Implementation of the four habits model in intermediate care services in Norway: a process evaluation.

BACKGROUND: Intermediate care (IC) services bridge the transition for older patients from the hospital to the home. Despite the goal of involving individuals in their recovery process, these services often become standardised, leading to communication breakdowns. While evidence-based practices, such as the Four Habits Model (4HM), for effective communication are crucial for enhancing high-quality healthcare, research suggests their integration into routine practice remains limited. In this study, we aimed to investigate the implementation process of the 4HM through a two-day course that engaged healthcare professionals and managers in IC. METHODS: We conducted a process evaluation employing qualitative and quantitative methods: (i) individual interviews with three managers and two course participants pre-course, (ii) two focus group interviews with course participants (N = 11) and individual interviews with the same three managers post-course, and (iii) the NoMAD questionnaire (Normalisation MeAsure Development) administered four months later to assess the short- and long-term impact on course participants (N = 14). Reflexive thematic analyses were guided by Normalisation Process Theory (NPT), which offers insight into how new interventions become routine practices. The analysis of the NoMAD involved descriptive statistics. RESULTS: We identified four themes in the qualitative data: (i) Decoding Interactions: Making Sense of the 4HM in IC services, (ii) Fostering Change: Legitimising 4HM Through Staff Engagement, (iii) Harmonising Practice: Integrating 4HM into Complex Situations, and (iv) Embedding Value: Normalising the 4HM into Everyday Work. These themes illustrate the normalisation process of the 4HM course within IC, establishing standard practices. Healthcare professionals and managers highlighted the urgent need to integrate communication skills based on the 4HM into daily care. They noted positive changes in their communication habits following the course. The consistent findings from the NoMAD questionnaire underscore the sustainability of implementing the 4HM programme, as participants continue to utilise it in their clinical practice beyond the initial four-month period. CONCLUSION: The 4HM course programme was deemed feasible for expansion within IC services. Both managers and staff found its focus on addressing communication breakdowns and readiness for change sensible. The study findings may benefit the stakeholders involved in IC service routines, potentially improving services for older patients and relatives.

How Do Physicians Frame Medical Information in Talks With Their Patients? An Inductive Microanalysis.

During medical consultations, physicians need to share a substantial amount of information with their patients. How this information is framed can be crucial for patient understanding and outcomes, but little is known about the details of how physicians frame information in practice. Using an inductive microanalysis approach in the study of videotaped medical interactions, we aimed to identify the information frames (i.e., higher-level ways of organizing and structuring information to reach a particular purpose) and the information-framing devices (i.e., any dialogic mechanism used to present information in a particular way that shapes how the patient might perceive and interpret it) physicians use spontaneously and intuitively while sharing information with their patients. We identified 66 different information-framing devices acting within nine information frames conveying: (1) Do we agree that we share this knowledge?, (2) I don't like where I (or where you are) am going with this, (3) This may be tricky to understand, (4) You may need to think, (5) This is important, (6) This is not important, (7) This comes from me as a doctor, (8) This comes from me as a person, and (9) This is directed to you as a unique person. The kaleidoscope of information-framing devices described in this study reveals the near impossibility for neutrality and objectivity in the information-sharing practice of medical care. It also represents an inductively derived starting point for further research into aspects of physicians' information-sharing praxis.

First year junior doctors and medical uncertainty - a qualitative study. / LIS1-leger og medisinsk usikkerhet ­ en kvalitativ studie.

BACKGROUND: Few studies have investigated how doctors in Norway deal with medical uncertainty. The purpose of the study was to explore how first year junior doctors perceive and manage uncertainty in clinical practice. MATERIAL AND METHODS: Ten first year junior doctors at two hospitals in Norway were recruited for interviews following response pattern analysis from a mapping questionnaire. The interviews were analysed using systematic text condensation. RESULTS: The analysis revealed three main themes in the interviews: dealing with medical uncertainty, personal response to medical uncertainty, and working environment, feedback and preparation. Within all three thematic areas, the informants used the words 'certain/uncertain' and 'secure/insecure' interchangeably. INTEPRETATION: The first year junior doctors struggled with the inherent uncertainty of medicine and felt a marked sense of insecurity, particularly at the start of their training period. How the doctors were welcomed in the workplace and the feedback they were given were important factors. Their undergraduate medical education had not sufficiently prepared the first year junior doctors for how to deal with medical uncertainty in clinical practice.

Effects of Physicians' Information Giving on Patient Outcomes: a Systematic Review.

BACKGROUND: Providing diagnostic and treatment information to patients is a core clinical skill, but evidence for the effectiveness of different information-giving strategies is inconsistent. This systematic review aimed to investigate the reported effects of empirically tested communication strategies for providing information on patient-related outcomes: information recall and (health-related) behaviors. METHODS: The databases MEDLINE, Embase, PsycINFO (Ovid), Cochrane Central Register of Controlled Trials, and relevant bibliographies were systematically searched from the inception to April 24, 2020, without restrictions, for articles testing information-giving strategies for physicians (PROSPERO ID: CRD42019115791). Pairs of independent reviewers identified randomized controlled studies with a low risk of selection bias as from the Cochrane risk of bias 2 tool. Main outcomes were grouped into patient information recall and behavioral outcomes (e.g., alcohol consumption, weight loss, participation in screening). Due to high heterogeneity in the data on effects of interventions, these outcomes were descriptively reported, together with studies', interventions', and information-giving strategies' characteristics. PRISMA guidelines were followed. RESULTS: Seventeen of 9423 articles were included. Eight studies, reporting 10 interventions, assessed patient information recall: mostly conducted in experimental settings and testing a single information-giving strategy. Four of the ten interventions reported significant increase in recall. Nine studies assessed behavioral outcomes, mostly in real-life clinical settings and testing multiple information-giving strategies simultaneously. The heterogeneity in this group of studies was high. Eight of the nine interventions reported a significant positive effect on objectively and subjectively measured patients' behavioral outcomes. DISCUSSION: Using specific framing strategies for achieving specific communication goals when providing information to patients appears to have positive effects on information recall and patient health-related behaviors. The heterogeneity observed in this group of studies testifies the need for a more consistent methodological and conceptual agenda when testing medical information-giving strategies. TRIAL REGISTRATION: PROSPERO registration number: CRD42019115791.

"What should I do when I get home?" treatment plan discussion at discharge between specialist physicians and older in-patients: mixed method study.

BACKGROUND: During discharge from hospital, older patients and physicians discuss the plan for managing patients' health at home. If not followed at home, it can result in poor medication management, readmissions, or other adverse events. Comorbidities, polypharmacy and cognitive impairment may create challenges for older patients. We assessed discharge conversations between older in-patients and physicians for treatment plan activities and medication information, with emphasis on the role of cognitive function in the ongoing conversation. METHODS: We collected 11 videos of discharge consultations, medication lists, and self-reported demographic information from hospitalised patients ≥65 years at the Geriatric department in a general hospital. Mini Mental State Examination score < 25 was classified as low cognitive function. We used microanalysis of face-to-face dialogue to identify and characterise sequences of interaction focused on and distinguishing the treatment plan activities discussed. In addition to descriptive statistics, we used a paired-sample t-test and Mann-Whitney U test for non-parametric data. RESULTS: Patients' median age was 85 (range: 71-90);7 were females and 4 males. Median of 17 (range: 7 to 23) treatment plan activities were discussed. The proportions of the activities, grouped from a patient perspective, were: 0.40 my medications, 0.21 something the hospital will do for me, 0.18 someone I visit away from home, 0.12 daily routine and 0.09 someone coming to my home. Patients spoke less (mean 190.9 words, SD 133.9) during treatment plan activities compared to other topics (mean 759 words, SD 480.4), (p = .001). Patients used on average 9.2 (SD 3.1) medications; during the conversations, an average of 4.5 (SD 3.3) were discussed, and side effects discussed on average 1.2 (SD 2.1) times. During treatment plan discussions, patients with lower cognitive function were less responsive and spoke less (mean 116.5 words, SD 40.9), compared to patients with normal cognition (mean 233.4 words, SD 152.4), (p = .089). CONCLUSION: Physicians and geriatric patients discuss many activities during discharge conversations, mostly focusing on medication use without stating side effects. Cognitive function might play a role in how older patients respond. These results may be useful for an intervention to improve communication between physicians and older hospitalised patients.

Codebook for rating clinical communication skills based on the Calgary-Cambridge Guide.

BACKGROUND: The aim of the study was to confirm the validity and reliability of the Observation Scheme-12, a measurement tool for rating clinical communication skills. METHODS: The study is a sub-study of an intervention study using audio recordings to assess the outcome of communication skills training. This paper describes the methods used to validate the assessment tool Observation Scheme-12 by operationalizing the crude 5-point scale into specific elements described in a codebook. Reliability was tested by calculating the intraclass correlation coefficients for interrater and intrarater reliability. RESULTS: The validation of the Observation Scheme-12 produced a rating tool with 12 items. Each item has 0 to 5 described micro-skills. For each item, the codebook described the criteria for delivering a rating from 0 to 4 depending on how successful the different micro-skills (or number of used jargon words) was accomplished. Testing reliability for the overall score intraclass correlation coefficients was 0.74 for interrater reliability and 0.86 for intrarater reliability. An intraclass correlation coefficient greater than 0.5 was observed for 10 of 12 items. CONCLUSION: The development of a codebook as a supplement to the assessment tool Observation Scheme-12 enables an objective rating of audiotaped clinical communication with acceptable reliability. The Observation Scheme-12 can be used to assess communication skills based on the Calgary-Cambridge Guide.

How do international medical graduates and colleagues perceive and deal with difficulties in everyday collaboration? A qualitative study.

AIMS: Many medical doctors work outside their countries of origin. Consequently, language barriers and cultural differences may result in miscommunication and tension in the workplace, leading to poor performance and quality of treatment and affecting patient safety. However, there is little information about how foreign doctors and their colleagues perceive their collaboration and handle situations that can affect the quality of health services. METHODS: Individual, semi-structured in-depth interviews were conducted with two groups of informants: 16 doctors who had recently started working in Norway and 12 unrelated Norwegian-born healthcare providers who had extensive experience of working with doctors from foreign countries. The interviews were analysed according to the systematic text condensation method. RESULTS: The foreign doctors described themselves as newcomers and found it difficult to speak with their colleagues about their shortcomings because they wanted to be seen as competent. Their Norwegian colleagues reported that many new foreign doctors had demanding work schedules and therefore they were reluctant to give them negative feedback. They also feared that foreign doctors would react negatively to criticism. All participants, both the new foreign doctors and their colleagues, reported that they took responsibility for the prevention of misunderstandings and errors; nevertheless, they struggled to discuss such issues with each other. CONCLUSIONS: Silence was the coping strategy adopted by both the foreign doctors and native healthcare professionals when facing difficulties in their working relationships. In such situations, many foreign doctors are socialized into a new workplace in which uncertainty and shortcomings are not discussed openly. Effective leadership and procedures to facilitate communication may alleviate this area of concern.

Double reading rates and quality assurance practices in Norwegian hospital radiology departments: two parallel national surveys.

BACKGROUND: Double reading as a quality assurance (QA) tool is employed extensively in Norwegian hospital radiology departments. The practice is resource consuming and regularly debated. PURPOSE: To investigate the rates of double reading in Norwegian hospital radiology departments, to identify department characteristics associated with double reading rates, and to investigate associations between double reading and other quality improvement. MATERIAL AND METHODS: We issued two parallel national surveys to management and to consultant radiologists, respectively. Management was defined as the chief medical officer and/or the head of the radiology department. The management survey covered staffing, perceived resource situation, double reading, guidelines, and quality improvement. The radiologist survey served to validate management responses concerning double reading. Management survey items concerning practices of quality improvement were organized into three indices reflecting different quality approaches, namely: appropriateness of investigations; personal performance feedback; and system performance feedback. RESULTS: The response rates of the surveys were 100% (45/45) for management and 55% (266/483) for radiologists. Of all exams read by consultants, 33% were double read. The double reading rate was highest in university hospital departments (59%), intermediate in other teaching departments (30%), and lowest in non-teaching departments (11%) (P = 0.01). Among the quality indices, mean scores were highest on appropriateness index (68%), intermediate on the person index (56%), and lowest on system index (37%). There were no correlations between double reading rates and scores on any of the quality indices. CONCLUSION: The rate of double reading in Norwegian hospital radiology is significantly correlated to department teaching status, but not to other practices of quality work.

International medical graduates' perceptions of entering the profession in Norway.

BACKGROUND: There is little knowledge available about how it feels for an international medical graduate arriving in Norway. We have investigated how the initial period as an employee of the Norwegian health services is perceived. MATERIAL AND METHOD: We conducted semi-structured interviews with 16 international medical graduates who had foreign training and citizenship. They had worked as doctors in Norway for less than two years. Transcriptions of the interviews were analysed using the Systematic Text Condensation method. RESULTS: Their background for working in Norway varied. Some had an affiliation to the country and a social network, which appeared to be a support during the initial period. Many perceived the authorisation process as bureaucratic and as throwing suspicion on them. The doctors felt that they could cope with most of their work assignments, but reported having faced challenges in terms of language, a lack of insight into systems and uncertainty regarding what was expected of the doctor's role in a Norwegian context. There was also uncertainty associated with a perceived absence of collegial support. Because of the availability of jobs, some had adjusted their career plans towards psychiatry, geriatrics or general practice. INTERPRETATION: It appears that preparatory measures such as training courses, tests and the authorisation process fail to provide the practice-related experience and local knowledge that many doctors feel that they need in their new job situation. Measures such as language training and introduction to systems would be likely to improve their general well-being as well as integration.

Reinforcing the humanity in healthcare: The Glasgow Consensus Statement on effective communication in clinical encounters.

Contemporary healthcare is characterized by multidisciplinary teamwork across a vast array of primary, secondary and tertiary services, augmented by progressively more technology and data. While these developments aim to improve care, they have also created obstacles and new challenges for both patients and health professionals. Indeed, the increasingly fragmented and transactional nature of clinical encounters can dehumanize the care experience across disciplines and specialties. Effective communication plays a pivotal role in reinforcing the humanity of healthcare through the delivery of person-centered care - compassionate, collaborative care that focuses on the needs of each patient as a whole person. After convening at the International Conference on Communication in Healthcare (Glasgow, 2022), an interdisciplinary group of researchers, educators and health professionals worked together to develop a framework for effective communication that both acknowledges critical challenges in contemporary health services and reinforces the humanity of healthcare. The Glasgow Consensus Statement is intended to function as a useful international touchstone for the training and practice of health professionals, fully recognizing and respecting that different countries are at different stages when it comes to teaching, assessment and policy. It also provides a vocabulary for monitoring the impact of system-level challenges. While effective communication may not change the structure of healthcare, it can improve the process if health professionals are supported in infusing the system with their own innate humanity and applying the framework offered within this consensus statement to reinforce the humanity in everyday practice.

What do patients with heart failure disclose about medication adherence at home to their hospital and primary care doctors? Exploratory interaction-based observational cohort study.

OBJECTIVES: The main objective of this study was twofold: to investigate what kind of information patients with heart failure (HF) tell their doctors about their medication adherence at home, and how often such information is provided in consultations where medication reconciliation is recommended. To meet these objectives, we developed an analysis to recognise, define, and count (1) patient utterances including medication adherence disclosures in clinical interactions (MADICI), (2) MADICI including red-flags for non-adherence, and (3) MADICI initiated by patients without prompts from their doctor. DESIGN: Exploratory interaction-based observational cohort study. Inductive microanalysis of authentic patient-doctor consultations, audio-recorded at three time-points for each patient: (1) first ward visit in hospital, (2) discharge visit from hospital, and (3) follow-up visit with general practitioner (GP). SETTING: Norway (2022-2023). PARTICIPANTS: 25 patients with HF (+65 years) and their attending doctors (23 hospital doctors, 25 GPs). RESULTS: We recognised MADICI by two criteria: (1) they are about medication prescribed for use at home, AND (2) they involve patients' action, experience, or stance regarding medications. Using these criteria, we identified 427 MADICIs in 25 patient trajectories: 143 (34%) at first ward visit (min-max=0-35, median=3), 57 (13%) at discharge visit (min-max=0-8, median=2), 227 (53%) at GP-visit (min-max=2-24, median=7). Of 427 MADICIs, 235 (55%) included red-flags for non-adherence. Bumetanide and atorvastatin were most frequently mentioned as problematic. Patients initiated 146 (34%) of 427 MADICIs. Of 235 'red-flag MADICIs', 101 (43%) were initiated by patients. CONCLUSIONS: Self-managing older patients with HF disclosed information about their use of medications at home, often including red-flags for non-adherence. Patients who disclosed information that signals adherence problems tended to do so unprompted. Such disclosures generate opportunities for doctors to assess and support patients' medication adherence at home.

Sensitivity and specificity of Norwegian optometrists' evaluation of diabetic retinopathy in single-field retinal images - a cross-sectional experimental study.

BACKGROUND: In the working age group, diabetic retinopathy is a leading cause of visual impairment. Regular eye examinations and early treatment of retinopathy can prevent visual loss, so screening for diabetic retinopathy is cost-effective. Dilated retinal digital photography with the additional use of ophthalmoscopy is the most effective and robust method of diabetic retinopathy screening. The aim of this study was to estimate the sensitivity and specificity of diabetic retinopathy screening when performed by Norwegian optometrists. METHODS: This study employed a cross-sectional experimental design. Seventy-four optometrists working in private optometric practice were asked to screen 14 single-field retinal images for possible diabetic retinopathy. The screening was undertaken using a web-based visual identification and management of ophthalmological conditions (VIMOC) examination. The images used in the VIMOC examination were selected from a population survey and had been previously examined by two independent ophthalmologists. In order to establish a "gold standard", images were only chosen for use in the VIMOC examination if they had elicited diagnostic agreement between the two independent ophthalmologists. To reduce the possibility of falsely high specificity occurring by chance, half the presented images were of retinas that were not affected by diabetic retinopathy. Sensitivity and specificity for diabetic retinopathy was calculated with 95% confidence intervals (CIs). RESULTS: The mean (95%CI) sensitivity for identifying eyes with any diabetic retinopathy was 67% (62% to 72%). The mean (95%CI) specificity for identifying eyes without diabetic retinopathy was 84% (80% to 89%). The mean (95%CI) sensitivity for identifying eyes with mild non-proliferative diabetic retinopathy or moderate non-proliferative diabetes was 54% (47% to 61%) and 100%, respectively. Only four optometrists (5%) met the required standard of at least 80% sensitivity and 95% specificity that has been previously set for diabetic retinopathy screening programmes. CONCLUSIONS: The evaluation of retinal images for diabetic retinopathy by Norwegian optometrists does not meet the required screening standard of at least 80% sensitivity and 95% specificity. The introduction of measures to improve this situation could have implications for both formal optometric training and continuing optometric professional education.

Poor title--poor manuscript?

BACKGROUND: The title of a scientific article is important for several reasons. Does the title of a manuscript submitted for publication in a medical journal reflect the quality of the manuscript itself? MATERIAL AND METHOD: We prepared criteria for poor, fair and good titles and tested them in pilot studies. All manuscripts submitted to the Journal of the Norwegian Medical Association during the period 1 September 2009-31 August 2011 as original articles (n = 211) or review articles (n = 110) were recorded. The quality of the titles was scored by two former editors. Primary outcome measures were rejection rates and odds ratio for rejection of manuscripts with a poor title compared to those with a good title. RESULTS: For original articles, the rejection rate for manuscripts with a poor, fair or good title amounted to 88%, 73% and 61% (p = 0.002) respectively, and for review articles 83%, 56% and 38% (p < 0.001). The odds ratio for rejection of manuscripts with a poor title compared to those with a good title was 4.6 (95% CI: 1.7-12.3) for original articles and 8.2 (95% CI: 2.6-26.4) for review articles. In a logistic regression model, the quality of the title explained 14% and 27% of the variance in outcome for original articles and review articles respectively. INTERPRETATION: In this study, a poor manuscript title was significantly associated with manuscript rejection. This indicates that the quality of the title often reflects the quality of the manuscript itself.

WITHDRAWN: If I say teach-back.

The Publisher regrets that this article is an accidental duplication of an article that has already been published in , . The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/policies/article-withdrawal.

What does shared decision making ask from doctors? Uncovering suppressed qualities that could improve person-centered care.

OBJECTIVE: Shared decision making (SDM) is infrequently seen in clinical practice despite four decades of efforts. We propose a need to explore what SDM asks from doctors in terms of enabling competencies and necessary, underlying qualities, and how these can be nurtured or suppressed in medical training. DISCUSSION: Key SDM tasks call for doctors to understand communication and decision mechanisms to carry them out well, including reflecting on what they know and do not know, considering what to say and how, and listening unprejudiced to patients. Different doctor qualities can support accomplishing these tasks; humility, flexibility, honesty, fairness, self-regulation, curiosity, compassion, judgment, creativity, and courage, all relevant to deliberation and decision making. Patient deference to doctors, lack of supervised training opportunities with professional feedback, and high demands in the work environment may all inflate the risk of only superficially involving patients. CONCLUSIONS: We have identified ten professional qualities and related competencies required for SDM, with each to be selected based on the specific situation. The competencies and qualities need to be preserved and nurtured during doctor identity building, to bridge the gap between knowledge, technical skills, and authentic efforts to achieve SDM.

"The challenge is the complexity" - A qualitative study about decision-making in advanced lung cancer treatment.

INTRODUCTION: The value of shared decision-making and decision aids (DA) has been well documented yet remain difficult to integrate into clinical practice. We wanted to investigate needs and challenges regarding decision-making about advanced lung cancer treatment after first-line therapy, focusing on DA applicability. METHODS: Qualitative data from separate, semi-structured focus groups with patients/relatives and healthcare professionals were analysed using systematic text condensation. 12 patients with incurable lung cancer, seven relatives, 12 nurses and 18 doctors were recruited from four different hospitals in Norway. RESULTS: The participants described the following needs and challenges affecting treatment decisions: 1) Continuity of clinician-patient-relationships as a basic framework for decision-making; 2) barriers to information exchange; 3) negotiation of autonomy; and 4) assessment of uncertainty and how to deal with it. Some clinicians feared DA would steal valuable time and disrupt consultations, arguing that such tools could not incorporate the complexity and uncertainty of decision-making. Patients and relatives reported a need for more information and the possibility both to decline or continue burdensome therapy. Participants welcomed interventions supporting information exchange, like communicative techniques and organizational changes ensuring continuity and more time for dialogue. Doctors called for tools decreasing uncertainty about treatment tolerance and futile therapy. CONCLUSION: Our study suggests it is difficult to develop an applicable DA for advanced lung cancer after first-line therapy that meets the composite requirements of stakeholders. Comprehensive decision support interventions are needed to address organizational structures, communication training including scientific and existential uncertainty, and assessment of frailty and treatment toxicity.