Implementation of a New Integrated Healthcare Model; Quality Aspects to Support the Complex Home Care of Older Adults with Multiple Needs.

Aim: This study aims to describe experiences of the implementation of a new integrated healthcare model for older adults with complex care needs due to multimorbidity, living at home, from a health and welfare personnel perspective. The goal was to diminish hospitalization and still carry out high quality care at home for older adults living with multimorbidity. The model was implemented by two organizations working in cooperation, the municipality, and the region that handles interprofessional social care and healthcare in people's homes. Materials and Method: Open-ended group interviews with personnel were carried out, three of the group interviews pre-implementations of the model, and three of the group interviews post-implementation. The interviews were audiotaped and analysed according to the procedure of thematic analysis. Results: The quality of the integrated care model was based on care-chain cooperation, shared professionalism, and creating relations with the patient including closeness to next of kin, which was underlined by the participants. Unencumbered time gave the professionals the possibility to develop quality in integrated healthcare as part of integrated and person-centred care. The coproduction of education, research interviews and the follow-up meeting identified successes in diminishing hospitalization rates according to the participants' experiences of the post-implementation interviews. An identified failure was, however, that shared professionalism was not developed over time, rather the different responsibilities were accentuated according to the information retrieved at the follow-up meeting. Conclusion: Quality aspects of the model were identified in the present study. However, when implementation of a new model is completed, the organizations always have their own interpretation of how to further understand the model in question.

The intention of the present study was to follow the process of working with a new model of providing care at home, thus preventing increased numbers of hospital readmissions, based on the professionals´ point of view of what quality care is for older adults with complex care needs due to multimorbidity, living in their own home. The professionals were interviewed in group settings on several occasions during the implementation. The result showed hopeful expectations expressed by the professionals before the new model was implemented, such as a hope for getting more time for high-quality care for the older adults with multimorbidity. During the teamwork, the conversation within the team members was praised as a key factor that included shared professionalism from professionals with different levels of education and focus on their work. According to the staff, unnecessary hospital stays were reduced, while the interprofessional care-chain cooperation was improved through the work of the integrated care team. For many team members, the positive difference in both work and care satisfaction was highlighted in comparison to regular home care as they were able to use their multi-disciplinary skills and support.

Illuminating health aspects for immigrant Thai women in Swedish transnational marriages.

BACKGROUND: Women who are migrants experience discrimination and face major risks, including sexual exploitation, trafficking, and violence, which affect their health and well-being. This study explored critical health incidents experienced by immigrant Thai women in marriage migration. METHODS: A qualitative explorative approach with in-depth interviews was used. Forty immigrant Thai women who currently or previously had a Swedish spouse were recruited for the study. An inductive critical incident technique was used to collect and analyze the data as the first step. In a second deductive step, the Newman system model was used to categorize health dilemmas. RESULTS: The women reported 438 critical health incidents in five main areas. Psychological health dilemmas included emotional abuse, feeling overwhelmed due to family responsibilities and the stress of leaving family behind. Sociocultural health dilemmas included transnational family duties or not performing family duties. Physiological health dilemmas included experiencing physical violence and environmental, domestic or work accidents. Developmental health dilemmas included failing health, difficulties upholding the duties expected of a spouse in the target culture and caring for an elderly husband. Spiritual health dilemmas included critical incidents in which the women perceived themselves to have failed in their hopes and duties as a wife, which intensified their dependence on faith, particularly the Buddhist concept of karma. CONCLUSION: Professionals in health and welfare practices in Thailand together with professionals in Western countries who work with women in marriage migration situations need to recognize the psychological, sociocultural, physiological, developmental, and spiritual health dilemmas experienced by these women. Furthermore, civil organizations that meet Thai women in foreign countries, such as Buddhist cultural associations, would benefit from the multicultural knowledge revealed by the present study. This knowledge can facilitate healthcare and welfare support for women in marriage migration situations.

The need for acute assessments in home healthcare - Swedish registered nurses' experiences.

PURPOSE: The study aims to describe Swedish RNs' experiences of acute assessments at home. More patients with complex nursing needs are cared for at home due to an ageing population. Registered nurses (RNs) who work with home healthcare need a broad medical competence and clinical experience alongside adapted decision support systems for maintaining patient safety in acute assessments within home healthcare. METHODS: A content analysis of qualitative survey data from RNs (n = 19) working within home healthcare in Sweden. RESULTS: There were challenges in the acute assessments at home due to a lack of competence since several of the RNs did not have much experience working as an RN in home healthcare. Important information was missing about the patients, such as access to medical records due to organizational challenges and limited access to equipment and materials. The RNs needed support in the form of cooperation with a physician, support from colleagues, and a decision support system. CONCLUSION: To increase the possibility of patient-safe assessments at home, skills development, collegial support, and an adapted decision support system are needed. Collaboration with primary healthcare, on-call physicians, and nursing staff, and having the opportunity to consult with someone also provide security in acute assessments.

Healthcare and social care professionals' experiences of respite care: a critical incident study.

INTRODUCTION: Aging in place is favoured among older persons and supported by research in Sweden, although it poses challenges for overburdened informal caregivers. While respite care can offer support, its accessibility is hindered by organizational challenges and informal caregivers' delays in using it. The experiences of informal caregivers are well-studied, but the professionals' experiences of respite care quality and critical incident management are underexplored. AIM: To explore professionals' experiences of critical incidents in respite care, consequences for the persons being cared for, and strategies to manage critical incidents. MATERIALS AND METHODS: A qualitative, critical incident technique was used, and three group interviews with a total of 16 professionals were conducted. RESULTS: Barriers to quality respite care included communication gaps during care transitions, environmental shortcomings in respite care facilities, lack of support for informal caregivers, and inadequacies in respite care decisions. Strategies to manage critical incidents included individualized care, continuity and communication in care transitions, a conducive environment, support for informal caregivers, and care professionals' positive approach. CONCLUSIONS: The study emphasizes the need for focused efforts on communication, continuity, and a supportive environment. Addressing identified challenges and applying suggested strategies will be key to maximizing the potential of respite care as a vital support for care recipients and their informal caregivers.

Effectiveness of integrated person-centered interventions for older people's care: Review of Swedish experiences and experts' perspective.

Older adults have multiple medical and social care needs, requiring a shift toward an integrated person-centered model of care. Our objective was to describe and summarize Swedish experiences of integrated person-centered care by reviewing studies published between 2000 and 2023, and to identify the main challenges and scientific gaps through expert discussions. Seventy-three publications were identified by searching MEDLINE and contacting experts. Interventions were categorized using two World Health Organization frameworks: (1) Integrated Care for Older People (ICOPE), and (2) Integrated People-Centered Health Services (IPCHS). The included 73 publications were derived from 31 unique and heterogeneous interventions pertaining mainly to the micro- and meso-levels. Among publications measuring mortality, 15% were effective. Subjective health outcomes showed improvement in 24% of publications, morbidity outcomes in 42%, disability outcomes in 48%, and service utilization outcomes in 58%. Workshop discussions in Stockholm (Sweden), March 2023, were recorded, transcribed, and summarized. Experts emphasized: (1) lack of rigorous evaluation methods, (2) need for participatory designs, (3) scarcity of macro-level interventions, and (4) importance of transitioning from person- to people-centered integrated care. These challenges could explain the unexpected weak beneficial effects of the interventions on health outcomes, whereas service utilization outcomes were more positively impacted. Finally, we derived a list of recommendations, including the need to engage care organizations in interventions from their inception and to leverage researchers' scientific expertise. Although this review provides a comprehensive snapshot of interventions in the context of Sweden, the findings offer transferable perspectives on the real-world challenges encountered in this field.

Dilemmas in rehabilitation and patient strategies in an intensive home intervention: a follow-up study.

BACKGROUND: The original project, where older persons received reablement performed by an interprofessional team showed success factors for IHR. However, since there is a lack of knowledge about why some persons do not recover despite receiving IHR, this study follows up patients' experiences of IHR. AIM: To describe older persons' perceived dilemmas in the reablement process within the framework of IHR. METHOD: 11 CIT interviews with participants who have previously received IHR, were analysed, interpreted and categorized according to CIT. The study was approved by the Swedish Ethical Review Authority. RESULTS: The results showed disease-related dilemmas, fatigue or pain so that participants could not cope with the prescribed exercises. New diseases appeared, as well as medication side effects made exercising difficult, and painkillers became a prerequisite for coping with IHR. Low self-motivation and mistrust towards the staff emerged like lack of trust due to otherness such as sex, cultural background, or language also became critical. CONCLUSIONS: Interventions that consider individual- and contextual dilemmas are very important. By recognizing critical situations, this study can work as a basis of evidence to further develop interventions for older people living in their own homes and to ensure them to stay there.

Culturally sensitive active ageing seen through the lens of the welfare theory of health: assistant nurses' views.

Assistant nurses caring for older adults with immigrant backgrounds are on the front lines of a practical, theoretical, and policy battlefield. They need to implement culturally sensitive care provision while not overstating the importance of culture, thereby, contributing to a negative picture of older immigrants as especially problematic. One proposed way to strike such a balance is the welfare theory of health (WTH). In this article, we let assistant nurses apply the WTH to a series of questions in four different vignettes representing the life stories of older persons who characterize typical dilemmas described by the theory. The results show that, through the lens of the WTH, assistant nurses looked for individual care preferences rather than stereotypical ideas about cultural characteristics. Further, the assistant nurses expressed a desire to get to know the persons more deeply to better interpret and understand their individual preferences. Thus, the theoretical framework is useful not only for exposing vulnerabilities to which some older adults with immigrant backgrounds may be exposed, but also for finding ways to mitigate the vulnerability by illuminating vital life goals and using them as a framework to organize care. This approach allows for mitigating the gap between the vital life goals and available resources to achieve a holistic state of health.

"Intensive-Home-Rehabilitation" Intervention for Older Persons: A Follow-Up Study of Team Members' Perceptions.

Background: Reablement as a concept includes a health-promoting perspective with the goal of strengthening health and the ability to perform and participate in daily activities, a broader perspective than in general home care and rehabilitation. Reablement interventions have shown to be both more effective and to a greater extent improve the function and health-related quality of life of older persons when compared to traditional home-based care. Success factors for intensive-home-rehabilitation (IHR), an intervention based on the reablement concept, have been described earlier; however, there is a lack of knowledge about why some persons do not recover despite receiving IHR. Aim: The aim was to shed light on the older persons' conditions during IHR from the perspective of the rehabilitation team members and to describe obstacles to recovery. Methods: Qualitative analysis of health and care records of persons (65+) who received IHR (n=19) performed by an interprofessional team. Results: The analysis revealed various problematic situations, dilemmas, that occurred in the older persons' lives during IHR, as well as their consequences and the strategies employed by the older persons as a result. IHR aspects perceived as successful by the older persons also emerged, as well as differences in experiences of the physical and mental aspects of the IHR. Analysis also revealed reasons why the IHR might be experienced as broadly successful. Conclusion: The older persons seemed to be satisfied with IHR and achieved their goals; however, some seemed to need more time to reach their goals. Background factors such as having additional diagnoses and living alone might affect the rehabilitation process. Implication for Practice: The study provides knowledge regarding the importance of IHR for the recovery process for the increasing numbers of older persons, which might also be useful in other patient groups requiring otherwise long-term rehabilitation and recovery such as after covid-19 infection.

Psychometric evaluation of the subjective well-being measure GP-CORE in a group of older adults in Sweden.

BACKGROUND: The world's growing population of older adults is one population that needs to be focused more regarding subjective well-being. It is therefore important to evaluate self-report instruments that measures general well-being for this specific group - older adults. The aim of the present study was to investigate psychometric properties of the Swedish translation of the GP-CORE (general population - Clinical Outcomes in Routine Evaluation) in a group of older adults (> 65 years). METHODS: In this study, a psychometric evaluation of the GP-CORE is presented for 247 Swedish older adults (> 65 years), 184 women and 63 men who applied for home care assistance for the first time. RESULTS: The psychometric evaluation showed high acceptability; provided norm values in terms of means, standard deviations and quartiles; showed satisfactory reliability in terms of both internal consistency and stability; showed satisfactory validity in terms of convergent and discriminant validity; provided a very preliminary cut-off value and quite low sensibility and sensitivity and showed results which indicated that this scale is sensitive to changes. One gender difference was identified in that women without a cohabitant had a higher well-being than men without a cohabitant (as measured by GP-CORE). CONCLUSIONS: The GP-CORE showed satisfactory psychometric properties to be used to measure and monitor subjective well-being in older adults (> 65 years) in the general population of community dwelling. Future studies should establish a cut-off value in relation to another well-being measure relevant for mental health in older adults.

Actions taken to safeguard the intended health care chain of older people with multiple diagnoses - a critical incident study.

BACKGROUND: Older people with multiple diagnoses often have problems coping with their daily lives at home because of lack of coordination between various parts of the healthcare chain during the transit from hospital care to the home. To provide good care to those persons who have the most complex needs, regions and municipalities must work together. It is of importance to develop further empirical knowledge in relation to older persons with multiple diagnoses to illuminate possible obstacles to person-centred care during the transition between healthcare institutions and the persons livelihood. The aim of the present study was to describe nurses' experienced critical incidents in different parts of the intended healthcare chain of older people with multiple diagnoses. METHODS: The sample consisted of 18 RNs in different parts of the healthcare system involved in the care of older people with multiple diagnoses. Data were collected by semi structured interviews and analysed according to Critical Incident Technique (CIT). A total of 169 critical incidents were identified describing experiences in recently experienced situations. RESULTS: The result showed that organizational restrictions in providing care and limitations in collaboration were the main areas of experienced critical incidents. Actions took place due to the lack of preventive actions for care, difficulties in upholding patients' legal rights to participation in care, deficiencies in cooperation between organizations as well as ambiguous responsibilities and roles. The RNs experienced critical incidents that required moral actions to ensure continued person-centred nursing and provide evidence-based care. Both types of critical incidents required sole responsibility from the nurse. The RNs acted due to ethics, 'walking the extra mile', searching for person-centred information, and finding out own knowledge barriers. CONCLUSIONS: In conclusion and based on this critical incident study, home-based healthcare of older people with multiple diagnoses requires a nurse that is prepared to take personal and moral responsibility to ensure person-centred home-based healthcare. Furthermore, the development of in-between adjustments of organizations to secure cooperation, and transference of person-centred knowledge is needed.

Gaining reconciliation when living with insulin treated diabetes: a qualitative study using content analysis.

PURPOSE: The aim was to describe experiences of the reconciliation process when living with insulin treated diabetes. METHODS: The study has a qualitative descriptive design, based upon nineteen in- depth interviews with persons diagnosed with insulin treated diabetes, analysed using qualitative content analysis. RESULTS: The study show the reconciliation process during different time periods that appeared as domains in the interviews. The time at diagnosis showed experiences of striving for control getting insights and knowledge. It meant striving for control of life circumstance changes, supported by professionals but also from others. In Presence showed developing strategies as a tool struggling for balance in body and life and the need of evaluating relations to others. Future was sometimes avoided as this might lead to speculations about a future life with threats and uncertainty about disease complications, as well as adaption. This meant on the same time an uncertainty, as a degree of risk-taking and hope for the best. CONCLUSIONS: Persons with insulin treated diabetes need to develop flexible strategies for daily life to continuously re-evaluate their planning for attaining reconciliation. A conclusion is also that these persons need to develop a flexible regime that facilitates both quality of life and medical outcomes to reach reconciliation.

Informal caregiving from the perspectives of older people living alone in India.

BACKGROUND: The cultural and social norms in India stipulate that family and preferably children of the older person, provide the support and care that is needed. In recent years, we have witnessed an overall upsurge in interest in informal care from all countries in the developed world considering their ageing populations. The older people living alone group is, especially interesting in this matter, since it seems to deviate from the expectations of extended family living. OBJECTIVE: The aim was to describe older persons' experiences of informal care when living alone in India. METHODS: The study has a hermeneutic design, analysing interviews of older persons living alone in India. RESULTS: Findings revealed informal care as the thematic patterns: Informal care as a fundamental human responsibility, an obligation and thereby a way to act in 'common sense'. It was a way of 'paying-back' care that they had received from others in their life history, motivated by governmental care was not presented as an option. Informal care also created safety by the provision of alert and actionable care by loved ones, including spatial safety. Most of the informants experienced themselves as informal caregivers assisting others in need even if they themselves were old and fragile. Providing self care was also seen as a part of informal care conducted by capable and worthy persons. They also pointed out their own obligation to seek informal care and even to listen to the suggestions of younger generations regarding the type and scope of care. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Informal care in India is not only dependent on having children who ensure that you receive the care you need. Extended family, neighbours and friends feel a basic human obligation to care for the older people in their environment. This responsibility is deeply rooted even within the older people who become fragile in old age.

Balancing security and care: Gender relations of nursing staff in forensic psychiatric care.

This study departs from the built-in tension of the dual goals of forensic psychiatric care in Sweden, which are to protect society as well as to care for patients. The majority of violence that takes place is perpetrated by men. Therefore, the views of nursing staff on violence as a gendered phenomenon have an impact on the care provision. There is a need for further knowledge of how norms of violence are intertwined with the construction of gender. The aim of this study was to use a gender perspective to demonstrate the views of nursing staff on security and care and the consequences for their relationships with patients. The study adopts an ethnographic approach, with data consisting of field notes from participatory observations and interviews with nursing staff at two maximum-security clinics. We show how the perceptions of nursing staff about gender relations are based on heteronormative thinking, which affects their practice. This implies that if gender is ignored in relation to the dual goals, there is a risk of perpetrating patterns of unequal conditions. Therefore, it is vital to make gender visible to counteract unequal conditions for nursing staff and address patients' individual care needs.

Swedish experts' understanding of active aging from a culturally sensitive perspective - a Delphi study of organizational implementation thresholds and ways of development.

Background: International migration and aging populations make for important trends, challenging elderly care regimes in an increasingly globalized world. The situation calls for new ways of merging active aging strategy and cultural sensitivity. This study aim to illuminate the gap between cultural sensitivity and active aging to identify perceived thresholds by Swedish municipal officials in the understanding of older late-in-life-immigrants situation. Methods: Delphi methodology in three rounds. Twenty-three persons in municipal decision-making positions participated and generated 71 statements, of which 33 statements found consensus. Results: The 33 statements show that the decision makers prefer not to use cultural sensitivity as a concept in their work, but rather tailor interventions based on individual preferences that may or may not be present in a certain culture. However, as the complexity of care increases, emphasis drifts away from personal preferences toward text-book knowledge on cultures and activity.

What does FSC forest certification contribute to biodiversity conservation in relation to national legislation?

Forest certification has emerged as a voluntary, market-driven tool for sustainable forest management (SFM). Its legitimacy depends on its ability to achieve its objectives and to retain the support of stakeholders such as NGOs and the companies that adopt it. This study presents a novel approach for assessing the contributions of forest certification to biodiversity conservation, based on Forest Stewardship Council (FSC) certification in four northern European countries (Finland, Sweden, Estonia, Latvia). In each case, national FSC certification requirements related to specific biodiversity targets were compared with requirements in national legislation. Nearly 80% of the assessed certification requirements were more prescriptive than the national legislation. One-third of these requirements (3-8 per country) were assessed to have a positive contribution to biodiversity conservation, whereas four requirements (up to 2 per country) were assessed to have a low positive contribution. FSC requirements to protect Woodland Key Habitats were identified as having a positive contribution in all four countries, whereas requirements regarding live tree retention in harvests and preserving dead wood had a positive contribution in three countries each. Despite often prescribing similar measures, the other requirements with positive contributions varied between countries depending on the national legislative baseline. The remaining requirements could not be assessed through expert evaluation, indicating the need for additional empirical research to evaluate how the normative requirements translate to impacts in the field, and how the national context may affect their implementation. The approach is globally applicable, repeatable, and provides a basis for designing systematic empirical assessments of the certification impact.

Disturbance interval modulates the starting point for vegetation succession.

Increased frequency and new types of disturbances caused by global change calls for deepened insights into possible alterations of successional pathways. Despite current interest in disturbance interactions there is a striking lack of studies focusing on the implication of decreasing times between disturbances. We surveyed forest-floor vegetation (vascular plants and bryophytes) in a Pinus sylvestris-dominated, even-aged production forest landscape, unique because of the presence of stands under a precisely dated disturbance interval gradient, ranging from 0 to 123 yr between clearcutting and a subsequent megafire. Despite a dominance of early-successional species in all burned stands 5 yr after fire, progression of succession was linked to time since the preceding clearcutting disturbance. This was most clearly seen in increased frequency with time since clearcutting of the dominant, late-successional dwarf shrub Vaccinium myrtillus, with surviving rhizomes as an important mechanism for postfire recovery. Our results demonstrate the role of legacy species as significant drivers of succession. We conclude that the starting point for succession is modulated by disturbance interval, so that shortened intervals risk reducing development towards late-successional stages. We suggest that a decrease in long successional sequences caused by more frequent disturbances may represent a general pattern, relevant also for other forest types and ecosystems.

Experiences of surviving life-threatening illness: The meaning of recovery.

BACKGROUND: Recovery from life-threatening illness may be experienced as more demanding and lasts longer than patients first expect. Many patients experience recovery after life-threatening illness, as filled with complex problems. These problems are primarily physical and psychological, although also social, and adversely affect daily life as well as perceived quality of life. Patients experience uncertainty about living with the legacy of a life-threatening illness and how it negatively limits their daily lives and experienced health. AIM: The purpose is to illuminate experiences of the meaning of recovery from life-threatening disease. ETHICAL APPROVAL: Approval for the study was obtained through a Regional Research Ethics Committee. METHODS: This study was conducted as a qualitative narrative study. This means that written stories of human recovery beyond suffering from life-threatening disease were collected and analysed with a phenomenological hermeneutic method. RESULTS: The findings reveal two major areas - intrapersonal meanings and relational meanings. Four themes were found in these areas, each of which was divided into subthemes as follows: obstacles, for example disappointment of life, alienation of self and opportunities/resources: for example balance, own knowledge, hope and gratitude; relational obstacles, for example a lack of care, stigmatisation and economic stress; and relational resources such as informal care and professional care. STUDY LIMITATIONS: The informants were predominantly women that may be explained by the fact that females seem to be more often engaged in social media and willing to participate in these kinds of studies. Another limitation is that we only reached out to Swedish speaking Facebook groups when recruiting our informants. CONCLUSIONS: In the narratives of their recovery process, surprisingly few focused on professional health care as a resource. Experiences from the study may be used to further develop care, especially to support patient self-care regarding intrapersonal and relational resources that promote patient recovery beyond suffering from life-threatening disease.

Silence or Voice? Agency Freedom among Elderly Women Living in Extended Families in Urban India.

The preferential form of living for the elderly in India is within the extended family. India is undergoing rapid economic development, an increase in mobility, and changes in gender norms due to an increase in women's labour force participation, which places challenges on traditional intergenerational relationships. Ageing and the well-being of the elderly is a rising concern, especially considering that their proportion of the population is expected to grow rapidly in coming decades. There is a lack of universal state provision for the elderly's basic needs, which is especially profound for elderly women, since most do not have an independent income. This leaves the elderly dependent upon the benevolence of their adult children's families or other relatives. This paper explores, with help of narrative analysis and critical contributions from capability theory, elderly women's agency freedoms and how this can be contextualised with their varying capability sets. With help of Spivak's notion of the silent subaltern, the paper anchors elderly women's abilities to voice to their agency freedom. The master narrative of the silent supportive wife and side-lined mother-in-law as well as three counter-narratives explore alternative agencies taken by elderly women.

Keeping pace with forestry: Multi-scale conservation in a changing production forest matrix.

The multi-scale approach to conserving forest biodiversity has been used in Sweden since the 1980s, a period defined by increased reserve area and conservation actions within production forests. However, two thousand forest-associated species remain on Sweden's red-list, and Sweden's 2020 goals for sustainable forests are not being met. We argue that ongoing changes in the production forest matrix require more consideration, and that multi-scale conservation must be adapted to, and integrated with, production forest development. To make this case, we summarize trends in habitat provision by Sweden's protected and production forests, and the variety of ways silviculture can affect biodiversity. We discuss how different forestry trajectories affect the type and extent of conservation approaches needed to secure biodiversity, and suggest leverage points for aiding the adoption of diversified silviculture. Sweden's long-term experience with multi-scale conservation and intensive forestry provides insights for other countries trying to conserve species within production landscapes.

Retention as an integrated biodiversity conservation approach for continuous-cover forestry in Europe.

Retention forestry implies that biological legacies like dead and living trees are deliberately selected and retained beyond harvesting cycles to benefit biodiversity and ecosystem functioning. This model has been applied for several decades in even-aged, clearcutting (CC) systems but less so in uneven-aged, continuous-cover forestry (CCF). We provide an overview of retention in CCF in temperate regions of Europe, currently largely focused on habitat trees and dead wood. The relevance of current meta-analyses and many other studies on retention in CC is limited since they emphasize larger patches in open surroundings. Therefore, we reflect here on the ecological foundations and socio-economic frameworks of retention approaches in CCF, and highlight several areas with development potential for the future. Conclusions from this perspective paper, based on both research and current practice on several continents, although highlighting Europe, are also relevant to other temperate regions of the world using continuous-cover forest management approaches.