"I Feel Like I Have Lost Part Of My Identity" - A Qualitative Study Exploring The Impact Of Chronic Ankle Instability

Introduction

Lateral ankle sprain is the most common ankle injury and up to 40% of those who sustain a lateral ankle sprain will develop chronic ankle instability (CAI). The aim of this study was to explore the thoughts and expectations of CAI-patients concerning their condition and expectations of care in an orthopedic setting. .

Study Design

Qualitative study.

Methods

Nine semi-structured one-to-one interviews were conducted with CAI-patients who were referred to an orthopedic setting. Interviews were recorded, transcribed, and analyzed using systematic text condensation with an inductive goal free approach. .

Results

Seven themes emerged. The themes were Injury history and symptoms (Lateral ankle sprain during sport, pain and instability), Information from health professional (conflicting information about management and prognosis), Management (mental and physical challenges), Expectation and hope (explanation of symptoms, prognosis and imaging to provide clarification of condition), Activity and participation (restriction in sport and daily life and feelings of uncertainty), Support (support from family/friends) and Identity (low ability to participate in sport and social life result in loss of identity). .

Conclusion

The impact of CAI exceeds an experience of pain and instability. Patients experienced loss of identity, having to manage uncertainty regarding their diagnosis and prognosis and had hopes of being able to explain their condition. .

Level of Evidence

Not applicable.

Action plans in telephone-based self-management support among patients at risk of hospitalization - A process evaluation of the Danish RCT Proactive Health Support (PaHS)

OBJECTIVE

Self-management support (SMS) aims to improve management of chronic diseases. While SMS core components are frequently documented, person-centered action plans and goal achievement is unknown. The aim of this study was to explore predictors of goal achievement in action plans during the Proactive Health Support study (PaHS).

METHOD

PaHS is a Danish randomized controlled trial of telephone-based SMS for patients at risk of hospitalization. The present study includes the trial intervention group with completed action plans as part of the trial process evaluation. The association between baseline characteristics of action plans and subsequent goal achievement were analyzed with logistic regression.

RESULTS

In this study, 1400 participants with a total of 2363 action plans were included. The results show higher goal achievement when the patients' goals were related to management of disease and treatment compared to health behavior. Furthermore, a stronger feeling of empowerment was associated with subsequent goal achievement.

CONCLUSION

Goal achievement in PaHS was generally high. The probability of goal achievement was highest with goals related to disease management, everyday-life management, and treatment. Higher baseline empowerment was associated with increased goal achievement.

PRACTICE IMPLICATIONS

SMS should focus on treatment management and patients with lower levels of active engagement and motivation.

Why do patients want medication free treatment for psychosis? An explorative study on reasons for applying to medication free programs

BACKGROUND

A focus on patient's and service user's perspectives regarding long-term antipsychotic treatment led to a declaration from the Norwegian Ministry of Health in 2015 to offer treatment without psychotropic medication in mental health as a voluntary option in all four health care regions. In the northernmost region, a 6-bed inpatient ward unit was established, uniquely designed to give people with severe mental illness the possibility to choose such treatment. Only voluntary admissions were accepted. The aim of the present study was to explore the motivation for applying for medication free treatment among patients with several years of treatment history due to psychosis.

METHOD

We performed nineteen semi-structured, in-depth interviews with persons having at least one admission at the medication free treatment ward during the period 01.01.17 - 17.10.2021. The interviews were recorded, transcribed and analysed using computer-assisted qualitative data analysis software (NVivo). Systematic Text Condensation was applied, with analysis of data from the first interview. Exploration of connections, similarities and nuances was performed through axial coding with continuous comparison of data and memo writing, followed by focused coding identifying core concepts.

RESULTS

All participants had a diagnosis of severe mental illness and a history of use of antipsychotics throughout many years. The motivation to apply for medication free treatment was complex. Negative experiences with medication were described, but also positive. Many had tried to taper off before, but described this as a lonely and difficult process. Five core concepts were formed and developed from the participants' narratives: 1) Medication experiences, 2) Developing illness, 3) Treatment in general, 4) Social life and 4) Growing up.

CONCLUSION

The concept of medication free treatment represents a salutogenetic hope for change, closely linked to self-efficacy and an experience of mastery. Potential conflicts concerning guidelines or evidence on medication does not come forward as important. Support from family and professionals is crucial, in contrast to the feeling of being alone when hoping for change. Motivational factors are closely linked to the concept of recovery, where interaction happens on both an individual and a structural level.

Developing and Evaluating a Data-Driven and Systems Approach to Health Promotion Among Vocational Students: Protocol for the Data Health Study

BACKGROUND

Vocational school students exhibit significant risk behaviors in terms of poor diet, frequent use of nicotine products, inadequate fruit and vegetable intake, low levels of physical activity, and poor mental health. This makes vocational students vulnerable to the development of noncommunicable diseases. Therefore, effective health promotion programs targeting vocational students are required.

OBJECTIVE

The Danish study "Data-driven and Systems Approach to Health Promotion Among Vocational Students" (Data Health) aims to develop, implement, and evaluate a systems approach to support vocational schools, municipalities, and local communities in implementing locally relevant health promotion actions among and for vocational students. This paper describes the Data Health program and how implementation and preliminary effectiveness will be evaluated.

METHODS

The Data Health program offers an iterative 5-step process to develop changes in the systems that shape health behavior and well-being among vocational students. The program will be implemented and evaluated in 8 Danish vocational schools in 4 municipalities. The implementation of the process and actions will be explored using a systems-based evaluation design that assesses contextual differences and the mechanisms through which the program leads to changes in the systems. Preliminary effectiveness at the individual level (students' self-reported health behavior and well-being) and organizational level (school organizational readiness reported by school staff) will be assessed using a quasi-experimental design, and cross-sectional data will be collected at all 8 schools simultaneously 4 times during the 2-year study period.

RESULTS

This study was launched in 2021, and data collection is expected to be completed in June 2024. The first results are expected to be submitted for publication in January 2024.

CONCLUSIONS

We expect that the Data Health study will make significant contributions to complex intervention research by contributing to the paucity of research studies that have used systems approaches in school settings. The study will also provide evidence of successful elements for systems change and effectiveness to determine whether a national scale-up can be recommended.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05308459; https://clinicaltrials.gov/study/NCT05308459.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52571.

Challenges to cross-sectoral care experienced by professionals working with patients living with low back pain: a qualitative interview study

BACKGROUND

While interdisciplinary, cross-sectoral collaboration promotes the effectiveness of rehabilitation programmes for persons with low back pain, challenges remain for this process. Few studies have explored challenges to cross-sectoral care as experienced by all the involved professionals across sectors during a course of treatment. The aim of this study was to explore challenges to cross-sectoral care as experienced by professionals involved in the course of treatment for patients with low back pain.

METHOD

This semi-structured, qualitative interview study included 28 health care professionals and 8 social workers who interacted with patients with low back pain. A systematic text condensation method was used to analyse data. Nvivo was used to structure and thematise the interview data.

RESULTS

Professionals expressed challenges in relation to a lack of collaboration, knowledge sharing and acknowledgement of one other and they appeared to differ in their approach to patients with pain or patients with limited function. Additional challenges included time constraints, availability and subjective approaches to managing guidelines for low back pain. A lack of a common information technology (IT) registration system and limited knowledge of the work of other professions disrupted knowledge sharing among sectors.

DISCUSSION

The different approach to patients with pain or patients with limited function challenged mutual understanding and collaboration among professionals. The lack of mutual understanding and knowledge of each other's work appeared to create an environment of disrespect and distrust among professionals that generated feelings of a lack of acknowledgement from other health care professionals.

CONCLUSION

To provide cross-sectoral care, we must ensure that professionals work together towards transparent and informed transitions from one sector to the next. This study contributes to the existing literature by presenting challenges to cross-sectoral care that are experienced by the diverse groups of professionals involved in a course of treatment for patients with low back pain.

Experiences and challenges to cross-sectoral care reported by patients with low back pain. A qualitative interview study

Background

Cross-sectoral care comprises interdisciplinary and coordinated efforts for patients with complex care needs involving various competencies and professions across the primary health care sector, hospital sector, and municipal services. Cross-sectoral care can increase the effectiveness of rehabilitation programmes, but the treatment courses often lack coherence. Establishing successful treatment pathways requires a better understanding of the health care challenges faced by patients with low back pain. The aim of this study was to explore how patients with low back pain experience cross-sectoral care.

Method

A qualitative interview study including 25 patients with low back pain. Patients were recruited in connection with their appointment at the Spine Centre of Southern Denmark. Recruitment stopped when the interviews no longer added new knowledge to the subject. The data were analysed using a systematic text condensation approach.

Results

Patients with low back pain experienced cross-sectoral care to be fragmented, with episodes lacking collaboration, information, and acknowledgement of their problem. They desired recognition of having a serious back problem and of being more than the diagnosis itself. Patients found it hard to keep track of their course of treatment due to a perceived lack of organisational support and collaboration between professionals. The patients called for more information about the treatment plan and the reasons for further referral in order to better understand and manage their treatment.

Conclusion

Patients’ experiences indicate a need for a stronger person-centred approach in cross-sectoral care, in which the individual’s experiences of living with low back pain are taken into account.

Emergency medical technicians' experiences with unplanned births outside institutions: A qualitative interview study

AIM

To explore emergency medical technicians' experiences with unplanned births outside institutions.

DESIGN

A qualitative interview study.

METHODS

Individual semi-structured interviews with 12 emergency medical technicians in Norway. Systematic text condensation was used to analyse the data material.

RESULTS

Analysis showed that there is a mismatch between society's expectations about emergency medical technicians and the reality they encounter in out-of-hospital maternity care, that emergency medical technicians experience a general lack of training in caring for labouring women and that poor communication with other health professions challenges patient safety. The participants expressed how they do their best in caring for both mother and child, in spite of a lack of education, training and competence in assisting labouring women.

From child to grown up in a medical world: developing an adolescent transition programme at a Norwegian University hospital

Background Akershus University Hospital has since 2012 worked systematically towards improving the process of transfer for adolescents from the Department for Paediatric and Adolescent Medicine (DPAM) to adult services in our hospital. Objective To improve the transfer process of adolescents we aimed at moving from a more administrative focus on transfers to a transition programme. The aim was both short-term and long-term gains, namely quality improvement of the healthcare we are providing and valued health promotion outcomes. Methods A guided transition programme for adolescents was developed, piloted and introduced. It was developed in close collaboration with our youth council. An e-learning programme and a handbook for health care professionals were developed for implementation. Results Data from the pilot testing the transition programme show that the adolescent participants found the information material to be relevant. They reported that it was used actively by the health professionals in their consultations and that they found this to be helpful. It was crucial that the management acknowledged and took responsibility for the programme. We experienced that a shared understanding of the adolescent patient in both sending and receiving departments was crucial. Conclusion Adolescent medicine should include competence and professionalism. Health care personnel must possess knowledge, skills and attitude that enable good, health promoting encounters. Further evaluation of pre- and post-implementation clinical outcomes, of patient empowerment and of satisfaction among employees will need to follow for evaluation of the effectiveness of this transition programme.

Completing a Questionnaire at Home Prior to Needs Assessment in General Practice: A Qualitative Study of Cancer Patients' Experience

BACKGROUND

Systematic assessments of cancer patients' rehabilitation needs are recommended, and questionnaires are considered to be useful tools when making such assessments.

OBJECTIVE

The aim of this study was to explore patients' experience of completing a questionnaire about their problems and distress at home prior to a needs assessment in general practice.

METHODS

Sixteen patients were recruited by their general practitioners (GPs). Semi-structured interviews were conducted in the home of the participants and at the general practice, with one interview taking place over the phone. Data were analyzed using systematic text condensation.

RESULTS

Twelve women and four men aged between 49 and 83 years of age, and diagnosed with various cancers between 1 month and 4 years ago, participated in the study. The results showed how the completion of a questionnaire at home provided patients with an opportunity to reflect on different problems, and the importance of these problems to the patient's everyday life, as well as an opportunity to articulate which problems they wanted to discuss with their GPs.

CONCLUSIONS

The results demonstrate that completing a questionnaire seems to stimulate patients' ability to reflect on their situation, clarify the importance of different problems to their everyday lives, and articulate these considerations to their GPs. Furthermore, we have shown that a questionnaire has the ability to interact with the patient and instigate a process of awareness. It is important to acknowledge this process of interaction between patient and questionnaire as an important part of understanding how and why questionnaires may support the patient when completing a questionnaire prior to a clinical encounter.

Factors impacting upon timely and adequate allocation of prehospital medical assistance and resources to cardiac arrest patients

AIM

Explore, understand and address issues that impact upon timely and adequate allocation of prehospital medical assistance and resources to out-of-hospital cardiac arrest (OHCA) patients.

METHODS

Mixed-methods design obtaining data for one year in three emergency medical communication centres (EMCC); Oslo-Akershus (OA), Vestfold-Telemark (VT) and Østfold (Ø). Data collection included quantitative data from analysis of dispatch logs, ambulance records and audio files. Qualitative data were collected through in-depth interviews and non-participant observations.

RESULTS

OA-, VT- and Ø-EMCC responded to 1095 OHCAs and 579 of these calls were included for further analysis (333, 143 and 103, respectively). There were significant site differences in their recognition of OHCA (89, 94 and 78%, respectively, p<0.001), provision of CPR instructions (83, 83 and 61%, respectively, p<0.001), time from call answered to initial CPR instructions (1.4min (1.2, 1.6), 1.1min (0,9, 1.2) and 1.3 (1.2, 1.7) respectively, p=0.002). The most frequent reason for delayed or failed recognition of OHCA was misinterpretation of agonal breathing. Interviews and observations revealed individual differences in protocol use, interrogation strategy and assessment of breathing. Use of protocol was only part of decision making, dispatchers trusted their own clinical experience and intuition, and used assumptions about the patient and the situation as part of decision making.

CONCLUSION

Agonal breathing continues to be the main barrier to recognition of cardiac arrest. Individual differences among dispatchers' strategies can directly impact on performance, mainly due to the wide definition of cardiac arrest and lack of uniform tools for assessment of breathing.

Challenges in home-based palliative care in Norway: a qualitative study of spouses' experiences

INTRODUCTION

Issues around patients' preferred place of care and death are taking greater precedence of late. However, little is known about patients' and carers' experiences of palliative care in the home setting. This study explored carers' views of what determines the quality of home care at the end of life.

METHODS

The study made use of systems theory, the purpose of which is to obtain a broad understanding of a phenomenon by looking at the relations between its individual elements. Seven carers (spouses) of people who died having received home-based palliative care in three different municipalities in Norway were interviewed.

RESULTS

None of the participants had planned to give or receive palliative care in the home. However, they did not regret that the home had been the place of care. Factors deemed important to acheiving the best possible home-based palliative care included around-the-clock help, holistic care, and affirmation of the significance of the carer's role.

CONCLUSION

Health professionals should be more forthcoming in discussing the benefits and challenges of home-based palliative care and make greater acknowledgment of the carer's role. Treatment plans may be helpful in acheiving these goals.

Sexual and reproductive health in Greenland: evaluation of implementing sexual peer-to-peer education in Greenland (the SexInuk project)

Background

For decades, the rates of sexually transmitted infections (STIs), such as gonorrhoea, chlamydia and syphilis, have increased in Greenland, especially within the young age groups (15–29 years). From 2006 to 2013, the number of abortions has been consistent with approximately 800–900 abortions per year in Greenland, which is nearly as high as the total number of births during the same period. Previous studies in Greenland have reported that knowledge about sexual health is important, both as prevention and as facilitator to stop the increasing rates of STIs. A peer-to-peer education programme about sexual health requires adaption to cultural values and acceptance among the population and government in order to be sustainable.

Objective

Formative evaluation of a voluntary project (SexInuk), in relation to peer-to-peer education with focus on sexual health. Two workshops were conducted in Nuuk, Greenland, to recruit Greenlandic students.

Design

Qualitative design with focus group interviews (FGIs) to collect qualitative feedback on feasibility and implementation of the project. Supplemented with a brief questionnaire regarding personal information (gender, age, education) and questions about the educational elements in the SexInuk project. Eight Greenlandic students, who had completed one or two workshops, were enrolled.

Results

The FGIs showed an overall consensus regarding the need for improving sexual health education in Greenland. The participants requested more voluntary educators, to secure sustainability. The articulation of taboo topics in the Greenlandic society appeared very important. The participants suggested more awareness by promoting the project.

Conclusion

Cultural values and language directions were important elements in the FGIs. To our knowledge, voluntary work regarding peer-to-peer education and sexual health has not been structurally evaluated in Greenland before. To achieve sustainability, the project needs educators and financial support. Further research is needed to investigate how peer-to-peer education can improve sexual and reproductive health in Greenland.

Nothing to complain about? Residents' and relatives' views on a "good life" and ethical challenges in nursing homes

Background:

Nursing home residents are a vulnerable population. Most of them suffer from multi-morbidity, while many have cognitive impairment or dementia and need care around the clock. Several ethical challenges in nursing homes have been described in the scientific literature. Most studies have used staff members as informants, some have focused on the relatives’ view, but substantial knowledge about the residents’ perspective is lacking.

Objective:

To study what nursing home residents and their relatives perceive as ethical challenges in Norwegian nursing homes.

Research design:

A qualitative design with in-depth interviews with nursing home residents, and focus-group interviews with relatives of nursing home residents. The digitally recorded interviews were transcribed verbatim. Analysis was based on Interpretive Description.

Participants and research context:

A total of 25 nursing home residents from nine nursing homes in Norway, and 18 relatives of nursing home residents from three of these nursing homes.

Ethical considerations:

This study was reported to and approved by the Regional Ethics Committee in Oslo, Norway.

Findings and discussion:

The main ethical challenges in Norwegian nursing homes from the residents’ and relatives’ perspective were as follows: (a) acceptance and adaptation, (b) well-being and a good life, (c) autonomy and self-determination, and (d) lack of resources. The relationship with the staff was of outmost importance and was experienced as both rewarding and problematic. None of the residents in our study mentioned ethical challenges connected to end-of-life care.

Conclusion:

Residents and relatives experience ethical challenges in Norwegian nursing homes, mostly connected to “everyday ethical issues.”

Educator challenges using participatory methods in group-based patient education

Purpose

– The purpose of this paper is to explore educators’ experiences of putting a participatory and patient-centered education model, “The Health Education Juggler,” into practice after having attended a one-day seminar. The model consists of four educator roles in participatory group-based patient education in chronic illness: embracer (takes care of the group), facilitator (generates dialogue and participation), translator (communicates professional knowledge) and initiator (motivates action in patients).

Design/methodology/approach

– Qualitative analysis of observations of eight group-based patient education sessions and seven in-depth semi-structured interviews with 11 educators.

Findings

– Educators find it difficult to include disease-specific knowledge when working with a flexible patient-centered approach. They tend to stay in the role they find most comfortable during education sessions (most often that of embracer), rather than adopting new and more challenging roles in the teaching process. Educators theoretically understand the role of facilitator, but they do not know how to perform in this role in practice. The ability to juggle all educator roles depends on the ability to master each.

Practical implications

– The Health Education Juggler model shows promise in promoting participation and patient-centeredness and as a reflection tool for educators and an analytic tool for quality assessment of patient education. These findings support further development of model use.

Originality/value

– This model of educator roles in group-based patient education in chronic illness provides a new approach to patient education. It indicates the need for various professional competencies among educators to provide patient-centered education in a flexible way, with a strong focus on patient-identified problems and challenges, social learning processes and generation of internal motivation in patients.

Triage in Norwegian emergency departments

BACKGROUND

An increasing number of patients and stricter requirements for quality and efficiency in the management of emergency patients have spurred several Norwegian emergency departments (EDs) to introduce triage as one of several measures. This introduction has taken place without any accompanying research. We therefore wanted to investigate the use and organisation of triage, as well as the use of triage scales in the emergency departments.

MATERIAL AND METHOD

In the spring of 2010, a cross-sectional survey was undertaken among EDs with the aid of a questionnaire and telephone interviews.

RESULTS

Altogether 45 of a total of 56 Norwegian emergency hospitals (80%) participated. All our respondents reported that emergency patients underwent assessment for level of urgency. 34 (76%) reported to use triage scales, and 17 (50%) of these used self-composed scales. 21 (68%) of a total of 31 EDs that had goals for triage reported to evaluate these goals. 14 and 15 EDs respectively reported to have designated triage personnel and triage area. 24 EDs required internal triage training for nurses and assistant nurses.

INTERPRETATION

Our study reveals varying practices for use and organisation of triage in Norwegian EDs. This may be an effect of the absence of guidelines from the health authorities and reflect the insufficient priority which is given to ED work.

To live as mentally disabled in the risk society

The contemporary society is to some extent characterized by longitudinal changes, towards individualization, uncertainty, and risk. Numerous risks and dangers in modern society have been mastered, while others have emerged, often created by human actions. The individual's freedom of choice has increased, but also the responsibility for the choices made. In this society, the risk society, there is a greater need for formative and situation-related knowledge to manage risks. The aims of this paper are to discuss the concept of risk society in the light of everyday experiences made by people with mental disabilities, how challenges can be mastered and positive possibilities can be utilized. Data collection was made through a multistage focus group, and the data were analysed by qualitative content analysis. The results show that characteristics of the risk society are identified by people with mental disabilities. Change and uncertainty, obstacles created by societal institutions, lack of trust, and the need of adapted working conditions are frequently experienced, impersonal relations and feelings of loneliness as well. However, these conditions can be partly counteracted by belonging to an alternative fellowship, which might lead to quality of life-related personal improvements.

Ethical issues in physiotherapy--reflected from the perspective of physiotherapists in private practice

BACKGROUND

An important aspect of physiotherapy professional autonomy is the ethical code of the profession, both collectively and for the individual member of the profession. The aim of this study is to explore and add additional insight into the nature and scope of ethical issues as they are understood and experienced by Danish physiotherapists in outpatient, private practice.

METHODS

A qualitative approach was chosen and semi-structured interviews with 21 physiotherapists were carried out twice and analyzed, using a phenomenological hermeneutic framework.

RESULTS

One main theme emerged: The ideal of being beneficent toward the patient. Here, the ethical issues uncovered in the interviews were embedded in three code-groups: 1) ethical issues related to equality; 2) feeling obligated to do one's best; and 3) transgression of boundaries.

CONCLUSIONS

In an ethical perspective, physiotherapy in private practice is on a trajectory toward increased professionalism. Physiotherapists in private practice have many reflections on ethics and these reflections are primarily based on individual common sense arguments and on deontological understandings. As physiotherapy by condition is characterized by asymmetrical power encounters where the parties are in close physical and emotional contact, practiced physiotherapy has many ethical issues embedded. Some physiotherapists meet these issues in a professional manner, but others meet them in unconscious or unprofessional ways. An explicit ethical consciousness among Danish physiotherapists in private practice seems to be needed. A debate of how to understand and respect the individual physiotherapist's moral versus the ethics of the profession needs to be addressed.

Negotiating the coresearcher mandate - service users' experiences of doing collaborative research on mental health

PURPOSE

Traditionally, the voices of service users have been silent in research into mental health issues. A Norwegian research network, however, recognizes the importance of involving service users as coresearchers and initiated a training program in research methodology and design intended to empower them as active participants in research projects. In this article, we explore how these coresearchers with a mental health service user background experience their participation in projects as well as in attending the training: What is it like being a service user coresearcher in collaborative studies on issues in mental health? How do coresearchers negotiate their roles and mandate?

METHOD

We used focus groups as our data collection method, transcribed the group discussions verbatim, and analyzed the transcriptions using qualitative methodology. We then took the preliminary analyses back to the participants for discussion, auditing, and reanalysis.

RESULTS

We identified themes that represent important social processes around which the participants developed a consensual understanding: self-definition, constructive differentiation and negotiations.

CONCLUSION

Our findings generate hypotheses on how participatory research into mental health issues can be fruitfully organized, in a way that empowers service users to active and constructive participation.

Exercise maintenance: COPD patients' perception and perspectives on elements of success in sustaining long-term exercise

Our goal was to elucidate how patients with COPD who successfully maintain a long-term exercise programme understand concordance with maintenance exercise and see potential solutions. The information, collected from 11 individuals through six in-depth interviews and one focus-group interview, was analysed by means of qualitative content analysis. Four themes were identified: (1) perception and acknowledgement of the disease; (2) the personal manner and empowering skills of the therapist; (3) perception of the exercise programme; and (4) left to myself-a pitfall in maintenance. Motivation to continue long-term exercise was related to how the patient is empowered to come to terms with the situation, the relational skills and expert competence of the physiotherapist, the patient's perceived mastery of the intensity of the exercise programme, and the physiotherapist's ability to individualize the exercise, peer support, and the availability and continuity of the programme. More attention should be paid to the link between PR programs and follow-up programmes. Crucial factors in this context are guidance of a municipal physiotherapist or instructor with extensive knowledge of exercise for patients with COPD, social interaction with peers in the exercise setting, enthusiasm, support, and ongoing communication between patients and practitioners across an entire continuum of care.

Preventing burnout among general practitioners: is there a possible route?

Stress and burnout among general practitioners (GPs) is a serious problem. Some authors suggest supervision groups or Balint groups as a means of preventing burnout and others address how to treat the condition. This paper reports a case study of a supervision group for Danish GPs which, as well as training reflective practice, focuses specifically on the prevention of burnout. The concept of compassion fatigue is extended to cover the circumstances reported by some practitioners in supervision.

Older adults' motivating factors and barriers to exercise to prevent falls

The aim of this study was to describe motivating factors and barriers for older adults to adhere to group exercise in the local community aiming to prevent falls, and thereby gain knowledge about how health professionals can stimulate adherence. The motivation equation was used as a theoretical framework. Data were collected from individual semi-structured interviews (n = 10). The interviews were taped, transcribed, and thereafter analysed by using a descriptive content analysis consisting of four steps. The results showed that motivating factors to adhere to recommended exercise were perceived prospects of staying independent, maintaining current health status, and improving physical balance and the ability to walk. Barriers were reduced health status, lack of motivation, unpleasant experience during previous exercise group sessions, and environmental factors. All participants wanted information from health professionals on the benefit of exercise. Many considered individual variations in functional skills within each group as a disadvantage. The knowledge gained from this study suggests a greater involvement from all health professionals in motivating older adults to attend exercise groups. The results also suggest that physical therapists should be more aware of the importance of comparative levels of physical function when including participants in exercise groups.

"You may wade through them without seeing them": general practitioners and their young patients with mental health problems

OBJECTIVE

To gain insight into the management of children and adolescents with mental health problems by their GPs as the GPs describe it.

DESIGN

A qualitative analysis of data from focus group interviews with GPs.

SETTING

Western Coast of Norway.

SUBJECTS

A strategic sample of 19 GPs.

RESULTS

According to the informants psychosomatic and other internalizing disorders are the most frequent mental health problems in their practice. Their assessments were based on history taking, physical examination and acquired knowledge of development and prevalence of common health problems. Their interventions mostly consisted of parental counselling. Their assessments and interventions to a lesser extent relied on specific knowledge in child and adolescent psychiatry.

CONCLUSION

The interested GP is in a good position to provide services to these patients. They have the parents' trust, insight into family and local community, and essential general medical knowledge about management of mental health problems in this age group. There is need for mutual research and educational programmes between GPs and child and adolescent psychiatry to explore the interface between the fields.

New rules meet established sickness certification practice: a focus-group study on the introduction of functional assessments in Norwegian primary care

OBJECTIVE

To explore how general practitioners view and handle new standards for functional assessments in sickness certification practice.

DESIGN

Qualitative study using focus group interviews. Data were analysed according to Giorgi's phenomenological approach and supported by theories on knowledge.

SETTING

General practitioners from three neighbouring counties in Norway.

SUBJECTS

Four focus groups with a total of 23 participants were recruited through the Norwegian Medical Association and its Continuous Medical Education system.

RESULTS

The participants reported difficulties and reluctance to act in accordance with new functional assessment demands on both a practical and a conceptual level. In established sickness certification practice functional assessment was described as an unspoken part of the medical examination. After the introduction of formal, written functional assessments they identified problems of terminology, communication, and trust. Strategies were developed to circumvent these problems.

CONCLUSIONS

A gap was noticeable between the participants' established practice and the new standards' demand for a more theoretical and communicative functional assessment. The general lack of training, being confronted with new terminology, and increasingly high pressure to reduce sickness absences create an atmosphere of insecurity when assessing function.