What constitutes medically professional responsibility and diligent care for children and adolescents with gender dysphoria? / Hva er faglig forsvarlig og omsorgsfull helsehjelp til barn og unge med kjønnsdysfori?

Children and adolescents with gender dysphoria are a vulnerable group who need good health care. However, the Norwegian Directorate of Health's guidelines do not provide adequate recommendations in accordance with the requirements for professional responsibility and diligent health care.

Boys perpetrating sexual harassment on peer girls in secondary school: A focus group study about pupils' experiences.

AIMS: To explore experiences of sexual harassment of adolescent girls by peer boys during school hours. METHODS: Focus group study with a convenience sample of six girls and 12 boys aged 13-15 years from two different lower secondary schools in Norway. Thematic analysis with Systematic Text Condensation was used with data from three focus group discussions, supported by theory about gender performativity. RESULTS: Analysis demonstrated how girls experienced specific aspects of unwanted sexual attention perpetrated by male peers. When boys trivialized sexualized behaviour perceived as intimidating by girls, the behaviour was perceived as 'normal'. Among the boys, sexual name-calling was only meant as a joke to put the girls in their place, while girls were silenced. In this way, patterns of gendered interaction contribute to performing and maintaining sexual harassment. Responses from co-pupils and teachers had strong impact on further harassment, contributing to either escalation or resistance. Signalling disapproval when being harassed was difficult when bystander behaviour was lacking or degrading. The participants wanted teachers to intervene in response to sexual harassment, emphasizing that being present or showing concern is not enough to stop the harassment. The lack of proactive responses from bystanders may also represent gender performativity, where invisibility contributes to social conventions such as normalization. CONCLUSIONS: Our analysis indicates a need for interventions targeting sexual harassment among pupils in Norwegian schools, with a special awareness of gendered performance. Both teachers and pupils would benefit from increased knowledge and skills in how to detect and stop unwanted sexual attention.

Developing and promoting qualitative methods in general practice research: Lessons learnt and strategies convened.

Fifty years ago, qualitative research methods were unknown in medicine. Biomedicine and the positivist paradigm were universal academic standards. In the late 1980s, however, humanist perspectives emerged as substantial values in general practice. This progress fostered an effort among Nordic general practitioners to find research methods best suited to exploring clinical communication and the doctor-patient relationship. Simultaneously, qualitative methods were promoted internationally in medicine, mostly by social scientists. This article is a personal narrative of the history and impact of Nordic general practitioners customising qualitative methods for the study of clinical practice. I present lessons learnt and strategies convened in developing qualitative methods in this Nordic context. The patient-centred method paved the way for research standards consistent with our clinical ontology. We struggled to develop dialogues that promoted methodological legitimacy among medical colleagues. Methodological standards like rigour and reflexivity became important and contributed to intersubjectivity by sharing the research process. Gradually, our endeavours gained notice. In the last couple of decades, the number of published qualitative studies has increased, though perhaps at the cost of methodological quality. Indeed, there are also indications of a methodological backlash among influential journal editors. Nordic general practitioners have been prominent in developing qualitative methods suitable for cultivation of medical knowledge. Our position of knowing, close to the experiences of the individual patient and the everyday context, is different from that of a social scientist. It offers a unique point of departure for knowledge development that can make an important difference for both patients and doctors.

General practice - a fertile lagoon in the ocean of medical knowledge.

General practitioners (GPs) often find that linear, deductive knowledge does not provide a sufficient map for clinical management. But experience, accompanied by enduring familiarity with individual patients, may offer unique complementary skills to interpret a patient's symptoms and navigate skilfully through diagnosis, treatment, follow-up and prevention.In this article, we draw attention to the nature of this tacit knowing that is executed by many GPs every day. We argue that the nonlinear, unpredictable complexity of this domain nurtures a particular logic of clinical knowing. This kind of knowledge is not intuition and can to some extent be intersubjectively accessible. We substantiate and discuss how and why general practice research can contribute to knowledge development by transforming reflection-in-action to reflection-on-action.We briefly present some concepts for reflection-on-action of clinical knowing in general practice. The VUCA model (volatility, uncertainty, complexity, ambiguity) embraces dynamic and confusing situations in which agile work (adaptive, flexible and responsive behaviour and cognitive creativity) is assumed to be an appropriate response. Using such perspectives, we may sharpen our gaze and apply reflexivity and analytic elaboration to interpret unique incidents and experiences and appreciate the complexity of general practice. In this way, exploratory research can fertilize general practice and offer innovation to the entire domain of clinical knowledge.

Agenda navigation in consultations covering multiple topics. A qualitative case study from general practice.

OBJECTIVE: To explore how agenda navigation may be accomplished underway in consultations covering multiple topics, we identified and analyzed one GP's communicative strategies. DESIGN, SETTING, AND SUBJECTS: A qualitative observational case study with linguistic microanalysis of an exemplary consultation between a female patient with diabetes and her male GP. We used speech act theory to identify communicative actions that indicated agenda navigation by the GP in transitions between episodes concerning ten topics. RESULTS: Microanalysis revealed different aspects of agenda navigation by the GP using speech acts, especially ways of opening or closing an episode. The opening of episodes was characterized by speech acts accepting the patient's request to discuss a topic, mostly at the beginning of the consultation. Speech acts to inform or to request information from the patient dominated later in the consultation. The GP closed all episodes using speech acts to instruct or appraise the patient, or to make agreements and plans. CONCLUSION AND PRACTICE IMPLICATIONS: Skilful agenda navigation is an important tool for consultations covering multiple issues and could be further developed for medical education. The opening and closing of episodes were vital communicative strategies supporting patient-centered communication in a complex consultation while maintaining the focus of the consultation agenda.KEY POINTSWhile traditional consultation models cover one health problem, GP consultations often include many patient issues in each session.Linguistic microanalysis of speech acts helped to identify communication strategies in a GP consultation with multiple topics.The GP conducted agenda navigation by distinctly opening and closing episodes concerning specific topics.Episodes were opened by accepting, informing, and requesting and closed by instruction, appraisal, making agreements, or plans.

Why do doctors in Norway choose general practice and remain there? A qualitative study about motivational experiences.

Objective: To explore experiences motivating doctors to become and remain GPs.Design and contributors: Qualitative analysis of written responses from an open-ended question about motivational experiences posted on an internet discussion list for GPs in Norway. Texts from 25 contributors were analysed with Systematic Text Condensation, supported by theories about calling as motivation.Results: Analysis revealed numerous aspects of motivation to become and remain a general practitioner. Inspirations from early experiences and skilled role models had conveyed values and offered insight into a fascinating world of care, gratitude and respect. Close and continuous relationships with patients provided GPs with humbling experiences and learning moments. Contributors described how these encounters became rewarding sources of insight and mutual trust, improving interpersonal skills. Also, the extensive variety of tasks during the workday and the space for autonomy and independence was emphasised.Implications: Understanding motivational experiences influencing GPs' choice of medical career is necessary to develop strategies for recruitment and stability and contribute to prevention of burn-out and improper work-life balance. GPs' professional identities and commitments should be recognized and developed in dialogues between authorities and GPs to enhance communication, improve the structural frames of work environment and thereby sustainable recruitment.Key pointsGPs regard their choice of medical career as strongly influenced by motivational experiences in childhood, adolescence and as medical studentsRole models, diversity of work, feelings of being able to contribute and rewarding and continuous relationships with patients were mentioned to activate and maintain general practice commitmentKnowledge about motivational influences, professional identities and commitment for GPs is crucial for medical education and dialogue to promote general practice as a career choice and prevent dangers of work overload and burnout.

Life satisfaction and mental health among transgender students in Norway.

BACKGROUND: Social attitudes to transgender persons and other gender minorities vary around the world, and in many cultures, prejudices and social stigma are common. Consequently, transgender persons face challenges related to discrimination and negative attitudes among the public. The purpose of this study was to compare life satisfaction, loneliness, mental health, and suicidal behavior among transgender students with cisgender students' experiences in a nationwide sample of Norwegian students pursuing higher education. METHODS: In total,50,054 full-time Norwegian students completed an online questionnaire (response rate 30.8%), of whom 15,399 were cisgender males, 34,437 cisgender females, 28 individuals who reported being binary transgender (12 transwomen and 16 transmen), and 69 individuals non-binary transgender persons. The measures included questions concerning gender identity, life satisfaction (Satisfaction With Life Scale), loneliness (The Three-Item Loneliness Scale), mental health problems (Hopkins Symptoms Check List), mental disorders, and suicidal ideation, suicidal behavior, and self-harm. Chi-square tests, Independent-Samples Kruskal-Wallis tests, and logistic regression analyses were used to examine differences between gender identities. RESULTS: Transgender students reported significantly more psychosocial burdens on all measures. There were no significant differences in any of the measures between the binary and non-binary transgender students. CONCLUSION: The findings call for increased awareness about welfare and health for transgender students in Norway. Higher education institutions need to consider measures at various levels to establish a learning environment that is more inclusive for gender minorities.

How can task shifting put patient safety at risk? A qualitative study of experiences among general practitioners in Norway.

Objective: To describe experiences among general practitioners (GPs) in Norway regarding horizontal task shifting experiences associated with adverse events that potentially put patient safety at risk.Design and contributors: We conducted a qualitative study with data from a retrospective convenience sample of consecutive, already posted comments in a restricted Facebook group for GPs in Norway. The sample consisted of 43 unique posts from 38 contributors (23 women and 15 men), presenting thick and specific accounts of potentially adverse events in the context of horizontal task shifting. Analysis was conducted with systematic text condensation, a method for thematic cross-case analysis.Results: Contributing GPs reported several types of adverse events associated with horizontal task shifting that could put patient safety at risk. They described how spill-over work dispatched to GPs may generate administrative hassle and hazardous delay of necessary examinations. Overdiagnosis, reduced access and endangered accountability occur when time-consuming procedures and pre-investigation before referral are pushed upon GPs. Resource-draining chores beyond GPs' proficiency is also dispatched without appropriate instruction or equipment. Furthermore, potential malpractice is imposed by hospital colleagues who overrule the GPs' medical judgement.Implications: Patient safety is endangered when horizontal task shifting is initiated and performed without a systematic process involving all stakeholders that considers available resources. A risk and vulnerability analysis, securing competent staff, resources, time and equipment before launching such reforms is necessary to protect patient safety. Infrastructure comprised of local coordination groups may facilitate dialogue between health care service levels and negotiate responsibilities and workload.Key pointsTask shifting between different levels of health care is a relevant and legitimate strategy for planning and policy.GPs in Norway report adverse events related to task shifting from specialist colleagues without proper resource allocation.Patient safety may be put at risk by hazardous delay, overdiagnosis, endangered accountability and potential malpractice.Planning and implementation of task shifting must involve all system levels and relevant stakeholders to ensure patient safety.

Patients participating as co-researchers in health research: A systematic review of outcomes and experiences.

Aims: We aimed to map out the scope and type of health research studies with patients involved as co-researchers throughout the research process and to explore the outcomes and experiences of such research. Methods: We conducted a narrative review by systematically searching selected databases. A total of 1451 hits were identified and screened, and 17 studies were included and categorised by type of health problem, design, publication sources and modes of presentation. We conducted an inductive, iterative analysis of outcomes and experiences of patient involvement. Results: We identified two types of impact from studies with patients participating as co-researchers: (a) patient involvement as primary focus, where seven articles largely reported and reflected upon the shared experiences, and (b) patient involvement as strategy, where 10 articles presented results from empirical studies of specific health problems, with patient involvement used as a strategy to expand understanding. The first group of studies reported collaborative processes and resource investments, while the second group addressed specific health problems from a distinctive perspective due to patient involvement. Several studies in both groups repeated or confirmed positive values of user involvement rather than providing original findings. In both groups, methodological standards were often downgraded to provide access for the co-researchers. Conclusions: These articles, where the co-researcher model represents the contemporary superior level of patient involvement, may indicate that mere collaboration efforts are prioritised at the expense of knowledge outcomes and scientific quality. Collaboration formats other than participation as co-researchers may be necessary for patient involvement in medical research to add to the existing knowledge.

Diagnostic knowing in general practice: interpretative action and reflexivity.

Background: Getting the right diagnosis is supposed to provide an explanation of a patient's health problem and inform health care decisions. As a core element of clinical reasoning, diagnosis deserves systematic and transparent analysis. Conceptual tools can make doctors become aware of and explore diagnostic knowing.Methods: We demonstrate diagnostic knowing analysed as interpretative and contextualised activity. Our analysis is based on Lonergan's theory of knowing, constituting the cognitive structures as experiencing, understanding, and judging, in a general practice case.Findings: Analysis makes the complexity of diagnostic knowing in this context more transparent, in this case concluding with four diagnostic labels: a corn, constipation, headache and atrial fibrillation. We demonstrate how a medically significant diagnosis does not necessarily evolve deductively from complaints. The opening lines from the patient give ideas of where to look for possible explanations - questions for understanding - rather than diagnostic hypotheses. Such questions emerge from the GP's experiences from meeting the patient, including imaginations and interpretations. When ideas and questions regarding diagnoses have been developed, they may be judged and subjected to reflection. Questioning may also emerge as transitory concerns, not extensively ruled out. Lonergan's theory demonstrated a strong fit with these aspects of diagnostic knowing in general practice.Implications: Analysis demonstrated systematic, transparent approaches to diagnostic knowing, relevant for clinical teaching. We argue that an interpretative understanding of diagnosis can change clinical practice, complementing hypothetico-deductive strategies by recognising additional substantial diagnostic modes and giving access to scholarly reflection.Key PointsDiagnosis is a core element of clinical reasoning, deserving systematic and transparent analysis beyond hypothetico-deductive reasoning or pattern recognitionDiagnostic knowing in general practice is a special instance of all human knowing with subjectivity, interpretation and reflexivity as essential elementsLonergan's theory for knowing based on experiencing, understanding, and judging allowed us to map, decode and recognise advanced acts of clinical reasoning We share our experiences of how these concepts gave us a tool for systematic analysis of the complexities taking place in the GP's office on an ordinary day.

Burdened parents sharing their concerns for their children with the doctor. The impact of trust in general practice: a qualitative study.

Objective: The aim of this study was to recognise the preconditions experienced by general practitioners (GPs) in addressing the children's needs when ill and substance abusing parents consult for their own health problems. Design: Qualitative analysis of 38 case stories told by GPs in focus group interviews. Setting: Focus group interviews of four continuing medical education groups for GPs in western Norway. Subjects: 27 GPs (nine females) with at least 5 years' experiences in general practice. Results: Different aspects of the GPs' perceived mandate of trust from the parents was a precondition for the children's situation to be addressed. In some case stories the participants took an open mandate from the parent for granted, while in others they assumed that the parent did not want to discuss their family situation. Sometimes the participants had faith that by continuing with their ordinary GP tasks, they might obtain a more open mandate of trust. Their evaluation of the mandate of trust seemed to impact on how the GP could adopt a mediating role between the parents and various support agencies, thus supporting children who were at risk. Discussion/conclusion: The children most at risk may remain invisible in GPs' encounters with their parents, possibly because their parent's health problems and overall situation overshadow the children's situation. The mandate of trust from burdened parents to GPs can be a fruitful concept in understanding the interaction regarding the welfare of the parent's children. Negotiating the mandate of trust with parents by explicitly addressing trust and having an ongoing discussion about the mandate and its limits might be an option to secure the children support if necessary. KEY POINTS Offering children of burdened parents information and support can be crucial for health promotion and illness prevention. A general practitioner's (GP's) evaluation of the trust parents have in them can determine the extent of support children receive. Depending on the parents' level of trust, GPs may take a mediating role between support services and parents for the benefit of the children. A negotiation concerning the trust parents have in the GP may open up possibilities for GPs to offer children necessary support.

Queer narratives and minority stress: Stories from lesbian, gay and bisexual individuals in Norway.

AIMS: This study aims to explore how minority stress related to sexual orientation is reflected in narratives from lesbian, gay and bisexual (LGB) individuals in Norway, with an impact for national public health policy. METHODS: Arthur Frank's dialogical narrative analysis was applied to personal stories from 65 persons self-referring to different categories of queer identities, submitted online anonymously to a Norwegian national archive for queer history. A purposive sample of three different stories were selected due to their capacity to illuminate how various aspects of minority stress are narrated in diverse interplays between individual voices and resources, and cultural scripts and societal influences. RESULTS: Our analysis highlighted how stories may offer significant glimpses into the dynamic and complex fashioning of sexual identities, giving precious clues to the vulnerabilities and strengths of the narrator. Contemporary queer narratives from Norway reflect meaning-making related to sexual orientation that are influenced by, and expand upon, the classical scripts dominated by tragedy and tristesse, personal progress or simply no particular tension. LGB individuals of different ages and backgrounds had experienced aspects of minority stress related to their sexual orientation, with a substantial impact on identity, even when significant others were encouraging. CONCLUSIONS: The stories indicate that positive proximal processes, such as personal resilience and sympathetic environments, can support mental health and counteract negative effects of distal processes contributing to minority stress, such as heteronormativity and subtle microaggression. Public health strategies addressing attitudes to sexual orientation among the general population may contribute to diverse affirmative cultural scripts about queer lives, thereby enhancing queer mental health.

Workplace inclusion of employees with back pain and mental health problems: A focus group study about employees' experiences.

AIM: To explore how employees experience workplace inclusion of their colleagues or themselves when having back pain or mental health problems. METHODS: Three focus group interviews with a sample of 16 kindergarten employees were conducted. Systematic Text Condensation was used for analysis. RESULTS: The participants emphasized that it was easier to include colleagues whose health problems were specific, especially when they were open about having problems and expressed their needs for accommodation clearly. Discussions revealed difficulties of acceptance and accommodating colleagues with longstanding health problems, when the burden on the other staff members was heavy, and if it had negative consequences for the kindergarten children. Some of the participants had experienced health problems themselves, which was also described as challenging. Having health problems at work often induced feelings of guilt, being a burden to their colleagues, and experiencing a disparity between the ideals and the realities of inclusion practices. CONCLUSIONS: Workplace inclusion of employees is difficult when their health problems are unspecific, longstanding, and lead to negative consequences for children or colleagues. System level efforts are necessary to reduce negative stereotypes about employees with health problems and facilitate inclusion practices.

The Impact of Evidence-Based Medicine on Qualitative Metasynthesis: Benefits to be Harvested and Warnings to be Given.

Qualitative metasynthesis, developed as an interpretative and inductive methodology, is increasingly influenced by standards from evidence-based medicine, established as a strategy to support policy decisions and guidelines. Currently, principles and procedures from the format developed for systematic reviews are often applied for review and synthesis of all kinds of evidence, including results from qualitative studies. In this article, I substantiate these claims, discussing benefits to be harvested and warnings to be given when qualitative metasynthesis approaches the evidence-based medicine methodology. Situating my exploration in the context of clinical practice, I contrast missions and values of these methodologies regarding review and synthesis of research literature, highlighting potential mismatches between ontology and epistemology, emphasizing challenges regarding sample, analysis, and transferability. Approving systematic and transparent strategies as generic for such purposes, I warn against the idea that methodology developed for evidence-based medicine is a universal gold standard for synthesis of research evidence.