How do oilcloth sessions work? A realist evaluation approach to exploring ripple effects in an implementation strategy.

PURPOSE: To explore the mechanisms of the implementation strategy, "oilcloth sessions" and understand and explain the ripple effects of oilcloth sessions as a strategy to implement a new emergency department. DESIGN/METHODOLOGY/APPROACH: A qualitative design was used whereby data were collected using field notes from an ethnographic study of the oilcloth sessions and follow-up semi-structured interviews with staff, managers and key employees who participated in the oilcloth sessions. The data analysis was inspired by the realist evaluation approach of generative causality proposed by Pawson and Tilley. FINDINGS: The primary ripple effect was that the oilcloth sessions were used for different purposes than the proposed program theory, including being used as: (1) a stage, (2) a battlefield, (3) a space for imagination and (4) a strategic management tool influencing the implementation outcomes. The results bring essential knowledge that may help to explain why and how a well-defined implementation strategy has unplanned outcomes. ORIGINALITY/VALUE: Unintended outcomes of implementation strategies are an underexplored issue. This study may help implementation researchers rethink the activities required to reduce unintended negative outcomes or explore potential unplanned outcomes and, in this way, hinder or enhance outcomes, effectiveness and sustainability. Future studies within implementation research should incorporate attention to unintended outcomes to fully understand the impact of implementation strategies.

Influences of specialty identity when implementing a new emergency department in Denmark: a qualitative study.

BACKGROUND: The Danish Health Authority recommended the implementation of new types of emergency departments. Organizational changes in the hospital sector challenged the role, identity, and autonomy of medical specialists. They tend to identify with their specialty, which can challenge successful implementation of change. However, investigations on specialty identity are rare in implementation science, and how the co-existence of different specialty identities influences the implementation of new emergency departments needs to be explored for the development of tailored implementation strategies. The aim of this study was to examine how medical specialty identity influences collaboration between physicians when implementing a new emergency department in Denmark. METHODS: Qualitative methods in the form of participants' observations at 13 oilcloth sessions (a micro-simulation method) were conducted followed up by 53 individual semi-structured interviews with participants from the oilcloth sessions. Out of the 53 interviews, 26 were conducted with specialists. Data from their interviews are included in this study. Data were analysed deductively inspired by Social Identity Theory. RESULTS: The analysis yielded three overarching themes: [1] ongoing creation and re-creation of specialty identity through boundary drawing; [2] social categorization and power relations; and [3] the patient as a boundary object. CONCLUSIONS: Specialty identity is an important determinant of collaboration among physicians when implementing a new emergency department. Specialty identity involves social categorization, which entails ongoing creation and re-creation of boundary drawing and exercising of power among the physicians. In some situations, the patient became a positive boundary object, increasing the possibility for a successful collaboration and supporting successful implementation, but direct expressions of boundaries and mistrust were evident. Both were manifested through a dominating power expressed through social categorization in the form of in- and out-groups and in an "us and them" discourse, which created distance and separation among physicians from different specialties. This distancing and separation became a barrier to the implementation of the new emergency department.

Acceptability Among Frontline Staff Toward Distributing an Anonymous Alcohol Survey in Emergency Departments: A Mixed Methods Study.

ABSTRACT: Emergency departments (EDs) serve as the front line when patients encounter the hospital system. Limited data are available of patients' alcohol habits collected during Danish ED visits, and no studies have, to our knowledge, examined frontline staffs' (registered nurses and medical secretaries) acceptability to deliver anonymous alcohol surveys to patients. We aimed at examining the proportion of survey respondents and the prevalence of patients' alcohol habits and also exploring frontline staff acceptability of the distribution of an anonymous survey regarding patients' alcohol habits in EDs. Intendedly, all eligible patients ≥18 years old entering two EDs in March 2019 should receive a survey based on the Alcohol Use Disorder Identification Test. The study was an explanatory, sequential, mixed methods design, and results were analyzed with descriptive statistics and a deductive content analysis based on the theoretical framework of acceptability. In total, 15% (n = 1,305) of the total 8,679 patients in the EDs returned the survey. Qualitative analysis of interviews (n = 31) with staff showed that they had been reluctant to distribute the survey primarily because of ethical concerns of anonymity, freedom of choice, and being nonjudgmental toward patients. Hence, patients with no obvious alcohol problems were more likely to receive the survey. Still, we found that 23% of the respondents had an Alcohol Use Disorder Identification Test score ≥ 8. Results indicate that frontline staffs' recognition of patients' alcohol use is inadequate, and findings show a low degree of acceptability among staff to deliver an anonymous survey, which is in line with earlier described barriers toward screening activities in EDs.

Acceptability of restrictions in the COVID-19 pandemic: a population-based survey in Denmark and Sweden.

Introduction: Denmark and Sweden initially adopted different responses to the COVID-19 pandemic although the two countries share many characteristics. Denmark responded swiftly with many mandatory restrictions. In contrast, Sweden relied on voluntary restrictions and a more "relaxed" response during the first wave of the pandemic. However, increased rates of COVID-19 cases led to a new approach that involved many more mandatory restrictions, thus making Sweden's response similar to Denmark's in the second wave of the pandemic. Aim: The aim was to investigate and compare the extent to which the populations in Denmark and Sweden considered the COVID-19 restrictions to be acceptable during the first two waves of the pandemic. The study also aimed to identify the characteristics of those who were least accepting of the restrictions in the two countries. Materials and methods: Cross-sectional surveys were conducted in Denmark and Sweden in 2021. The study population was sampled from nationally representative web panels in the two countries, consisting of 2,619 individuals from Denmark and 2,633 from Sweden. The questionnaire captured key socio-demographic characteristics. Acceptability was operationalized based on a theoretical framework consisting of seven constructs and one overarching construct. Results: The respondents' age and gender patterns were similar in the two countries. The proportion of respondents in Denmark who agreed with the statements ("agree" alternative) that captured various acceptability constructs was generally higher for the first wave than the second wave of the pandemic. The opposite pattern was seen for Sweden. In Denmark, 66% in the first wave and 50% in the second wave were accepting of the restrictions. The corresponding figures for Sweden was 42% (first wave) and 47% (second wave). Low acceptance of the restrictions, defined as the 25% with the lowest total score on the seven acceptability statements, was associated with younger age, male gender and lower education levels. Conclusion: Respondents in Sweden were more accepting of the restrictions in the second wave, when the country used many mandatory restrictions. In contrast, respondents in Denmark were more accepting of the restrictions in the first wave than in the second wave, implying an increased weariness to comply with the restrictions over time. There were considerable socio-demographic differences between those who expressed low acceptance of the restrictions and the others in both countries, suggesting the importance of tailoring communication about the pandemic to different segments of the population.

Using the app "Injurymap" to provide exercise rehabilitation for people with acute lateral ankle sprains seen at the Hospital Emergency Department-A mixed-method pilot study.

BACKGROUND: Acute lateral ankle sprains (LAS) account for 4-5% of all Emergency Department (ED) visits. Few patients receive the recommended care of exercise rehabilitation. A simple solution is an exercise app for mobile devices, which can deliver tailored and real-time adaptive exercise programs. PURPOSE: The purpose of this pilot study was to investigate the use and preliminary effect of an app-based exercise program in patients with LAS seen in the Emergency Department at a public hospital. MATERIALS AND METHODS: We used an app that delivers evidence-based exercise rehabilitation for LAS using algorithm-controlled progression. Participants were recruited from the ED and followed for four months. Data on app-use and preliminary effect were collected continuously through the exercise app and weekly text-messages. Baseline and follow-up data were collected though an online questionnaire. Semi-structured interviews were performed after participants stopped using the app. Results: Health care professionals provided 485 patients with study information and exercise equipment. Of those, 60 participants chose to enroll in the study and 43 became active users. The active users completed a median of 7 exercise sessions. Most of the active users were very satisfied or satisfied (79%-93%) with the app and 95.7% would recommend it to others. The interviews showed that ankle sprains were considered an innocuous injury that would recover by itself. Several app users expressed they felt insufficiently informed from the ED health care professionals. Only 39% felt recovered when they stopped exercising, and 33% experienced a recurrent sprain in the study period. Conclusion: In this study, only few patients with LAS became active app users after receiving information in the ED about a free app-based rehabilitation program. We speculate the reason for this could be the perception that LAS is an innocuous injury. Most of the patients starting training were satisfied with the app, although few completed enough exercise sessions to realistically impact clinical recovery. Interestingly more than half of the participants did not feel fully recovered when they stopped exercising and one third experienced a recurrent sprain. TRIAL-IDENTIFIERS: https://clinicaltrials.gov/ct2/show/NCT03550274, preprint (open access): https://www.medrxiv.org/content/10.1101/2022.01.31.22269313v1.

Challenges facing the clinical adoption of a new prognostic biomarker: a case study.

In this article, we show how a particular biomarker comes into being in an emergency department in a hospital in Copenhagen, Denmark. We explore the contextual becoming of this biomarker, suPAR, through interviews with nurses and physicians and through relational ontology. We find that as a prognostic biomarker suPAR is challenged in it becoming as an object for clinical practice in the emergency department by the power of diagnostic practices and the desire for experience-based scripts that quickly enable the clinician to reach the right diagnosis. Although suPAR is enacted as a promising triage strategy suggesting a low or high risk of disease, the inability to rule out specific diagnoses and producing the notion of secure clinical actions make its non-specificity and prognostic character problematic in clinical practices. Specific diagnostic criteria versus prognostic interpretation and non-specificity risk profiling challenges the way healthcare workers in an emergency department understand the tasks they are set to solve and how to solve them. We discuss how the becoming of suPAR is strengthened through enactments of specificity and engagement in triage strategies and we reflect on it's becoming through new diagnostic practices with the need to accommodate diagnostic ambiguity.

From expected to actual barriers and facilitators when implementing a new screening tool: A qualitative study applying the Theoretical Domains Framework.

AIM AND OBJECTIVES: To identify determinants for using a new screening tool to identify older patients eligible for targeted nurse-led intervention, as perceived by healthcare professionals implementing the tool, and to examine how these perceptions changed over time. DESIGN: A cross-sectoral longitudinal qualitative study based on semi-structured interviews with healthcare professionals in a Danish hospital and two collaborating municipalities. METHODS: In three focus groups, seven single interviews and a workshop, we examined the healthcare professionals' perceptions of and attitudes towards the new screening tool before, during and after the implementation. The Theoretical Domains Framework was used to identify the healthcare professionals' perception of barriers and facilitators, followed by content analysis. The results were further discussed using the COM-B system as an analytic framework. This qualitative study is reported according to the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist. RESULTS: 'Professional role', 'Goals' and 'Environmental context' were the domains most talked about by the healthcare professionals across the three time points. The content analysis identified four determinants for using the new screening tool:Making time for the project, External motivation and management, Expectations and reality, and Professional identity. The healthcare professionals' perception of the determinants changed during the implementation, influencing their behaviour and, consequently, the implementation's sustainability. CONCLUSION: Perception of barriers and facilitators to the interventions were time- and context-sensitive. Beliefs and motivational factors changed during the project, which points out the importance of following implementation processes systematically to understand the outcome of an intervention. RELEVANCE FOR CLINICAL PRACTICE: Perceptions and attitudes towards a new initiative may change over time, emphasising the importance of following barriers and facilitators during the implementation of an intervention and working with an implementation plan that can be adapted along the way.

Oilcloth sessions as an implementation strategy: a qualitative study in Denmark.

BACKGROUND: The aim of this study was to explore healthcare professionals, managers, and other key employees' experiences of oilcloth sessions as a strategy when implementing new emergency departments in Denmark, based on their participations in these sessions. The study addresses the importance of securing alignment in implementation strategies. Too often, this does not get enough attention in the literature and in practice. In this study, alignment among components was achieved in an educational implementation strategy called oilcloth sessions. METHODS: The study is based on participants' observations of 13 oilcloth sessions and follow-up via 53 semi-structured interviews with the board of directors, managers, and key employees from the present emergency department and different specialty departments. Data were analysed deductively using Biggs and Tang's model of didactic alignment. RESULTS: The analysis showed the complexity of challenges when using oilcloth sessions as a strategy when implementing a new emergency department described in terms of three phases and nine main themes (a-i): the preparation phase: (a) preparing individually and collectively, (b) objectives, (c) involving participants, (d) selecting cases; the execution phase: (e) using materials, (f) facilitating the sessions, (g) temporal structures; evaluation: (h) following up on the sessions, (i) adapting to the context. CONCLUSIONS: This study shows that it is important to ensure alignment among elements in implementation strategies. Thus, oilcloth sessions with high alignment are useful if the challenges experienced are to be overcome and the strategy will be experienced as a useful way to support the implementation of a new emergency department from the participants' point of view. Bigg and Tang's didactic model is useful as an analytical framework to ensure alignment in implementation strategies in general.

Shared Decision Making with Acutely Hospitalized, Older Poly-Medicated Patients: A Mixed-Methods Study in an Emergency Department.

Shared decision making (SDM) about medicine with older poly-medicated patients is vital to improving adherence and preventing medication-related hospital admissions, but it is difficult to achieve in practice. This study's primary aim was to provide insight into the extent of SDM in medication decisions in the Emergency Department (ED) and to compare how it aligns with older poly-medicated patients' preferences and needs. We applied a mixed-methods design to investigate SDM in medication decisions from two perspectives: (1) observational measurements with the observing patient involvement (OPTION 5) instrument of healthcare professionals' SDM behavior in medication decisions and (2) semi-structured interviews with older poly-medicated patients. A convergent parallel analysis was performed. Sixty-five observations and fourteen interviews revealed four overall themes: (1) a low degree of SDM about medication, (2) a variation in the pro-active and non-active patients approach to conversations about medicine, (3) no information on side effects, and (4) a preference for medication reduction. The lack of SDM with older patients in the ED may increase inequality in health. Patients with low health literacy are at risk of safety threats, nonadherence, and preventable re-admissions. Therefore, healthcare professionals should systematically investigate older poly-medicated patients' preferences and discuss the side effects and the possibility of reducing harmful medicine.

Implementing a new emergency department: a qualitative study of health professionals' change responses and perceptions.

BACKGROUND: The aim of the study is two-fold. It explores how managers and key employees at the Emergency Department (ED) and specialist departments in a university hospital in the Capital Region of Denmark respond to the planned change to a new ED, and how they perceive the change involved in the implementation of the new ED. The study investigates what happens when health professionals are confronted with implementation of policy that changes their organization and everyday work lives. Few studies provide in-depth investigations of health professionals' reactions to the implementation of new EDs, and particularly how they influence the implementation of a nationwide organizational change framed within a political strategy. METHODS: The study used semi-structured individual interviews with 51 health professionals involved in implementation activities related to an organizational change of establishing a new ED with new patient pathways for acutely ill patients. The data was deductively analyzed using Leon Coetsee's theoretical framework of change responses, but the analysis also allowed for a more inductive reading of the material. RESULTS: Fourteen types of responses to establishing a new ED were identified and mapped onto six of the seven overall change responses in Coetsee's framework. The participants perceived the change as particularly three changes. Firstly, they wished to create the best possible acute patient pathway in relation to their specialty. Whether the planned new ED would redeem this was disputed. Secondly, participants perceived the change as relocation to a new building, which both posed potentials and worries. Thirdly, both hopeful and frustrated statements were given about the newly established medical specialty of emergency medicine (EM), which was connected to the success of the new ED. CONCLUSIONS: The study showcases how implementation processes within health care are not straightforward and that it is not only the content of the implementation that determines the success of the implementation and its outcomes but also how these are perceived by managers and employees responsible for the process and their context. In this way, managers must recognize that it cannot be pre-determined how implementation will proceed, which necessitates fluid implementation plans and demands implementation managements skills.

Feasibility and implementation fidelity of a co-designed intervention to promote in-hospital mobility among older medical patients-the WALK-Copenhagen project (WALK-Cph).

BACKGROUND: Mobility interventions can prevent functional decline among older patients, but implementation of such interventions may be complicated by barriers in the clinical setting. The WALK-Copenhagen project (WALK-Cph) is aimed at promoting a 24-h mobility among older medical patients during hospitalization. The WALK-Cph intervention was co-designed by researchers and stakeholders to tailor the intervention to the clinical context. The aim of this study was to investigate the feasibility and implementation fidelity of the WALK-Cph intervention before evaluating clinical effectiveness in a randomized controlled trial (ClinicalTrials.gov NCT03825497). METHODS: The WALK-Cph intervention consisted of six components: a welcome folder explaining the importance of in-hospital activity, a WALK-plan prescribing up to three daily walking sessions during and after hospitalization, a WALK-path in the hallway that patients were motivated to use daily, exercise posters in the hallways and bedrooms, self-service on beverages and clothes, and discharge with a WALK-plan. The present study reports on phase 2 of WALK-Cph and consists of a feasibility and a fidelity component. The study was conducted at the two WALK-Cph intervention departments after the initiation of the WALK-Cph intervention. A cohort of older medical patients (+65) was recruited for the feasibility study to assess recruitment and data collection procedures and the method for assessment of activity. Simultaneously, implementation fidelity was assessed by observing clinical practice and intervention delivery at the intervention departments. RESULTS: A feasibility cohort of 48 patients was included. Inclusion was considered feasible with recruitment rates between 62% and 70% of all eligible patients. Also, data collection was conducted without obstacles, and all patients accepted to wear activity monitors. The fidelity observations showed that three of the six intervention components were partially implemented as planned whereas three components were not implemented as planned. CONCLUSION: The WALK-Cph intervention was found feasible, and although the intervention was not implemented with fidelity, the level of fidelity was considered sufficient to continue with further testing of the WALK-Cph intervention in a large-scale trial. TRIAL REGISTRATION: ClinicalTrials.gov NCT03825497 (retrospectively registered). Protocol PubMed ID (PMID): 29523569.

Co-designing implementation strategies for the WALK-Cph intervention in Denmark aimed at increasing mobility in acutely hospitalized older patients: a qualitative analysis of selected strategies and their justifications.

BACKGROUND: Selecting appropriate strategies to target barriers to implementing interventions represents a considerable challenge in implementation research and practice. The aim was to investigate what categories of implementation strategies were selected by health care practitioners and their managers in a co-design process and how they justified these strategies aimed at facilitating the implementation of the WALK-Cph intervention. METHODS: The study used a qualitative research design to explore what implementation strategies were selected and the justifications for selecting these strategies. Workshops were used because this qualitative method is particularly well suited for studying co-design processes that involve substantial attention to social interaction and the context. Data were 1) analyzed deductively based on the Proctor et al. taxonomy of implementation strategies, 2) categorized in accordance with the ERIC compilation of implementation strategies by Powell et al., and 3) analyzed to examine the justification for the selected strategies by the Proctor et al. framework for justifications of implementation strategies. RESULTS: Thirteen different types of implementation strategies were chosen across two hospitals. The deductive analysis showed that selection of implementation strategies was based on pragmatic and theoretical justifications. The contents of the two types of justifications were thematized into nine subthemes. CONCLUSION: This study contributes with knowledge about categories and justification of implementation strategies selected in a co-design process. In this study, implementation strategies were selected through pragmatic and theoretical justifications. This points to a challenge in balancing strategies based on practice-based and research-based knowledge and thereby selection of strategies with or without proven effectiveness.

Development, implementation and evaluation of an optimized cross-sectoral rehabilitation program after acute hip fracture surgery: A mixed-methods study.

Fall-related hip fracture (HF) is a frequent trauma in Scandinavia with a yearly incidence of 8,000 among ≥65-year-old citizens in Denmark. The rising incidence and global predictions are alarming since a HF is a major, and potentially fatal, trauma to the citizen, requiring acute surgery, a multimodal approach and post-operative crosssectoral rehabilitation. However, continuity of the rehabilitation program is frequently interrupted in the transition between sectors, compromising optimal recovery of frail citizens. Thus, there is a need to develop and implement optimized cross-sectoral rehabilitation after HF. The purpose of this explorative study was to develop, implement and evaluate an optimized cross-sectoral rehabilitation program (OCRP) after HF surgery using validated theoretical frameworks. OCRP was developed, implemented and evaluated in one municipality using a pragmatic user-centered approach, quantitative and qualitative data collection and theoretical frameworks including the Behavior Change Wheel (BCW) and RE-AIM. Results of OCRP showed optimized rehabilitation based on motivated health professionals, high patient satisfaction and tendencies of improved levels of physical function. No re-referrals to rehabilitation were reported after OCRP. The BCW, RE-AIM and user-centered approach to program development, implementation and evaluation are useful to apply in program development and evaluation processes across sectors, professions, and medical specialties.

The challenge of involving old patients with polypharmacy in their medication during hospitalization in a medical emergency department: An ethnographic study.

BACKGROUND: More than 70% of patients admitted to emergency departments (EDs) in Denmark are older patients with multimorbidity and polypharmacy vulnerable to adverse events and poor outcomes. Research suggests that patient involvement and shared decision-making (SDM) could optimize the treatment of older patients with polypharmacy. The patients become more aware of potential outcomes and, therefore, often tend to choose less medication. However, implementing SDM in clinical practice is challenging if it does not fit into existing workflows and healthcare systems. AIM: The aim was to explore the determinants of patient involvement in decisions made in the ED about the patient's medication. METHODS: The design was a qualitative ethnographic study. We observed forty-eight multidisciplinary healthcare professionals in two medical EDs focusing on medication processes and patient involvement in medication. Based on field notes, we developed a semi-structured interview guide. We conducted 20 semi-structured interviews with healthcare professionals to elaborate on the findings. Data were analyzed with thematic analyses. FINDINGS: We found five themes (determinants) which affected patient involvement in decisions about medicine in the ED: 1) blurred roles among multidisciplinary healthcare professionals, 2) older patients with polypharmacy increase complexity, 3) time pressure, 4) faulty IT- systems, and 5) the medicine list as a missed enabler of patient involvement. CONCLUSION: There are several barriers to patient involvement in decisions about medicine in the ED and some facilitators. A tailored medication conversation guide based on the SDM methodology combined with the patient's printed medicine list and well-functioning IT- systems can function as a boundary object, ensuring the treatment is optimized and aligned with the patient's preferences and goals.

Adaptations and modifications to a co-designed intervention and its clinical implementation: a qualitative study in Denmark.

BACKGROUND: There is a long-standing debate in implementation research on whether adaptations to evidence-based interventions (EBIs) are desirable in health care. If an intervention is adapted and not delivered as conceived and planned, it is said to have low fidelity. The WALK-Cph project was developed based on the assumption that involving stakeholders in co-design processes would facilitate the fidelity of an intervention to increase the mobility of acutely admitted older medical patients and its implementation in two hospitals in Denmark. The purpose of this study is to describe and analyse adaptations and modifications that were made to the co-designed WALK-Cph intervention and its implementation. METHODS: This study used a qualitative design. An ethnographic field study was performed using participant observations, workshops and semi-structured interviews. Data were analysed twice using the Framework Method. The first analysis was based on the frameworks from Stirman, Moore and Proctor. The second analysis, a retrospective modifications analysis, was based on the Adaptation-Impact Framework. RESULTS: Many different types of adaptations and modifications were made to the WALK-Cph intervention and its implementation plan. Most of the modifications were made on the contents of the intervention. In total, 44 adaptations and modifications were made, of which 21 were planned (adaptations) and 23 were made haphazardly (modifications). Most of the content and context adaptations and modifications made on the intervention had a mixed result regarding enhanced fidelity. The retrospective modifications analysis showed that modifications were ongoing and both situationally and contextually shaped. CONCLUSIONS: Although an extensive co-design process was carried out to facilitate the fidelity of the WALK-Cph intervention, this study showed that many adaptations and modifications were still made to both the intervention and its implementation plan. It could indicate that the co-design process had a small effect or that adaptations and modifications are ongoing and both situationally and contextually shaped, which challenge the assumption and the desire to be able to plan and control changes.

Social Distancing Policies in the Coronavirus Battle: A Comparison of Denmark and Sweden.

Social distancing measures have been a key component in government strategies to mitigate COVID-19 globally. Based on official documents, this study aimed to identify, compare and analyse public social distancing policy measures adopted in Denmark and Sweden regarding the coronavirus from 1 March 2020 until 1 October 2020. A key difference was the greater emphasis on laws and executive orders (sticks) in Denmark, which allowed the country to adopt many stricter policy measures than Sweden, which relied mostly on general guidelines and recommendations (sermons). The main policy adopters in Denmark were the government and the Danish Parliament, whereas the Public Health Agency issued most policies in Sweden, reflecting a difference in political governance and administrative structure in the two countries. During the study period, Sweden had noticeably higher rates of COVID-19 deaths and hospitalizations per 100,000 population than Denmark, yet it is difficult to determine the impact or relative effectiveness of sermons and sticks, particularly with regard to broader and longer-term health, economic and societal effects.

An Ethnographic study of unhealthy alcohol use in a Danish Emergency Department.

BACKGROUND: Emergency Departments (EDs) are important arenas for the detection of unhealthy substance use. Screening, Brief Intervention, and Referral to Treatment (SBIRT) for unhealthy alcohol use has been used in some ED settings with funding support from external sources. However, widespread sustained implementation is uncommon, and research aimed at understanding culture as a determinant for implementation is lacking. This study aims to explore cultural practices concerning the handling of patients with unhealthy alcohol use admitted to an ED. METHODS: An ethnographic study was conducted in an ED in the Capital Region of Denmark. The data consists of participant observations of Health Care Professionals (HCPs) and semi-structured interviews with nurses. Data was collected from July 2018 to February 2020. A cultural analysis was performed by using Qualitative Content Analysis as an analytic tool. RESULTS: 150 h of observation and 11 interviews were conducted. Three themes emerged from the analysis: (1) Setting the scene describes how subthemes "flow," "risky environment," and "physical spaces and artefacts" are a part of the contextual environment of an ED, and their implications for patients with unhealthy alcohol use, such as placement in certain rooms; (2) The encounter presents how patients' and HCPs' encounters unfold in everyday practice. Subtheme "Professional differences" showcases how nurses and doctors address patients' alcohol habits differently, and how they do not necessarily act on the information provided, due to several factors. These factors are shown in remaining sub-themes "gut-feeling vs. clinical parameters," "ethical reasoning," and "from compliance to zero-tolerance"; and (3) Collective repertoires shows how language shapes the perception of patients with unhealthy alcohol use, which may cause stigma and stereotyping. Subthemes are "occupiers" and "alcoholic or party animal?". CONCLUSIONS: Unhealthy alcohol use in the ED is entangled in complex cultural networks. Patients with severe and easily recognizable unhealthy alcohol use-characterized by an alcohol diagnosis in the electronic medical record, intoxication, or unwanted behavior-shape the general approach and attitude to unhealthy alcohol use. Consequently, from a prevention perspective, this means that patients with less apparent unhealthy alcohol use tend to be overlooked or neglected, which calls for a systematic screening approach.

Challenges in co-designing an intervention to increase mobility in older patients: a qualitative study.

PURPOSE: The aim of this study is to explore and discuss key challenges associated with having stakeholders take part in co-designing a health care intervention to increase mobility in older medical patients admitted to two medical departments at two hospitals in Denmark. DESIGN/METHODOLOGY/APPROACH: The study used a qualitative design to investigate the challenges of co-designing an intervention in five workshops involving health professionals, patients and relatives. "Challenges" are understood as "situations of being faced with something that needs great mental or physical effort in order to be done successfully and therefore tests a person's ability" (Cambridge Dictionary). Thematic content analysis was conducted with a background in the analytical question: "What key challenges arise in the material in relation to the co-design process?". FINDINGS: Two key challenges were identified: engagement and facilitation. These consisted of five sub-themes: recruiting patients and relatives, involving physicians, adjusting to a new researcher role, utilizing contextual knowledge and handling ethical dilemmas. RESEARCH LIMITATIONS/IMPLICATIONS: The population of patients and relatives participating in the workshops was small, which likely affected the co-design process. PRACTICAL IMPLICATIONS: Researchers who want to use co-design must be prepared for the extra time required and the need for skills concerning engagement, communication, facilitation, negotiation and resolution of conflict. Time is also required for ethical discussions and considerations concerning different types of knowledge creation. ORIGINALITY/VALUE: Engaging stakeholders in co-design processes is increasingly encouraged. This study documents the key challenges in such processes and reports practical implications.

Older medical patients' experiences with mobility during hospitalization and the WALK-Copenhagen (WALK-Cph) intervention: A qualitative study in Denmark.

For years, bed rest and low mobility amongst older, hospitalized patients have attracted researchers' attention and efforts have been made to understand how and why interventions might work or not. This study explores older medical patients' experiences with the WALK Copenhagen (WALK-Cph) intervention, which aims at increasing in-hospital mobility and with mobility during hospitalization more generally. Semi-structured interviews were conducted with 20 patients aged 65 to 93 (mean=77, SD=8) in two Danish hospital departments. Overall, the fundamental idea of the intervention was regarded meaningful and relevant by the patients. The intervention components, however, were interpreted in different ways and risked becoming invisible. Thus, the intervention was not a quick fix to increase mobility, as the patients had different experiences with in-hospital mobility. The patients' practices of in-hospital mobility were influenced by personal experiences with illness and recovery, encouragement and support from others, hospital materialities and wishes to return to everyday active lives.