The Roots of Genetic Coding in Aminoacyl-tRNA Synthetase Duality.

Codon-dependent translation underlies genetics and phylogenetic inferences, but its origins pose two challenges. Prevailing narratives cannot account for the fact that aminoacyl-tRNA synthetases (aaRSs), which translate the genetic code, must collectively enforce the rules used to assemble themselves. Nor can they explain how specific assignments arose from rudimentary differentiation between ancestral aaRSs and corresponding transfer RNAs (tRNAs). Experimental deconstruction of the two aaRS superfamilies created new experimental tools with which to analyze the emergence of the code. Amino acid and tRNA substrate recognition are linked to phase transfer free energies of amino acids and arise largely from aaRS class-specific differences in secondary structure. Sensitivity to protein folding rules endowed ancestral aaRS-tRNA pairs with the feedback necessary to rapidly compare alternative genetic codes and coding sequences. These and other experimental data suggest that the aaRS bidirectional genetic ancestry stabilized the differentiation and interdependence required to initiate and elaborate the genetic coding table.

Bridging and breaking silos: Transformational governance of the migration-sustainability nexus.

Sustainability and migration are typically treated as discrete policy spheres in international, national, and local fora, separated in governance structures and institutions. This results in policy incoherence that hinders just transitions toward more sustainable societies cognizant of mobile realities. This explorative effort identifies the (dis)connections between policy domains using data collected on how the sustainability-migration nexus is governed in four countries with a special emphasis on urban areas: Belgium, the Netherlands, Sweden, and the United States. Results of 73 interviews show that migration and sustainability actors find it challenging to see how they could be working together and that migrants are rarely conceived of as sustainability actors and/or targeted populations of sustainability policy. Despite the cross-sectoral nature of sustainability, it appears that migration and sustainability are sequestered into silos that hinder collaborative actions. Lamenting the existence of silos is not enough to encourage new lines of thinking or practice in how sustainability is governed; therefore, we examine the evidence to ascertain current barriers blocking synergetic governance and the opportunities for change perceived by respondents via three critical elements of transformations toward sustainability: structural, systemic, and enabling conditions. We argue that for sustainability transitions to happen, a wider set of societal actors needs to be included from policy intention to action, but that this transformation may require more than policy integration via horizontal coordination. It demands reflexivity and pluralistic pathways that close vertical gaps between national and municipal levels and diminish structural inequalities as they intersect with migration type and status.

Reflexivity and positionality applied to medical practice: a study on implicit gender bias with medical students in a Swiss university.

BACKGROUND: An array of evidence shows how the presence of implicit bias in clinical encounters can negatively impact provider-patient communication, quality of care and ultimately contribute to health inequities. Reflexive practice has been explored as an approach to identify and address implicit bias in healthcare providers, including medical students. At the Lausanne School of Medicine, a clinically integrated module was introduced in 2019 to raise students' awareness of gender bias in medical practice using a reflexivity and positionality approach. The purpose of this study is to describe the gender bias that were identified by medical students, analysing their types, places and modes of emergence during a clinical encounter. It further explores how positionality supported students' reflection on the way in which social position modulates their relationship to patients. METHODS: As part of the teaching activity, medical students individually reflected on gender bias in a specific clinical encounter by answering questions in their electronic portfolio. The questionnaire included a section on positionality. We qualitatively analysed the students' assignments (n=76), applying a thematic analysis framework. RESULTS: Medical students identified and described gender biases occurring at different moments of the clinical encounter (anamnesis (i.e. patient history), physical exam, differential diagnosis, final management). They causally associated these biases with wider social phenomena such as the gendered division of labour or stereotypes around sexuality and gender. Analysing students' reflections on how their position influenced their relationship with patients, we found that the suggested exercise revealed a major contradiction in the process of medical enculturation: the injunction to be neutral and objective erases the social and cultural context of patients and impedes an understanding of gender bias. CONCLUSION: Gender biases are present in the different steps of a clinical consultation and are rooted in broader gendered social representations. We further conclude that the tension between a quest for objectivity and the reality of social encounters should be made explicit to students, because it is constitutive of medical practice.

Perceived Quality of Life in Intensive Care Medicine Physicians: A French National Survey.

Purpose: There is a growing interest in the quality of work life (QWL) of healthcare professionals and staff well-being. We decided to measure the perceived QWL of ICU physicians and the factors that could influence their perception. Methods: We performed a survey coordinated and executed by the French Trade Union of Intensive Care Physicians (SMR). QWL was assessed using the French version of the Work-Related Quality of Life (WRQoL) scale, perceived stress using the French version of 10 item-Perceived Stress Scale (PSS-10) and group functioning using the French version of the Reflexivity Scale, the Social Support at Work Questionnaire (QSSP-P). Results: 308 French-speaking ICU physicians participated. 40% perceived low WRQoL, mainly due to low general well-being, low satisfaction with working conditions and low possibility of managing the articulation between their private and professional lives. Decreased QWL was associated with being a woman (p = .002), having children (p = .022) and enduring many monthly shifts (p = .022). Conclusions: This work highlights the fact that ICU physicians feel a significant imbalance between the demands of their profession and the resources at their disposal. Communication and exchanges within a team and quality of social support appear to be positive elements to maintain and/or develop within our structures.

Negotiating access to community-based participatory research.

PURPOSE: Community-based participatory research (CBPR) that improves social capital can be a powerful tool for promoting mental health and well-being. This work explores what gaining, maintaining, and losing access to this type of CBPR looks like from a reflexive research perspective. METHOD: I describe and reflect on my experiences conducting a mixed-methods study of an existing CBPR to increase social capital in Switzerland. I draw on ethnographic observations, field notes, and reflexive memos collected during fieldwork between 2016 and 2020. RESULTS: I negotiated access to the CBPR across three levels: (1) formal organizational with intervention leaders, (2) implementational with facilitators, and (3) the community/group level with participants. Intervention leaders let me conduct research if they benefitted from my work in a timely and reinforcing way, facilitators granted access if I made myself helpful and supported their work, and community members accepted me if I participated in their community meaningfully. I lost access when my findings posed a potential risk to the intervention funding. CONCLUSION: I highlight how access is a fluid and complex process that can change throughout CBPR. I show the importance of reflexive analysis to understand how access is negotiated in diverse settings, what sources of social capital are needed to engage in these negotiations, and how positionality and power play a role in this process.

Translational bioethics: Reflections on what it can be and how it should work.

Translational ethics (TE) has been developed into a specific approach, which revolves around the argument that strategies for bridging the theory-practice gap in bioethics must themselves be justified on ethical terms. This version of TE incorporates normative, empirical and foundational ethics research and continues to develop through application and in the face of new ethical challenges. Here, I explore the idea that the academic field of bioethics has not yet sufficiently analysed its own philosophical foundation for how it can, and should, be practically relevant; neither has it comprehensively discussed the limitations on what impacts bioethicists should pursue. As a result, there has not been adequate training on how to suitably and appropriately impact real-world practices. Moreover, bioethical perspectives are often competing with other strong interests, for example, economic and political, which may weaken their impact on policy-making. The TE approach I propose can not only facilitate practical impacts of academic bioethics by being better informed by real-world ethical issues but it also supports targeted and ethical justifications of the actual impact of academic work in real-world contexts. In this paper, I clarify the premises for this TE approach, identify further challenges and sketch out potential solutions for the implementation of this methodological framework.

The reflexive imperative in the digital age: Using Archer's 'fractured reflexivity' to theorise widening inequities in UK general practice.

'Reflexivity', as used by Margaret Archer, means creative self-mastery that enables individuals to evaluate their social situation and act purposively within it. People with complex health and social needs may be less able to reflect on their predicament and act to address it. Reflexivity is imperative in complex and changing social situations. The substantial widening of health inequities since the introduction of remote and digital modalities in health care has been well-documented but inadequately theorised. In this article, we use Archer's theory of fractured reflexivity to understand digital disparities in data from a 28-month longitudinal ethnographic study of 12 UK general practices and a sample of in-depth clinical cases from 'Deep End' practices serving highly deprived populations. Through four composite patient cases crafted to illustrate different dimensions of disadvantage, we show how adverse past experiences and structural inequities intersect with patients' reflexive capacity to self-advocate and act strategically. In some cases, staff were able to use creative workarounds to compensate for patients' fractured reflexivity, but such actions were limited by workforce capacity and staff awareness. Unless a more systematic safety net is introduced and resourced, people with complex needs are likely to remain multiply disadvantaged by remote and digital health care.

The Remote Approach in a Qualitative Study During the COVID-19 Pandemic: A Perspective Considering the Researcher's Life Experiences and the Trustworthiness.

The COVID-19 pandemic has raised a wide range of challenges for qualitative researchers, especially when most of the world was facing isolation during the first wave in 2020. The scientific literature rapidly raised discussion regarding data collection adaptation for remote inquiry and ethical dilemmas. However, it is still necessary to discuss the implications of running qualitative studies as a researcher immersed in a global emergency, precisely when the researchers themselves are involved in this context. To what extent, or in what way, can being fully immersed in this context influence all phases of the research? What is the role of reflexivity in this context? We proposed a new discussion based on the study we performed remotely in 2020, among infected pregnant women, using concepts of the Freudian feeling of uncanny to explore the life experience of the researcher. We also considered the concept of the discourse of the master from Jacques Lacan to debate the researchers' position during the pandemic and to bring practical implications.

Threading a decolonial feminist response to COVID-19: One community psychologist's reflection on the assemblages of violence.

To challenge and interrogate the assemblages of violence produced by racial capitalism, and exacerbated by the COVID-19 pandemic, community psychologists must engage in a transdisciplinary critical ethically reflexive practice. In this reflexive essay, or first-person account, I offer a decolonial feminist response to COVID-19 that draws strength from the writings of three women of Color decolonial and postcolonial feminist thinkers: Gloria E. Anzaldúa, Sylvia Wynter, and Arundhati Roy. Through their writings I share my reflections on the sociopolitical moment associated with COVID-19. Of importance, I argue in support of engaging a decolonial feminist standpoint to understand the inequitable and dehumanizing conditions under COVID-19, and the possibilities for transformative justice. I offer this reflexive essay with the intention of summoning community psychology and community psychologists to look toward transdisciplinarity, such as that which characterizes a decolonial standpoint and feminist epistemologies. Writings oriented toward imagination, relationality, and borderland ways of thinking that are outside, in-between or within, the self and the collective "we" can offer valuable guidance. The invitation toward a transdisciplinary critical ethically reflexive practice calls us to bear witness to movements for social justice; to leverage our personal, professional and institutional resources to support communities in struggle. A decolonial feminist standpoint guided by the words of Anzaldúa, Wynter, and Roy can cultivate liberatory conditions that can materialize as racial freedom, community wellbeing, and societal thriving.

Performing Platform Governance: Facebook and the Stage Management of Data Relations.

Controversies surrounding social media platforms have provided opportunities for institutional reflexivity amongst users and regulators on how to understand and govern platforms. Amidst contestation, platform companies have continued to enact projects that draw upon existing modes of privatized governance. We investigate how social media companies have attempted to achieve closure by continuing to set the terms around platform governance. We investigate two projects implemented by Facebook (Meta)-authenticity regulation and privacy controls-in response to the Russian Interference and Cambridge Analytica controversies surrounding the 2016 U.S. Presidential Election. Drawing on Goffman's metaphor of stage management, we analyze the techniques deployed by Facebook to reinforce a division between what is visible and invisible to the user experience. These platform governance projects propose to act upon front-stage data relations: information that users can see from other users-whether that is content that users can see from "bad actors", or information that other users can see about oneself. At the same time, these projects relegate back-stage data relations-information flows between users constituted by recommendation and targeted advertising systems-to invisibility and inaction. As such, Facebook renders the user experience actionable for governance, while foreclosing governance of back-stage data relations central to the economic value of the platform. As social media companies continue to perform platform governance projects following controversies, our paper invites reflection on the politics of these projects. By destabilizing the boundaries drawn by platform companies, we open space for continuous reflexivity on how platforms should be understood and governed.

Salsa Rhythms and Soul Connections.

The rhythmic interplay of accent, tempo, and musical mood is expressed in the bodily postures, gestures, and expressions of attuned responsiveness in Salsa Dura, a genre of salsa music from the 1970s featuring improvisational dance solos. These dancers embrace the feelings and flows of soloing musicians going off and breaking free from any predictable form and structure. We inquire into how world-class salsa dancers and educators feel themselves moved by such intricate rhythms to experience soul connections. Video recordings and interviews yield insight into the call and response dynamics of this essentially tactful practice of alterity.

From study plans to capacity building: a journey towards health equity in cancer survivorship.

This article highlights the importance of pausing and reflecting on one's motivation, capacity, and positionality when engaging in health equity research and encourages researchers to engage in critical self-reflection and contribute to the ongoing dialogue on the ethical conduct of health equity-focused cancer research. In response to the urgent need to address health disparities and improve health equity in cancer survivorship care, the Cancer Prevention and Control Research Network (CPCRN) Survivorship workgroup discussed developing a study focused on understanding how racism impacts patient engagement in cancer survivorship care. However, during the study's development, the workgroup recognized limitations in research team composition and infrastructure. The workgroup engaged in critical self-reflections, individually and collectively, leading to the halting of the research study. Consequently, they redirected their efforts towards strengthening the necessary infrastructure for conducting such research, including diverse investigator representation and equitable partnerships with cancer survivors. The description of this process, along with suggestions for reflection, may be helpful and informative to other researchers and research networks seeking to center marginalized voices and work in partnership to address healthcare and health equity.

Recognizing reflexivity among conservation practitioners.

When deciding how to conserve biodiversity, practitioners navigate diverse missions, sometimes conflicting approaches, and uncertain trade-offs. These choices are based not only on evidence, funders' priorities, stakeholders' interests, and policies, but also on practitioners' personal experiences, backgrounds, and values. Calls for greater reflexivity-an individual or group's ability to examine themselves in relation to their actions and interactions with others-have appeared in the conservation science literature. But what role does reflexivity play in conservation practice? We explored how self-reflection can shape how individuals and groups conserve nature. To provide examples of reflexivity in conservation practice, we conducted a year-long series of workshop discussions and online exchanges. During these, we examined cases from the peer-reviewed and gray literature, our own experiences, and conversations with 10 experts. Reflexivity among practitioners spanned individual and collective levels and informal and formal settings. Reflexivity also encompassed diverse themes, including practitioners' values, emotional struggles, social identities, training, cultural backgrounds, and experiences of success and failure. Reflexive processes also have limitations, dangers, and costs. Informal and institutionalized reflexivity requires allocation of limited time and resources, can be hard to put into practice, and alone cannot solve conservation challenges. Yet, when intentionally undertaken, reflexive processes might be integrated into adaptive management cycles at multiple points, helping conservation practitioners better reach their goals. Reflexivity could also play a more transformative role in conservation by motivating practitioners to reevaluate their goals and methods entirely. Reflexivity might help the conservation movement imagine and thus work toward a better world for wildlife, people, and the conservation sector itself.

Reconocimiento de la reflexividad entre los practicantes de la conservación Resumen Cuando se decide cómo conservar la biodiversidad, quienes la practican sortean varias misiones, algunas veces con enfoques contrastantes y compensaciones inciertas. Estas elecciones no se basan solamente en las evidencias, prioridades de los financiadores, los intereses de los actores y las políticas, sino también en las experiencias personales, formación y valores de los practicantes. En la literatura sobre las ciencias de la conservación han surgido llamados para una mayor reflexividad - la habilidad individual o grupal para examinarse a sí mismo en relación con sus acciones e interacciones con otros. Pero ¿cuál es el papel de la reflexividad en la práctica de la conservación? Para responder esto, exploramos cómo la autorreflexión puede determinar cómo ocurre la conservación individual y grupal de la naturaleza. Realizamos una serie de talleres de discusión e intercambios virtuales durante un año para ejemplificar la reflexividad en la práctica de la conservación. Durante estas sesiones examinamos casos de la literatura gris y revisada por pares, nuestras propias experiencias y conversaciones con diez expertos. La reflexividad de los practicantes abarcó niveles individuales y colectivos y escenarios formales e informales. La reflexividad también comprendió diferentes aspectos de los practicantes, como los valores, conflictos emocionales, identidad social, preparación, contexto cultural y experiencias exitosas y fallidas. Los procesos reflexivos también tienen limitaciones, riesgos y costos. La reflexividad informal e institucionalizada requiere la distribución de tiempo y recursos limitados, puede ser difícil de poner en práctica y no puede resolver los retos de conservación por sí sola. Aun así, cuando se realizan intencionalmente, los procesos reflexivos pueden integrarse a los ciclos de manejo adaptativo en varios puntos, lo que ayuda a quienes practican la conservación a lograr sus metas de mejor manera. La reflexividad también podría tener un papel transformador en la conservación al motivar a los practicantes a reevaluar completamente sus metas y métodos. La reflexividad podría ayudar al movimiento de conservación a imaginar, y por lo tanto trabajar para tener, un mundo mejor para la vida silvestre, las personas y el propio sector de la conservación.

"Come and share your story and make everyone cry": complicating service user educator storytelling in mental health professional education.

It has become relatively common practice within health professional education to invite people who have used mental health and social care services (or service user educators) to share their stories with health professional learners and students. This paper reports on findings from a postcritical ethnographic study of the practice of service user involvement (SUI), in which we reflexively inquired into conceptualizations of service user educators' knowledge contributions to health professional education in the accounts of both service user- and health professional educators. This research was conducted in response to recent calls for greater scrutiny surrounding the risks, challenges, and complexities inherent in involving service users in health professional education spaces. 'Story/telling' was identified as a pronounced overarching construct in our analysis, which focuses on participants' reports of both the obvious and more subtle tensions and complexities they experience in relation to storytelling as a predominant tool or approach to SUI. Our findings are presented as three distinct, yet overlapping, themes related to these complexities or tensions: (a) performative expectations; (b) the invisible work of storytelling; and (c) broadening conceptualizations of service user educators' knowledge. Our findings and discussion contribute to a growing body of literature which problematizes the uncritical solicitation of service user educators' stories in health professional education and highlights the need for greater consideration of the emotional and epistemic labour expected of those who are invited to share their stories. This paper concludes with generative recommendations and reflexive prompts for health professional educators seeking to engage service user educators in health professional education through the practice of storytelling.

Developing a Women's Thought Collective methodology for health research: The roles and responsibilities of researchers in the reflexive co-production of knowledge.

BACKGROUND: Co-produced research holds enormous value within the health sciences. Yet, there can be a heavy focus on what research participants think, do and know; while the researcher's responsibility to explore and re/work their own knowledge or praxis tends to escape from view. This is reflected in the limited use of co-production to explore broad structural distributions of health and risk(s). We argue this missed opportunity has the potential to unfold as what Berlant calls a 'cruel optimism', where something desirable becomes an obstacle to flourishing and/or produces harm. We explore challenges to involving lay populations meaningfully in health research amidst a neoliberal cultural landscape that tends to responsibilise people with problems they cannot solve. METHODS AND FINDINGS: Drawing together principles from hermeneutic and feminist philosophy, we develop a novel methodology for co-producing research about determinants of health and health risk (using a case study of alcohol consumption as an example) that centres on what researchers do, know and think during research: Women's Thought Collectives. DISCUSSION: Keeping the constructed nature of social systems-because they shape ideas of value, expertise and knowledge-in view during co-produced research illuminates the potential for cruel optimisms within it. Such reflexive awareness carves out starting points for researchers to engage with how social hierarchies might (tacitly) operate during the co-production of knowledge. Our work has broad utility for diverse population groups and provides important considerations around the roles and responsibilities for reflexive co-production of knowledge at all levels of health systems. PATIENT OR PUBLIC CONTRIBUTION: The development of these ideas was sparked by working with lay participants during the Women's Thought Collectives for Kristen Foley's doctoral research 2021-2023, but undertaken without their direct involvement-in accordance with the responsibilities of researchers in the reflexive co-production of knowledge. Forthcoming publications will address the outcomes and processes of this work.

Meaningful engagement through critical reflexivity: Engaging people with lived experience in continuing mental health professional development.

Engaging people with lived experience of mental health system encounters in the design and actualization of continuing professional development initiatives for mental health professionals can have transformative systemic impacts. Yet, despite evidence that involving people with lived experience benefits mental health professional education, far less focus has been placed on how to engage people with lived experience in continuing professional development initiatives. Tensions persist regarding the role of lived experience perspectives in continuing professional development, as well as how to establish people with lived experience as partners, educators and leaders in a thoughtful way. We propose that meaningful and equitable partnerships with people with lived experience can be realized by engaging in critical reflexivity and by systematically challenging assumptions. This paper explores three topics: (1) the current state of engagement with people with lived experience in continuing professional development initiatives; (2) barriers to meaningful engagement and (3) recommendations for using critical reflexivity to support the involvement and leadership of people with lived experience in continuing professional development for mental health professionals. PATIENT OR PUBLIC INVOLVEMENT: This viewpoint manuscript was co-designed and co-written by people with diverse lived and learned experiences. Each author's professional roles involve meaningfully and equitably partnering with and centring the perspectives of those with lived experience of mental health system encounters. In addition, approximately half of the authorship team identifies as having lived experience of accessing the psychiatric system and/or supporting family members who are navigating challenges related to mental health. These lived and learned experiences informed the conception and writing of this article.

The 'Clinical Humanities & Wellbeing programme'- sustainable healthcare education for an era of uncertainty.

This article presents a case study where integration of arts and humanities into a clinical programme is being implemented at scale, as core mandatory learning for all students within a UK dental, undergraduate context. The cross-disciplinary programme described, that integrates the Humanities with Clinical Sciences, is a longitudinal professional identity formation curriculum for sustainable oral healthcare which aligns with the UK dental regulator's proposals for a 'safe practitioner' framework for new graduates. The Clinical Humanities & Wellbeing modules embrace the emotional and attitudinal aspects of learning and educate clinical students for the practical wisdom (phronesis) required to deliver 21st century oral healthcare in an era of uncertainty. The overarching aim of the curriculum and its accompanying assessment is to promote critical reflection, student insight and development of integrity, reflexivity, and responsibility. Enabling the subjectification of professional identity formation in this cross-disciplinary way aims to develop students as 'safe practitioners', with increased professional autonomy, responsible for their own actions, and who are better equipped for the uncertainties and phronesis of clinical practice. At present, the programme is being evaluated, employing illuminative evaluation methodology and we present some tentative initial findings. The authors believe that this unique approach and signature pedagogy is, with careful curation, transferrable to other health professions' contexts.

'Pretty cathartic actually': Reflections on the attempt to reduce re-traumatization of researchers and nurses taking part in a longitudinal interview study.

AIM: To critically evaluate the concepts of harm and re-traumatization in the research process and to explore the ethical implications of conducting research on distressing topics using our research on the experiences of nurses working during the COVID-19 pandemic as an exemplar. DESIGN: Longitudinal qualitative interview study. METHODS: Using qualitative narrative interviews, we explored the impacts of the COVID-19 pandemic on nurses' psychological well-being in the UK. RESULTS: To reduce the potential for harm to both research participants and researchers, the members of the research team were keen to establish ways to reduce the power differential between the researcher and participants. We found that our collaborative and team-based approach, with participant autonomy and researcher reflexivity embedded into the research framework, enabled the sensitive generation of data. CONCLUSION: Reduction of potential harm for both participants and researchers in the generation of at times highly distressing data with a traumatized population was achieved through a respectful, honest and empathetic approach within a team that met frequently for reflection. IMPACT: The research participants were not harmed by our research, instead they expressed gratitude at being given space and time to tell their stories in a supportive environment. Our work advances nursing knowledge through accentuating the value of giving autonomy to research participants to control their stories whilst working within a supportive research team with emphasis placed on reflexivity and debriefing. PATIENT AND PUBLIC CONTRIBUTION: Nurses working clinically during COVID-19 were involved in the development of this study. Nurse participants were given autonomy over how and when they participated in the research process.

How Clinicians Decide? Exploring Complexity of Antibiotic Prescribing in Emergency Departments Using Video-Reflexive Ethnography.

Antibiotic overprescribing is a global issue that significantly contributes to increased antimicrobial resistance. Strengthening antimicrobial prescribing practices should be considered a priority. The emergency department (ED) represents a setting where antibiotics are frequently prescribed, but the determinants that influence prescribing choices are complex and multifaceted. We conducted an exploratory qualitative study to investigate the contextual factors that influence antibiotic prescribing choices among clinicians in the ED. The study employed video-reflexive ethnography (VRE) to capture prospective clinical decision-making in situated practice. Data collection involved fieldwork observations, video observations, and delivery of facilitated group reflexive sessions, where clinicians viewed a selection of recorded video snippets relating to antibiotic prescribing. Study was conducted across two EDs within the same health service in Australia. A total of 29 clinical conversations focusing on antibiotic prescribing were recorded. Additionally, 34 clinicians participated in group reflexive sessions. Thematic analysis from the transcribed data yielded four themes: 'importance of clinical judgment', 'usability of prescribing guidelines', 'managing patient expectations', and 'context-dependent disruptions'. Our findings provide insights into the challenges faced by clinicians in navigating complex ED environment, utilising electronic decision-support tools and engaging in discussions about patient treatments with senior clinicians. The findings also indicate that VRE is useful in visualising full complexity of the ED setting, and in initiating meaningful discussions among clinical teams. Integrating the use of VRE in everyday clinical settings can potentially facilitate the implementation of pragmatic solutions for delivering effective antibiotic stewardship practices.

Analyzing implementation of public health interventions: A need for rigor, and the challenges of stakeholder involvement.

OBJECTIVES: This article shows how conceptual models can help to develop and evaluate public health interventions. It also reports on the challenges of getting stakeholders involved. METHOD: The analysis is based on the reflexive approach applied by the authors during their participation in two public health intervention research (PHIR) projects, in France and in Burkina Faso. RESULTS: In Paris, PHIR aimed to enable sub-Saharan immigrants to appropriate the existing means of prevention and sexual health care and to strengthen their empowerment in view of preserving their health. Evaluation was carried out using mixed methods. The intervention process theory is based on Ninacs' conceptual model of individual empowerment. The Consolidated Framework For Implementation Research (CFIR) was mobilized a posteriori to analyze the process. PHIR stemmed from collaboration between a research team and two associations. The different stakeholders were involved in the evaluation process, as were, at certain times, persons in highly precarious situations. In Ouagadougou, a community-based dengue vector control intervention was deployed to address an essential but neglected need. As regards evaluation, we opted for a holistic, mixed method approach (effectiveness and process). The contents of the intervention were determined based on tacit knowledge, a community preference survey and solid evidence. The theoretical framework of the intervention consisted in an eco-biological model of vector control. The implementation analysis combined an internal assessment of implementation fidelity with an external CFIR process analysis. All stakeholders were involved in the evaluation process. DISCUSSION: Analysis confirmed not only the value of process evaluations in PHIR, but also the primordial importance of a rigorous approach. Stakeholder involvement is a major challenge to be addressed early in the planning of RISPs; with this in mind, effective and ethically sound assessment mechanisms need to be drawn up. Interdisciplinary evaluative approaches should be preferred, and the use of justified, relevant, and flexible frameworks is highly recommended. CONCLUSION: Lessons learned for those wishing to engage in the process evaluation of a public health intervention are hereby presented.