. Healthcare professionals were trusted to provide possibilities for PA, but early-stage and tailored follow-up was often lacking.

CONCLUSION

This study illuminates changed PA perceptions after MS diagnosis and how affect, shaped by personal, interpersonal, and environmental aspects, drive PA engagement. Moreover, it calls for early follow-up and the implementation of tailored healthcare throughout the disease course to promote PA engagement. Considering these findings, we have put forth a model aimed at fostering a nuanced comprehension of PA in pwMS with mild disabilities. Further development and exploration of this model is needed.

Reducing asthma attacks in disadvantaged school children with asthma: study protocol for a type 2 hybrid implementation-effectiveness trial (Better Asthma Control for Kids, BACK)

BACKGROUND

Asthma is a leading cause of children's hospitalizations, emergency department visits, and missed school days. Our school-based asthma intervention has reduced asthma exacerbations for children experiencing health disparities in the Denver Metropolitan Area, due partly to addressing care coordination for asthma and social determinants of health (SDOH), such as access to healthcare and medications. Limited dissemination of school-based asthma programs has occurred in other metropolitan and rural areas of Colorado. We formed and engaged community advisory boards in socioeconomically diverse regions of Colorado to develop two implementation strategy packages for delivering our school-based asthma intervention - now termed "Better Asthma Control for Kids (BACK)" - with tailoring to regional priorities, needs and resources.

METHODS

In this proposed type 2 hybrid implementation-effectiveness trial, where the primary goal is equitable reach to families to reduce asthma disparities, we will compare two different packages of implementation strategies to deliver BACK across four Colorado regions. The two implementation packages to be compared are: 1) standard set of implementation strategies including Tailor and Adapt to context, Facilitation and Training termed, BACK-Standard (BACK-S); 2) BACK-S plus an enhanced implementation strategy, that incorporates network weaving with community partners and consumer engagement with school families, termed BACK-Enhanced (BACK-E). Our evaluation will be guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, including its Pragmatic Robust Implementation Sustainability Model (PRISM) determinants of implementation outcomes. Our central hypothesis is that our BACK-E implementation strategy will have significantly greater reach to eligible children/families than BACK-S (primary outcome) and that both BACK-E and BACK-S groups will have significantly reduced asthma exacerbation rates ("attacks") and improved asthma control as compared to usual care.

DISCUSSION

We expect both the BACK-S and BACK-E strategy packages will accelerate dissemination of our BACK program across the state - the comparative impact of BACK-S vs. BACK-E on reach and other RE-AIM outcomes may inform strategy selection for scaling BACK and other effective school-based programs to address chronic illness disparities.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT06003569, registered on August 22, 2023, https://classic.

CLINICALTRIALS

gov/ct2/show/NCT06003569 .

Postgraduate Year Two Medical Residents' Awareness of Personal Development as a Physician during the Management of Inpatients: A Qualitative Study

Clinical experiences, helping relationships, and reflection are key factors for personal development for physicians. However, few studies have shown which experiences are important for personal growth and how medical residents specifically use their experiences for personal growth. The aim of this study was to identify from the medical residents' perspective which clinical experiences contribute to their personal development. We employed a qualitative design, conducting semi-structured interviews with ten postgraduate year two medical residents at a Japanese teaching hospital. The interviews were transcribed in interview memos, anonymized, and subjected to reflective thematic analysis to generate themes relevant to personal and professional development. Successful clinical experiences with autonomy and responsibility in clinical management were shown to be essential points for personal development as a physician. Autonomy in this study was the attitude of making one's own choices when managing patients. Responsibility was the obligation of the resident to take charge of a patient. Instructing junior trainees, appreciation received from patients, and approval granted by attending physicians reinforced their feelings of personal growth. The realization of what experiences and concepts influence medical residents' personal growth and development will make their professional development more effective.

Migration Challenges and Their Impact on the Primary Healthcare System-A Qualitative Research

In 2020 it is estimated that 281 million people were international migrants. Migrants constitute a potentially vulnerable population in terms of facing discrimination, poor living and housing conditions, and insufficient access to healthcare services. Due to the armed conflict in Ukraine in 2022, almost 10 million people crossed the Polish border within a year of the outbreak of the conflict. The objective of this paper is to present the use of primary healthcare services by people migrating from Ukraine to Poland and identify the barriers in access to healthcare by this group of persons. This study used a qualitative research technique in the form of an expert interview using individual in-depth interviews (IDI). The study group consisted of professionally active primary healthcare providers (doctors, nurses, and facility managers) in Poland. Research was carried out in the areas regarding the availability of healthcare, the potential threats and challenges, and possible system solutions. The results showed that the most common cause for doctor's appointments among migrants are respiratory infections, including COVID-19. Many cases were related to back pain, mainly resulting from the physical work of the patients. Additionally, some barriers to access and the provision of healthcare services for patients from Ukraine were identified. The majority (75%) of respondents indicated language as a significant barrier when providing services. Based on the study results, we recommend creating a dedicated website and telephone hotline for this group of persons as well as the use of traditional media to distribute information about access to healthcare services. It is also essential to focus on assistance for older people, since they may experience more difficulties with language and navigating the healthcare system.

Dental care staff's experience with risk assessment of dental erosion: a qualitative study

BACKGROUND

The risk assessment of dental erosion among children and adolescents is an important aspect of dental care, as dental erosion constitutes a rapidly growing, global problem. Dental professionals rely solely on their own perception, as the current risk assessment process is not completely automatized, which affects the risk assessment reliability.

AIM

To explore dental professionals' experiences with risk assessment of dental erosion among children and adolescents.

METHOD

In-depth interview was used as data collection method. A total of 11 dental professionals were interviewed. The interviews were analyzed using qualitative content analysis.

RESULTS

The findings were summarized in the categories Professionals' responsibility, Systematic approach , and Collaboration and communication. Dental staff perceived that their basic knowledge regarding erosion should be improved, and skills development was desired to reduce the knowledge gaps around the risk assessment of dental erosion. They alleged that the systematic approach could be improved by reducing workplace stress, implementing a universal dental erosion index, improving the existing risk assessment software, and automating the risk assessment of the condition. Dental professionals also experienced a need to calibrate and collaborate with each other and with other healthcare professionals to improve patient care.

CONCLUSION

Dental professionals experienced their basic knowledge of dental erosion and their risk assessment as good, but a more advanced skill development was required. Furthermore, they experienced the risk assessment software as a good tool that should be improved to compile more objective risk assessment. A universal erosion index was also requested.

Compassionate nursing in challenging contexts: The importance of judgments

BACKGROUND

Nurses' demonstration of compassion is an ethical and often regulatory expectation. While research has been conducted to examine the barriers and facilitators of compassion in nurses, little is known about how nurses develop and express compassion for patients who may be blamed for their health condition. Unvaccinated COVID-19 patients are an example of such patients.

RESEARCH QUESTIONS

How do nurses provide compassionate care for unvaccinated adults infected with COVID-19? How did the context of COVID-19 vaccination in Canada shape nurses' relationships with unvaccinated patients?

RESEARCH DESIGN

A generic qualitative approach using interviews to gather data was used. Martha Nussbaum's conceptualization of compassion and its cognitive requirements was employed to add depth to the analysis.

PARTICIPANTS AND RESEARCH CONTEXT

Seventeen Registered Nurses, from a range of practice settings, who had cared for unvaccinated patients with COVID-19 participated.

ETHICAL CONSIDERATIONS

Ethics approval was received, and signed informed consent was obtained. Participants who were the current students of the researchers were excluded.

FINDINGS

Three themes were identified:1) Encountering Extreme Workplace Impediments to Compassion.2) Managing Emotions to Provide "Nonjudgmental Care."3) Practicing Narrative Imagination.

DISCUSSION

The difficult working conditions during the pandemic impeded nurses' capacity to be compassionate. Yet, none judged their patients' suffering as trivial, and all provided necessary nursing care. Some initially blamed these patients for the severity of their illness and suppressed their emotions to provide what they called "nonjudgmental care." Upon reflection, participants recognized that these patients' life circumstances may have been barriers to vaccination which, in the end, facilitated the development of compassion.

CONCLUSION

This research has implications that go beyond that of caring for patients with COVID-19. The ideal of "nonjudgmental care" requires critical re-examination because judgments and emotions are required for compassion.

Understanding the patient experience in nonsurgical management of endometrial cancer and complex atypical hyperplasia due to obesity: A qualitative analysis

Objectives

Patients with class 3 obesity (BMI ≥ 40) and significant medical comorbidities with complex atypical hyperplasia (CAH) and early-stage endometrial cancer (EC) present challenges in standard surgical management. Progestin therapy is an alternative used for patient-centered reasons, including the desire for uterine preservation or because surgery is not a safe option. Our objective was to gain insights into the patient experience when undergoing this treatment approach.

Methods

We identified and recruited patients who received oral or IUD progesterone in the last 5 years for EC or CAH. We conducted semi-structured phone interviews regarding patients' experience with non-surgical management as well as decision-making factors to start progesterone and weight loss. Interviews were audio-recorded and transcriptions were analyzed for common themes.

Results

A total of 20 interviews were performed. We enrolled nine patients with CAH, eight with grade 1 EC, and three with grade 2 EC. The majority of patients (18/20) were managed with IUD. We identified the following 5 common themes support in diagnostic workup and long-term outcomes, autonomy in care, thoroughness in counseling, emotional impact of diagnosis, and perception of obesity as a defining identity.

Conclusion

The themes identified in the present study highlight the challenges and the stigma these patients face. It also demonstrates areas of opportunity in their counseling and care, which will help to build a more effective therapeutic relationship and ultimately lead to greater adherence in care.

Mental health recovery in a collectivist society: Saudi consumers, carers and nurses' shared perspectives

In 2019, the World Health Organization urged a global shift towards recovery-focused practices in mental health care. In Western nations, this transition often prioritised individualism over collectivism. In contrast, collectivist societies prioritise recovery through community and social support. This study explored mental health recovery from the perspectives of consumers, carers and registered nurses in a mainly collectivist society (Saudi Arabia) using a qualitative exploratory descriptive design. Sixteen consumers, ten carers and eight registered nurses participated in online semi-structured interviews. Inductive thematic analysis was employed to analyse English-translated versions of the 34 interviews. Consolidated criteria for reporting qualitative studies 32-item checklist were used. The study found that recovery was perceived as a process of transforming towards living a meaningful life of goals and values supported by trusted people who share moments of comfort and empowerment. A unique finding was the 'bond of recovery' a collectivist value that aid consumers' community integration in society. Saudi consumers' experiences of recovery were similar to consumers' movement narratives of recovery. Future research should establish a recovery-focused educational program that incorporates our findings into a recovery-oriented approach. This will facilitate providing a collaborative care between consumers, carers and nurses that centres around consumers' recovery goals and values.

Barriers and facilitators for strengthening physiotherapy services in Nepal: perspectives from physiotherapists and health providers

BACKGROUND

Physiotherapy provides non-invasive and non-pharmaceutical intervention for curative, rehabilitation and preventative purposes. Physiotherapy is also a central provider of health promotion. As the global burden of non-communicable diseases and chronic health conditions is rising, the importance of physiotherapy services increases. Unfortunately, physiotherapy services in low- and middle-income countries (LMICs) are generally unsatisfactory. In Nepal, the earthquake in 2015 and the COVID pandemic have clearly illuminated the importance of physiotherapy.

OBJECTIVE

This qualitative study aimed to identify barriers and facilitators at different system levels for strengthening physiotherapy services in Nepal.

METHODS

Forty semi-structured individual interviews were performed with different health providers. Transcribed interviews were assessed with thematic analysis. A five-level socioecological framework conceptualised multilevel determinants of barriers and facilitators.

RESULTS

The study revealed various factors that were potential barriers and facilitators across five different levels, namely individual (taking the lead, need for advocacy), interpersonal (lack of recognition and autonomy, networking for referrals and coordination), community (lack of knowledge and awareness, social and family support), organisational (accessibility, workplace and clinical practice, educational opportunities, role of organisations and rehabilitation centres), and public policy level (planning and implementation of policies and programs, medical hegemony, priorities). Government officials, local leaders, and clinicians, half of whom were physiotherapists, agreed on many of the same issues, where a lack of awareness of what physiotherapy is and knowledge about what physiotherapists do was central.

CONCLUSIONS

The results provide information for the development of physiotherapy by pointing out key elements that need attention. Our broad and structured investigation strategy is applicable to others for a comprehensive analysis of barriers and facilitators for physiotherapy services.

"I feel like I'm changing people's lives, even if it's just two hours at a time": Understanding contingent instructors' emotion management in university teaching

This article extends existing scholarship on contingent or temporary-contract university instructors' emotional agency by employing the Bolton's emotion management and Cottingham's emotional capital typologies in tandem. In interviews with 40 instructors from universities across Canada, participants described acquiring both primary and secondary emotional capital as an embodied psychosocial resource through past education, upbringing and culture, and knowledge and skills from previous work and training experiences respectively. They then deployed this capital through emotion management based in both social and organizational feeling rules in their capacity as professors. This allowed instructors to reinforce their own sense of purpose, authority and competence as instructors, and to establish fulfilling relationships with students through teaching and mentoring which they infused with personal meaning. However, instructors' agency was also curtailed to varying degrees, by both institutional attitudes around academic contingency and sexist, and in some cases, racist or otherwise patronizing attitudes from students. Despite this, instructors were often able to reaffirm their identities as instructors by using emotion management in self-affirming ways, such as by drawing on self-confidence gained through previous occupations and training, and facilitating cultural backgrounds shared with students through emotional management.

"My Autism is Linked with Everything": at the Crossroads of Autism and Diabetes

Autistic adults experience stark health disparities and difficulties accessing health care. Their realities of managing complex health conditions are unknown. Our research explored the experience of Autistic adults self-managing diabetes. Interviews with Autistic adults with diabetes and their support people were thematically analysed to identify three key themes. The Autistic experience influenced diabetes self-management, including autism-unique challenges and strengths. Participants prioritised avoiding Autistic burnout over diabetes self-management; mitigating the psychosocial pressures of neurotypical systems took precedence. Health professionals often separated autism and diabetes subsequently overlooking key factors impacting diabetes self-management. To better meet the needs of Autistic adults, diabetes care and health management more broadly should be considered within the context of autism, including supports for self-management during Autistic burnout.

Assessing the Variability in Interpretation of the Catholic Directives Pertaining to Reproductive Health Services: An Exploratory Qualitative Study of Two Hospitals on the American East Coast

The ethics in Catholic hospitals are guided by the Ethical and Religious Directives for Catholic Health Care Services, which provide direction on many topics, including family planning. Previous research has demonstrated there is variability in the availability of prohibited family planning services at Catholic hospitals. This study aims to research a potential source of variability in interpretation and application of the directives through interviewing ethics committee members. Participants were recruited from two different hospitals on the east coast with a total sample size of eight. Ethics committee members were asked questions regarding their personal approach to ethics, their hospital's approach to ethics, and the permissibility of specific family planning methods at their hospital. Most ethics committee members stated that the Catholic faith and/or directives were important in their hospitals' approach to ethics. Most participants stated that they had instances in which their personal approach to ethics conflicted with their hospital's approach, citing women's health and end-of-life care as common causes of conflict. All but one ethics committee member stated that hormonal contraception was forbidden under the directives; however, many members stated that this was either a gray area or permissible under certain circumstances. Reproductive health issues rarely came before the ethics committee at either site with one participant referring to them as "black and white issues." This research suggests that ethics committee members did not see the directives governing family planning services to be ambiguous. However, given the low frequency in which these issues come to the attention of the ethics committee, it is difficult to determine whether the opinions expressed by our participants contribute to the variability between Catholic hospitals when it comes to reproductive healthcare provision. An interesting topic for future research would be interviewing executives at Catholic hospitals to determine where this variability arises.

Deprescribing as a Way to Reduce Inappropriate Use of Drugs for Overactive Bladder in Primary Care (DROP): Protocol for a Cluster Randomized Controlled Trial With an Embedded Explanatory Sequential Mixed Methods Study

BACKGROUND

Potentially inappropriate medication remains a significant concern in general practices, particularly in the context of overactive bladder (OAB) treatment for individuals aged 65 years and older. This study focuses on the exploration of alternative options for treating OAB and the deprescribing of anticholinergic drugs commonly used in OAB. The research aims to comprehensively evaluate the efficiency of deprescribing through a mixed methods approach, combining quantitative assessment and qualitative exploration of perceptions, experiences, and potential barriers among patients and health care personnel.

OBJECTIVE

This study aims to evaluate the efficiency and safety of the intervention in which health care staff in primary care encourage patients to participate in deprescribing their drugs for OAB. In addition, we aim to identify factors contributing to or obstructing the deprescribing process that will drive more informed decisions in the field of deprescribing and support effective and safe treatment of patients.

METHODS

The drugs for overactive bladder in primary care (DROP) study uses a rigorous research design, using a randomized controlled trial (RCT) with an embedded sequential explanatory mixed methods approach. All general practices within the North Denmark Region will be paired based on the number of general practitioners (GPs) and urban or rural locations. The matched pairs will be randomized into intervention and control groups. The intervention group will receive an algorithm designed to guide the deprescribing of drugs for OAB, promoting appropriate medication use. Quantitative data will be collected from the RCT including data from Danish registries for prescription analysis. Qualitative data will be obtained through interviews and focus groups with GPs, staff members, and patients. Finally, the quantitative and qualitative findings are merged to understand deprescribing for OAB comprehensively. This integrated approach enhances insights and supports future intervention improvement.

RESULTS

The DROP study is currently in progress, with randomization of general practices underway. While they have not been invited to participate yet, they will be. The inclusion of GP practices is scheduled from December 2023 to April 2024. The follow-up period for each patient is 6 months. Results will be analyzed through an intention-to-treat analysis for the RCT and a thematic analysis for the qualitative component. Quantitative outcomes will focus on changes in prescriptions and symptoms, while the qualitative analysis will explore experiences and perceptions.

CONCLUSIONS

The DROP study aims to provide an evidence-based intervention in primary care that ensures the deprescription of drugs for OAB when there is an unfavorable risk-benefit profile. The DROP study's contribution lies in generating evidence for deprescribing practices and influencing best practices in health care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06110975; https://clinicaltrials.gov/study/NCT06110975.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56277.

Life is better but not without challenges: experiences following discharge from community-based residential mental health rehabilitation-a qualitative content analysis

PURPOSE

Community-based residential mental health rehabilitation units for people experiencing severe and persistent mental illness are increasingly available in Australia. Research completed 20 years ago suggested that people leaving these services often experienced impoverished social lives and other challenges in the community. It is unclear whether contemporary consumers experience similar difficulties. This qualitative study explored contemporary consumers' experiences after leaving community-based residential services.

METHODS

An inductive qualitative content analysis of individual interviews was completed with consumers 12-18 months following discharge from three community care units (CCUs) in Queensland, Australia. The interview schedule explored three questions: (1) What does life look like after leaving the CCU, (2) Has the CCU impacted their life, and (3) How could the CCU experience be improved? A convenience sample was used, with sampling continuing until thematic saturation was achieved. A member of the research team who had relevant lived experience actively supported the analysis and interpretation.

RESULTS

Seventeen interviews were completed. Three themes were identified: 'life is better but not without challenges', 'the CCU helps you get ready to go out into the world', and 'strict rules are important but rigid expectations can be hard; things could be better'.

CONCLUSION

Consumers reflected positively on their lives post-discharge from a community-based residential rehabilitation unit and viewed the service as having supported improvements in their lives. The findings suggest the appropriateness of optimism about the possibility of sustained improvements in quality of life after leaving community-based transitional residential rehabilitation support.

Determinants for the development of creative tourism: A stakeholder perspective

This study aims to investigate the determinants that contribute to the sustainable development of creative tourism, a transformative shift from traditional cultural tourism which possess high economic potential. Grounded in stakeholder theory, a qualitative approach was employed to explore the perspectives of 23 existing suppliers of creative tourism in the Greater Bay Area, China, through semi-structured, in-depth interviews with key management in exiting business, this study uncovers determinants for the development of creative tourism. The findings shed light on the significance of fostering creative synergies and their implications for sustainable growth in the industry. While a positive attitude from suppliers is crucial, this study emphasizes the importance of mutual understanding of creativity to generate momentum, integration of local culture and regional knowledge, and the development of creative products. Moreover, removing barriers faced by suppliers such as a lack of financial support, insufficient government policies and regulations, and inadequate infrastructure is imperative for sustainable development. This research significantly contributes to the existing body of knowledge by providing an overview of the current research status on suppliers' perspectives towards creative tourism. It offers valuable directions for future scholarly inquiry in this field. Moreover, the research offers valuable insights that can assist policymakers and destination planners in developing efficient policies and sustainable planning approaches.

Effects of Exercise-Induced Laryngeal Obstruction in Adolescents: A Qualitative Study

PURPOSE

The purpose of this study was to examine the influence of exercise-induced laryngeal obstruction (EILO) on adolescents.

METHOD

Twenty patients (< 17 years) diagnosed with EILO participated in this study. Patients completed semistructured interviews examining their experience with the health care system, treatment, and the effects of EILO symptoms on quality of life. Interviews were analyzed using a combination of directed and conventional content analyses. Researchers identified seven overarching themes either prior to or during analysis, and 24 subthemes were inductively identified from patient interviews using open, axial, and selective coding.

RESULTS

On average, patients went 1.9 years between symptom onset and EILO diagnosis. Patients described symptom onset as frightening and confusing. Even after initially reporting symptoms to a medical provider, patients went an average of 10.5 months before diagnosis. Patients perceived that delays in diagnosis prevented efficient management and allowed symptoms to escalate. Patients reported that EILO detrimentally influenced athletic performance, forcing them to pace themselves or cease participation altogether. Social and academic effects of EILO included missed classes, difficulty in physical education courses, and resentment from teammates if athletic performance declined. Both athletes and nonathletes indicated that EILO elicited feelings of fear, frustration, dread, guilt, and embarrassment. Patients reported that therapy with a speech-language pathologist (SLP) effectively addressed symptoms; however, employing rescue breathing techniques was often more difficult than anticipated.

CONCLUSIONS

Physical and emotional sequelae associated with EILO may have widespread influence on patient quality of life. Therapy with an SLP reportedly ameliorated EILO symptoms; however, patients indicated that delayed diagnosis allowed negative effects to intensify prior to treatment.

Measuring Overweight and Obesity in Persons with Spinal Cord Injury: What Do Health Providers Use and What are the Challenges?

INTRODUCTION

Obesity is a significant health concern for veterans and individuals with spinal cord injury, yet screening for overweight/obesity can be challenging. This study examines how healthcare providers screen for overweight/obesity and the challenges encountered in identifying overweight/obesity in veterans and persons with spinal cord injury.

MATERIALS AND METHODS

Healthcare providers who provide care for persons with spinal cord injury completed a semi-structured interview. The interview explored their perspectives on measuring overweight/obesity in persons with spinal cord injury and the challenges they faced. Thematic analysis was used to identify themes that emerged from the interviews.

RESULTS

Twenty-five providers (88% female with an average experience of 9.6 ± 7.3 years in providing care for spinal cord injury patients) participated in the interviews. The themes described the health indicators and equipment used to assess overweight/obesity, provider concerns regarding measurement, and criteria for classifying overweight/obesity. Body weight and body mass index were the most commonly used indicators. However, concerns were raised regarding accuracy of these measures for spinal cord injury patients, as well as issues related to the accessibility, calibration, and usability of the equipment. Many providers reported using standard body mass index ranges and categories instead of those specific to spinal cord injury.

CONCLUSION

This study identified the most commonly used indicators of weight or body composition in veterans and persons with spinal cord injury and highlighted providers' concerns with these measures. Future research is needed to identify the most feasible, accurate, and appropriate health indicators that could be used in a clinical setting to identify overweight and obesity in this population.

No one really plans to have multiple sclerosis: Transition readiness and quality of life in paediatric multiple sclerosis

AIM

We sought to explore the experiences and perceptions of the quality of life of adolescents with pediatric-onset multiple sclerosis and assess their readiness for academic, employment and/or health care-related transitions.

BACKGROUND

Adolescents with pediatric-onset multiple sclerosis face unique challenges in managing a chronic illness while navigating future scholastic, social and occupational goals. We conducted a qualitative study with in-depth, semi-structured interviews from July 2017 to March 2019. Adolescents with pediatric-onset multiple sclerosis were recruited from a pediatric neurology subspeciality practice until reaching data saturation. A total of 17 interviews were completed via telephone with participants ages 15 through 26.

RESULTS

Through content analysis of the interviews, we identified five major themes: (1) receiving a new diagnosis; (2) adapting to life with pediatric-onset multiple sclerosis; (3) evaluating education/career transition preparedness; (4) adjusting within family life and establishing support systems; and (5) assessing current medical services and preparedness for adult medical care.

CONCLUSIONS

Autonomy in health care management, adequate control of physical symptoms and sufficient family support impacted perceptions of quality of life. Implementing a dedicated transition visit, including the parent(s) of those with pediatric-onset multiple sclerosis, early in adolescence may provide an avenue for appropriate anticipatory guidance regarding available services, independent medical management and continuity of care.

Patient and Medical Unit Staff Experiences of Proactive and Integrated Consultation-Liaison Psychiatry in The HOME Study: A Qualitative Investigation

BACKGROUND

Consultation-liaison (C-L) psychiatry services aim to help general hospital staff provide better care for their patients. Recently, many inpatient C-L psychiatry services have adopted proactive and integrated approaches to achieve this aim. Despite these developments, there have been no interview-based studies of patients' and staff members' experiences of the new approaches.

OBJECTIVE

To gain an in-depth understanding of patients' and medical unit staff members' experiences of a proactive and integrated C-L psychiatry service for older medical inpatients (Proactive Integrated C-L Psychiatry [PICLP]).

METHODS

We conducted an interview-based qualitative study with thematic analysis. The participants were patients and staff who had experienced PICLP during The HOME Study, a randomized trial that evaluated PICLP in 24 medical units of three UK general hospitals.

RESULTS

We conducted 97 interviews: 43 with patients or their proxies (family members who were interviewed on behalf of patients with significant cognitive impairment) and 54 with staff members of all relevant disciplines. Patients and staff both described how PICLP was a helpful addition to medical care and discharge planning. It enhanced the medical unit team's ability to address psychological, psychiatric, and social needs and provide patient-centered care. They welcomed proactive biopsychosocial assessments and the broader perspective that these offered on patients' complex problems. They also valued the integration of C-L psychiatrists into the unit teams and their daily contact with them. For patients, it fostered a therapeutic relationship and helped them to be more engaged in decisions about their medical care and discharge planning. For staff, it enabled ready access to psychiatric expertise and training opportunities. The few reported experiences of PICLP being unhelpful were mainly about the greater number of clinicians involved in patients' care and a lack of clarity about professional roles in the integrated team.

CONCLUSIONS

We found that older inpatients and medical unit staff experienced PICLP as both acceptable and generally helpful. Our findings add to the existing evidence for the benefits of proactive and integrated C-L psychiatry services.

Influence of policymakers and civil society stakeholders on sewage sludge management strategies: Empirical results from European utilities

Sewage sludge management is crucial for water utilities to move towards a circular valorisation of resources. The current literature focuses mainly on the technological aspects of sludge management strategies. However, the current discussion of these strategies does not consider possible pressures arising from the utilities' civil society stakeholders and from policymakers. To fill this gap, this paper develops a conceptual framework, based on the current literature, that identifies the utility's key decisions on sludge management strategies (valorisation route, overperformance and vertical integration), and links them to possible pressures arising from civil society and existing regulations. Subsequently, the study validates the framework through a multiple explanatory case study, investigating the empirical relevance of such pressures in six water utilities across Europe. The influence of citizens and municipalities is found to be crucial in the choice of sludge valorisation routes. Economic instruments, command and control instruments and, new to the literature, regulatory uncertainty are found to be key policy features influencing utilities' decisions on sludge management. The paper provides a first-of-its-kind investigation that highlights the mechanisms through which policymakers and civil society stakeholders shape utilities' sewage sludge management strategies. The results complement and extend existing theoretical knowledge on the role of institutional pressures in the implementation of sustainable environmental systems.

Navigating athlete mental health: Perspectives from performance directors within elite sport

Performance directors lead high-performance programmes within elite sport and where they opt to invest resources has implications for athletes. This study explores performance directors' perspectives on mental health and illness and their experiences of managing these within elite sport. We conducted semi-structured interviews with 11 performance directors, resulting in 18 h of data. Interviews were transcribed verbatim and analysed using reflexive thematic analysis. We constructed three themes: 1) making sense of mental health: legitimacy vs. scepticism; 2) mental health as athlete responsibility; and 3) simplifying and sanitising mental health. Performance directors used physical health analogies to make sense of mental health, sometimes describing unrealistic expectations regarding mental health management. They also positioned athletes as responsible for finding solutions to their mental health concerns, at times overlooking the impact of the elite sport environment. Some performance directors shared over-simplified perceptions of mental health, often focusing on 'the positive' and neglecting to talk about the more challenging aspects of mental health and illness. Educating performance directors, as well as others in leadership positions, on the complexities of mental health and illness is recommended. This should include how mental illness differs from physical illness and injury, how to respond when athletes disclose mental health concerns, and how mental illness recovery is often nonlinear and subjectively defined.

The influence of a digital clinical reasoning test on medical student learning behavior during clinical clerkships

Recently, a new digital clinical reasoning test (DCRT) was developed to evaluate students' clinical-reasoning skills. Although an assessment tool may be soundly constructed, it may still prove inadequate in practice by failing to function as intended. Therefore, more insight is needed into the effects of the DCRT in practice. Individual semi-structured interviews and template analysis were used to collect and process qualitative data. The template, based on the interview guide, contained six themes: (1) DCRT itself, (2) test debriefing, (3) reflection, (4) practice/workplace, (5) DCRT versus practice and (6) 'other'. Thirteen students were interviewed. The DCRT encourages students to engage more in formal education, self-study and workplace learning during their clerkships, particularly for those who received insufficient results. Although the faculty emphasizes the different purposes of the DCRT (assessment of/as/for learning), most students perceive the DCRT as an assessment of learning. This affects their motivation and the role they assign to it in their learning process. Although students appreciate the debriefing and reflection report for improvement, they struggle to fill the identified knowledge gaps due to the timing of receiving their results. Some students are supported by the DCRT in exhibiting lifelong learning behavior. This study has identified several ways in which the DCRT influences students' learning practices in a way that can benefit their clinical-reasoning skills. Additionally, it stresses the importance of ensuring the alignment of theoretical principles with real-world practice, both in the development and utilization of assessment tools and their content. Further research is needed to investigate the long-term impact of the DCRT on young physicians' working practice.