How can health systems approach reducing health inequalities? An in-depth qualitative case study in the UK.

BACKGROUND: Addressing socioeconomic inequalities in health and healthcare, and reducing avoidable hospital admissions requires integrated strategy and complex intervention across health systems. However, the understanding of how to create effective systems to reduce socio-economic inequalities in health and healthcare is limited. The aim was to explore and develop a system's level understanding of how local areas address health inequalities with a focus on avoidable emergency admissions. METHODS: In-depth case study using qualitative investigation (documentary analysis and key informant interviews) in an urban UK local authority. Interviewees were identified using snowball sampling. Documents were retrieved via key informants and web searches of relevant organisations. Interviews and documents were analysed independently based on a thematic analysis approach. RESULTS: Interviews (n = 14) with wide representation from local authority (n = 8), NHS (n = 5) and voluntary, community and social enterprise (VCSE) sector (n = 1) with 75 documents (including from NHS, local authority, VCSE) were included. Cross-referenced themes were understanding the local context, facilitators of how to tackle health inequalities: the assets, and emerging risks and concerns. Addressing health inequalities in avoidable admissions per se was not often explicitly linked by either the interviews or documents and is not yet embedded into practice. However, a strong coherent strategic integrated population health management plan with a system's approach to reducing health inequalities was evident as was collective action and involving people, with links to a "strong third sector". Challenges reported include structural barriers and threats, the analysis and accessibility of data as well as ongoing pressures on the health and care system. CONCLUSION: We provide an in-depth exploration of how a local area is working to address health and care inequalities. Key elements of this system's working include fostering strategic coherence, cross-agency working, and community-asset based approaches. Areas requiring action included data sharing challenges across organisations and analytical capacity to assist endeavours to reduce health and care inequalities. Other areas were around the resilience of the system including the recruitment and retention of the workforce. More action is required to embed reducing health inequalities in avoidable admissions explicitly in local areas with inaction risking widening the health gap.

For better or worse: Governing healthcare organisations in times of financial distress.

Due to processes of financialisation, financial parties increasingly penetrate the healthcare domain and determine under which conditions care is delivered. Their influence becomes especially visible when healthcare organisations face financial distress. By zooming-in on two of such cases, we come to know more about the considerations, motives and actions of financial parties in healthcare. In this research, we were able to examine the social dynamics between healthcare executives, banks and health insurers involved in a Dutch hospital and mental healthcare organisation on the verge of bankruptcy. Informed by interviews, document analysis and translation theory, we reconstructed the motives and strategies of executives, banks and health insurers and show how they play a crucial role in decision-making processes surrounding the survival or downfall of healthcare organisations. While parties are bound by legislation and company procedures, the outcome of financial distress can still be influenced. Much depends on how executives are perceived by financial stakeholders and how they deal with threats of destabilisation of the network. We further draw attention to the consequences of financialisation processes on the practices of healthcare organisations in financial distress.

Team experiences of the root cause analysis process after a sentinel event: a qualitative case study.

BACKGROUND: Root cause analysis (RCA) is a systematic approach, typically involving several stages, used in healthcare to identify the underlying causes of a medical error or sentinel event. This study focuses on how members of a Norwegian RCA team experience aspects of an RCA process and whether it complies with the Norwegian RCA method. METHOD: Based on a sentinel event in which a child died unexpectedly during childbirth in a Norwegian hospital in 2021, the following research questions are addressed: 1. What was the RCA team's experience of the RCA process? 2. Was there compliance with the Norwegian RCA method in this case? A case study was chosen out of the desire to understand complex social phenomena and to allow in-depth focus on a case. RESULTS: The result covered three main themes. The first theme related to the hospital's management system and aspects of the case that made it challenging to follow all recommendations in the Norwegian RCA guidelines. The second theme encompassed external and internal assessment. The RCA team was composed of members with methodological and medical expertise. However, the police's involvement in the case made it complex for the team to carry out the process. The third and final theme covered intrapersonal challenges RCA team members faced. Team members experienced various challenges during the RCA process, including being neutral, dealing with role-related challenges, grappling with ambivalence, and managing the additional time burden and resource constraints. As anticipated in the RCA guidelines, the team's ability to remain neutral was tested. CONCLUSION: The findings of this study can help stakeholders better comprehend how an inter-professional RCA teamwork intervention can affect a healthcare organization and enhance the teamwork experience of healthcare staff while facilitating improvements in work processes and patient safety. Additionally, these results can guide stakeholders in creating, executing, utilizing, and educating others about RCA processes.

Factors Associated with Implementing the Integrated Behavioral Health Care Model and Iraqi Refugees in the USA.

The aim was to identify which factors facilitate providing integrated behavioral health care for Iraqi refugees in nationally recognized community health center in Northern USA. The social-ecological model (SEM) framework guided this qualitative case study exploring the experience of 11 professional staff. Data were collected from June through August 2021 through individual interviews. Eight themes emerged based on the SEM levels: Intrapersonal-gender-driven engagement; interpersonal-the need for discretion and trusting relationship; community-collaboration with community resources and integrator from the community; organizational-holistic care, and long-term care; and policy-insufficient educational preparation. The results highlight components for clinical practice and policymakers regarding a population that is a big consumer of mental health care. Future research should explore other vulnerable populations, the effect of social groups, and the incorporation of community resources as part of the integrated care team.

Learning experiences of first year graduate entry nursing students in New Zealand and Australia: a qualitative case study.

BACKGROUND: Graduate entry nursing programmes provide students with an accelerated pathway to becoming a registered nurse. Motivations for study, together with commonly shared characteristics of students enrolling in such programmes is becoming well documented, however, their experiences of studying for a professional qualification in this manner is less understood. As a means of maintaining the relevance of these fast-tracked programmes in the future, an understanding of graduate entry nursing students' experiences of academic teaching and clinical placements is imperative. OBJECTIVE: To explore the academic and clinical experiences of students enrolled in the first year of graduate entry nursing programmes in New Zealand and Australia. METHODS: A qualitative case study approach was taken. Here we report the experiences of nine students enrolled in their first year of a two-year graduate entry nursing programme during 2020. Semi-structured interviews were used for data collection and analysed using Braun and Clarke's thematic analysis. FINDINGS: Three overarching themes were developed-affirmation, reflections on expectations and clinical experiences. CONCLUSION: This study highlights the experiences of first year graduate entry nursing students, with many experiencing affirmation that their altruistic career visions came to fruition. The findings indicate that these graduate-entry nursing students interviewed for this study tended to be flexible and adaptable in their approach to study as a means of meeting the challenges of the programme, all of which are key characteristics for a registered nurse; with personal growth and the development of the self, providing preparation for their second year of study.

A comprehensive eHealth implementation guide constructed on a qualitative case study on barriers and facilitators of the digital care platform CMyLife.

BACKGROUND: Substantial proliferation of eHealth has enabled a move in patient-centred cancer care from the traditional in-person care model to real-time, dynamic, and technology supported on-demand care. However, in general, the uptake of these innovations is low. Studies show that eHealth is helpful in providing patient empowerment through e.g. providing high quality and timely information, enabling self-monitoring and shared decision making, but dropout rates are high and guidance for optimal implementation is lacking. AIM: To explore barriers to and facilitators for nationwide implementation and consolidation of CMyLife, a multi-component, patient-centred, digital care platform, and to construct a comprehensive implementation guide for launching digital care platforms in daily clinical practice. METHODS: The first qualitative case study of a digital care platform like CMyLife was performed including five focus group- and eighteen in-depth interviews with stakeholders. Data were collected using a semi-structured interview guide, based on the frameworks of Grol and Flottorp. Transcripts of the interviews were analysed and barriers and facilitators were identified and categorized according to the frameworks. An iterative process including participation of main stakeholders and using the CFIR-ERIC framework led to creating a comprehensive implementation guide for digital care platforms. RESULTS: In total, 45 barriers and 41 facilitators were identified. Main barriers were lack of connectivity between information technology systems, changing role for both health care providers and patients, insufficient time and resources, doubts about privacy and security of data, and insufficient digital skills of users. Main facilitators mentioned were motivating patients and health care providers by clarifying the added value of use of a digital care platform, clear business case with vision, demonstrating (cost) effectiveness, using an implementation guide, and educating patients and health care providers about how to use CMyLife. Based on these barriers and facilitators a clear and comprehensive implementation guide was developed for digital care platforms. CONCLUSION: Several barriers to and facilitators for implementation were identified, a clear overview was presented, and a unique comprehensive implementation guide was developed for launching future digital care platforms in daily clinical practice. The next step is to validate the implementation guide in other (oncological) diseases.

COVID-19 - an opportunity to improve access to primary care through organizational innovations? A qualitative multiple case study in Quebec and Nova Scotia (Canada).

BACKGROUND: COVID-19 catalyzed a rapid and substantial reorganization of primary care, accelerating the spread of existing strategies and fostering a proliferation of innovations. Access to primary care is an essential component of a healthcare system, particularly during a pandemic. We describe organizational innovations aiming to improve access to primary care and related contextual changes during the first 18 months of the COVID-19 pandemic in two Canadian provinces, Quebec and Nova Scotia. METHODS: We conducted a multiple case study based on 63 semi-structured interviews (n = 33 in Quebec, n = 30 in Nova Scotia) conducted between October 2020 and May 2021 and 71 documents from both jurisdictions. We recruited a diverse range of provincial and regional stakeholders (e.g., policy-makers, decision-makers, family physicians, nurses) involved in reorganizing primary care during the COVID-19 pandemic using purposeful sampling (e.g., based on role, region). Interviews were transcribed verbatim and thematic analysis was conducted in NVivo12. Emerging results were discussed by team members to identify salient themes and organized into logic models. RESULTS: We identified and analyzed six organizational innovations. Four of these - centralized public online booking systems, centralized access centers for unattached patients, interim primary care clinics for unattached patients, and a community connector to health and social services for older adults - pre-dated COVID-19 but were accelerated by the pandemic context. The remaining two innovations were created to specifically address pandemic-related needs: COVID-19 hotlines and COVID-dedicated primary healthcare clinics. Innovation spread and proliferation was influenced by several factors, such as a strengthened sense of community amongst providers, decreased patient demand at the beginning of the first wave, renewed policy and provider interest in population-wide access (versus attachment of patients only), suspended performance targets (e.g., continuity ≥80%) in Quebec, modality of care delivery, modified fee codes, and greater regional flexibility to implement tailored innovations. CONCLUSION: COVID-19 accelerated the uptake and creation of organizational innovations to potentially improve access to primary healthcare, removing, at least temporarily, certain longstanding barriers. Many stakeholders believed this reorganization would have positive impacts on access to primary care after the pandemic. Further studies should analyze the effectiveness and sustainability of innovations adapted, developed, and implemented during the COVID-19 pandemic.

Positive school climate for school staff? The roles of administrators, staff beliefs, and school organization in high and low resource school districts.

Despite continued calls for positive school climate, school staff members are rarely included in school climate research or theories. This qualitative case study explored how socioeconomic status (SES), school districts, leadership, and school contexts combine to create school climate. Four schools were selected from a sample of positive and negative climate schools in one high and one low-SES district. Data collection involved key informant interviews and observation. District and school SES did not directly dictate the quality of climate. Organizational variables such as the principal's decisions and vision were key influences on the quality of climate for staff members. Staff members often prioritize student experiences of climate above their own experiences. School organization and the influence of the principal are critical for the quality of school climate staff members experience; these along with staff voice are critical ongoing contributions to school climate research, theory, and practice.

Health priority-setting for official development assistance in low-income and middle-income countries: a Best Fit Framework Synthesis study with primary data from Ethiopia, Nigeria and Tanzania.

BACKGROUND: Decision making process for Official Development Assistance (ODA) for healthcare sector in low-income and middle-income countries involves multiple agencies, each with their unique power, priorities and funding mechanisms. This process at country level has not been well studied. METHODS: This paper developed and applied a new framework to analyze decision-making process for priority setting in Ethiopia, Nigeria, and Tanzania, and collected primary data to validate and refine the model. The framework was developed following a scoping review of published literature. Interviews were then conducted using a pre-determined interview guide developed by the research team. Transcripts were reviewed and coded based on the framework to identify what principles, players, processes, and products were considered during priority setting. Those elements were further used to identify where the potential capacity of local decision-makers could be harnessed. RESULTS: A framework was developed based on 40 articles selected from 6860 distinct search records. Twenty-one interviews were conducted in three case countries from 12 institutions. Transcripts or meeting notes were analyzed to identify common practices and specific challenges faced by each country. We found that multiple stakeholders working around one national plan was the preferred approach used for priority setting in the countries studied. CONCLUSIONS: Priority setting process can be further strengthened through better use of analytical tools, such as the one described in our study, to enhance local ownership of priority setting for ODA and improve aid effectiveness.

Implementation, experience, and challenges of urban health extension program in Addis Ababa: a case study from Ethiopia.

BACKGROUND: Even though the urban health extension program (HEP) has been implemented since 2009, little was known about its implementation, experience and challenges. Therefore, this study was aimed at exploring the implementation, experience, and challenges of the urban HEP. METHODS: A qualitative case study was conducted in Addis Ababa from November 15 to December 29, 2017. The study participants were recruited purposefully. The parent populations were health extension professionals (HEPs). However, health post supervisors, health development army leaders (HDAs), Addis Ababa city HEP administrators, and other community members were also involved in the study. Four focus group discussions and 31 in-depth and key informant interviews were conducted. Data were transcribed verbatim, translated into the English, and analyzed by an inductive thematic analysis approach using Atlas ti7.1 software. RESULT: The study found that there were 15 health service packages of the urban HEP delivered to the community based on the need of the households. The strategies for the program implementation were provision of trainings, home visitation, creation of model households, strengthening of HDAs, supervision and reporting, referral and feedback, and social and community mobilization. However, program implementation was challenged by the health system related challenges (health service package and delivery, workload of HEPs, shortage of trained HEPs, lack of regular supervision or monitoring, lack of logistical or motivational support, poor supply chain management, dissatisfaction of HEPs, assigning of more than expected households for HEPs, etc.), multisectoral related and community related challenges (HDAs need of incentives, and lack of graduating model households as per the plan, etc.). CONCLUSIONS: Although the program had a significant contribution to the health of community, it was affected by different challenges that underscore the need to develop different strategies and taking of actions. Therefore, the district health office, health centers and stakeholders from different sectors should have to support and motivate the HEPs and HDAs, and work together with them for successful implementation of the program.

Experiences of Pain in Hospitalized Children During Hematopoietic Stem Cell Transplantation Therapy.

Children undergoing hematopoietic stem cell transplantation (HSCT) are vulnerable to pain due to the intensity and toxicity of this treatment. An instrumental case study design of two qualitative phases was conducted to examine the pain experiences of hospitalized children during HSCT therapy and how contextual factors related to the pediatric HSCT environment influenced their experience of pain. The Social Communication Model of Pain provided the conceptual framework for the study. In Phase 1, semi-structured interviews were conducted with parents of a child undergoing HSCT therapy at two time points. Phase 2 was conducted as a naturalistic observational study of the clinical care provided to children and semi-structured interviews with health-care providers. Children experienced complex and multifaceted pain with physical, psychological, and contextual contributors. Understanding the many factors contributing to the child's pain experience can inform strategies to improve the management of pain during HSCT therapy.

'It benefits patient care': the value of practice-based IPE in healthcare curriculums.

BACKGROUND: Practice-based interprofessional education (IPE) is essential to prepare students for collaborative working. Pockets of practice-based IPE are integrated into healthcare curriculums in some regions. Yet practice-based IPE is not globally valued as a key element of healthcare curriculums. As students and clinical educators are key stakeholders, this study presents a case example of their experiences in a country where practice-based IPE is at an emergent stage. Their experiential knowledge generated important insights into how practice-based IPE is perceived. This learning can be applied, both locally and further afield, by those seeking to embed practice-based IPE in their placement curriculums. METHODS: A qualitative case study was conducted at a school of allied health and partner placement sites in Ireland. Data collection comprised two participant observations, 13 interviews and 12 document analyses. Inductive thematic analysis and deductive framework analysis, underpinned by activity theory and Hofstede's cultural dimensions, informed data analysis and interpretations. RESULTS: Participants are grappling to establish the value of practice-based IPE, illustrated in three themes: clarifying the concept of practice-based IPE, mapping IPE activities and diversifying interprofessionalism. First, ambiguous conceptualisation of why and how to implement practice-based IPE was identified. Highlighting how practice-based IPE improved patient care and safety created a clear rationale for implementation. It was also helpful to demonstrate how adaptations to existing practice education models, rather than entirely new models, could achieve high-quality practice-based IPE. Second, the positioning of practice-base IPE in the placement curriculum was unclear. Overt mapping of practice-based IPE activities onto learning outcomes within assessment tools enhanced its value within practice education. Third, varying levels of professional engagement were noted, perpetuating stereotypes. Creating diverse educator networks and embedding practice-based IPE in organisational strategy may incentivise engagement across a greater range of professions. CONCLUSIONS: Implementing these recommendations could enhance the value of practice-based IPE and optimise student preparation for collaborative working. Practice-based IPE remains a complex model and the trajectory of embedding in healthcare curriculums will differ globally.

Developing evidence briefs for policy: a qualitative case study comparing the process of using a guidance-contextualization workbook in Peru and Uganda.

BACKGROUND: Translating research evidence from global guidance into policy can help strengthen health systems. A workbook was developed to support the contextualization of the WHO's 'Optimizing health worker roles to improve maternal and newborn health' (OptimizeMNH) guidance. This study evaluated the use of the workbook for the development of evidence briefs in two countries - Peru and Uganda. Findings surrounding contextual factors, steps in the process and evaluation of the workbook are presented. METHODS: A qualitative embedded case study was used. The case was the process of using the workbook to support the contextualization of global health systems guidance, with local evidence, to develop evidence briefs. Criterion sampling was used to select the countries, participants for interviews and documents included in the study. A template-organizing style and constant comparison were used for data analysis. RESULTS: A total of 19 participant-observation sessions and 8 interviews were conducted, and 50 documents were reviewed. Contextual factors, including the cadres, or groups, of health workers available in each country, the way the problem and its causes were framed, potential policy options to address the problem, and implementation considerations for these policy options, varied substantially between Peru and Uganda. However, many similarities were found in the process of using the workbook. Overall, the workbook was viewed positively and participants in both countries would use it again for other topics. CONCLUSIONS: Organizations that produce global guidance, such as WHO, need to consider institutionalizing the application of the workbook into their guidance development processes to help users at the national/subnational level create actionable and context-relevant policies. Feedback mechanisms also need to be established so that the evidence briefs and health policies arising from global guidance are tracked and the findings coming out of such guideline contextualization processes can be taken into consideration during future guidance development and research priority-setting.

The Structuration of Community-Based Mental Health Care: A Duality Analysis of a Volunteer Group's Local Agency.

Using a lens of structuration theory, this study highlights the ways that specific structures within the current community-based model of mental health care might enable and constrain individuals and families living with mental illness. Through a case study of a volunteer mental illness advocacy group, the authors employed a duality analysis on a variety of data collected from the case (i.e., interviews, organizational documents, and community health care data). Findings indicate that while group members encountered structural barriers to their organizational mission, they also used communicative agency creatively and collectively to (re)create structures within the current community-based model of mental health care. Member agency is examined in relation to perceived structural influence. Theoretical and practical applications of the findings are discussed.

Needs assessment regarding occupational health and safety interventions among textile workers: A qualitative case study in Karachi, Pakistan.

OBJECTIVE: To determine the perceived health and safety needs identified by textile workers, managers and experts as well as direct observation of the prevailing health and safety practices in the textile industry. METHODS: The qualitative study using the needs assessment conceptual framework was conducted in July-August 2015 in Karachi, and comprised focus group discussions with textile workers, in-depth interviews with factory managers and health and safety officers, and key informant interviews with relevant stakeholders and experts. A walk-through survey was also conducted in selected mills for which the Checklist of hazards in textiles was used. RESULTS: A total of 6focus group discussions, 6 in-depth interviews and 5 key informant interviews were conducted. Workers were found to have limited knowledge of occupational hazards, preventions and diseases. They identified lack of awareness and non-existent safety mechanisms as areas for improvement. Managers thought preventive practices and health services were not standardised while influence of buyers in the form of international business regulations and legislations were thought to be the enabling factors for enforcing health and safety standards. Poor governance, lack of knowledge regarding labour rights, low literacy level, poor compliance and low wages were the barriers for health promotion at workplace, as identified by the experts. Walk-through survey found mechanisms in place for fire safety, but the workers and managers were generally not using Personal Protective Equipment despite the presence of several hazards at workplace. CONCLUSIONS: There was found a need for context-specific occupational health and safety interventions at individual, organisational and policy levels.

The impact of a prolonged stay in the ICU on patients' fundamental care needs.

AIMS AND OBJECTIVES: To explore patients', families' and health professionals' experiences of a long-stay patient in an intensive care unit. BACKGROUND: The fast-paced technologically driven intensive care unit environment, designed for a short patient stay, supports the provision of complex physiologically focused care for those with life-threatening illnesses. Long-stay patients with pronounced fundamental care needs fall outside predicted patient pathways, and nurses can find caring for these patients challenging. DESIGN AND METHODS: A longitudinal, qualitative, multicase study of six cases from four New Zealand units. Case participants were patients, family members, nurses and other health professionals. Data collection methods included observation, conversations, interviews and document review. Data were analysed using thematic analysis, vignette development and trajectory mapping. RESULTS: Challenges and successes of providing fundamental care for long-stay ICU patients are attributed to two interlinked factors. First, the biomedical model influences ICU nursing practices, resulting in prioritising tasks and technology for patient survival while simultaneously devaluing relational and comfort work. Fundamental psychosocial needs such as family presence, comfort, relationships and communication may be unmet. Second, the unit environment and culture have a significant impact on long-stay patients' ICU experiences and form physical and psychological barriers to families being present and involved. Some nurses negotiated these challenges to provide fundamental, patient- and family-centred care by adopting an approach of knowing the patient and these nurses reported satisfaction when seeing patients' positive responses. CONCLUSION: The care environment and culture provide challenges to the provision of patient- and family-centred care for long-stay patients; however, when nurses prioritise knowing their patient these challenges can be overcome and patient and family distress reduced with the potential to improve patient outcomes. RELEVANCE TO CLINICAL PRACTICE: Recognition that patients have fundamental care needs irrespective of the setting where they receive care. Intensive care environments and cultures create challenges for nurses when there is such a heavy burden of physiological needs to be met and technological tasks to be undertaken, with a focus on acuity; however, improving provision fundamental care can result in positive patient outcomes.

Constructivist Simultaneous Treatment of Borderline Personality Disorder, Trauma, and Addiction Comorbidity: A Qualitative Case Study.

This qualitative case study explored one client's recovery from borderline personality disorder, trauma, and problem gambling. The client attended 18 months of integrative treatment and was followed for 5 years. The study included 106 data points of both client and therapist data. We identified three phases to treatment. First, alliance formation and normalization appeared as mechanisms, and the client experienced dependence. Second, working alliance and countertransference appeared as mechanisms, and the client experienced reduced gambling and suicidal ideation. Third, external controls and increased opportunity appeared as mechanisms, and "moving into the world" was the client experience. The findings give preliminary support to a phase-based constructivist treatment including trauma assessment to normalize self-feelings, countertransference work to support motivation for restraint, and case management principles to support continuity of change efforts.

Qualitative case study data analysis: an example from practice.

AIM: To illustrate an approach to data analysis in qualitative case study methodology. BACKGROUND: There is often little detail in case study research about how data were analysed. However, it is important that comprehensive analysis procedures are used because there are often large sets of data from multiple sources of evidence. Furthermore, the ability to describe in detail how the analysis was conducted ensures rigour in reporting qualitative research. DATA SOURCES: The research example used is a multiple case study that explored the role of the clinical skills laboratory in preparing students for the real world of practice. Data analysis was conducted using a framework guided by the four stages of analysis outlined by Morse ( 1994 ): comprehending, synthesising, theorising and recontextualising. The specific strategies for analysis in these stages centred on the work of Miles and Huberman ( 1994 ), which has been successfully used in case study research. The data were managed using NVivo software. REVIEW METHODS: Literature examining qualitative data analysis was reviewed and strategies illustrated by the case study example provided. Discussion Each stage of the analysis framework is described with illustration from the research example for the purpose of highlighting the benefits of a systematic approach to handling large data sets from multiple sources. CONCLUSION: By providing an example of how each stage of the analysis was conducted, it is hoped that researchers will be able to consider the benefits of such an approach to their own case study analysis. IMPLICATIONS FOR RESEARCH/PRACTICE: This paper illustrates specific strategies that can be employed when conducting data analysis in case study research and other qualitative research designs.

Prevention of involuntary admission through Family Group Conferencing: a qualitative case study in community mental health nursing.

AIM: To understand whether and how Family Group Conferencing might contribute to the social embedding of clients with mental illness. BACKGROUND: Ensuring the social integration of psychiatric clients is a key aspect of community mental health nursing. Family Group Conferencing has potency to create conditions for clients' social embedding and subsequently can prevent coercive measures. DESIGN: A naturalistic qualitative case study on the process of one conference that was part of 41 conferences that had been organized and studied from January 2011-September 2013 in a public mental health care setting in the north of the Netherlands. METHODS: Semi-structured interviews (N = 20) were conducted with four stakeholder groups (N = 13) involved in a conference on liveability problems in a local neighbourhood wherein a man with schizophrenia resides. FINDINGS: To prevent an involuntary admission to a psychiatric ward of a man with schizophrenia, neighbourhood residents requested a family group conference between themselves, the sister of the man and the mental health organization. As a possible conference aggravated psychotic problems, it was decided to organize it without the client. Nine months after the conference, liveability problems in the neighbourhood had been reduced and coercive measures adverted. The conference strengthened the community and resulted in a plan countering liveability problems. CONCLUSION: The case indicates that social embedding of clients with severe psychiatric problems can be strengthened by Family Group Conferencing and that hence coercive measures can be prevented. A shift is required from working with the individual client to a community driven approach.

Qualitative case study on the disability acceptance experiences of soldiers with disabilities.

PURPOSE: This study comprehensively examines the disability acceptance experience of individuals who become disabled following accidents in the military after enlistment. METHODS: In-depth interviews and participative observation of two soldiers with disabilities are conducted. Data sources encompass the transcripts from these interviews, relevant news videos, and articles on the participants. A qualitative case study approach is applied to conduct both "within-case" and "cross-case" analyses. RESULTS: Although the two participants survived a crippling accidents, their military units did not actively attempt to resolve the accident. They grappled with despair and found it challenging to accept their new status as individuals with disability. Over time, they noticed changes in their personal relationships and started considering themselves burdens on their caregivers. However, despite encountering psychological challenges, which were marked by repeated setbacks and disappointments, the soldiers consistently made determined efforts to realize their objectives. Moreover, they strove to lead purposeful lives despite suffering the adversities caused by their disabilities. CONCLUSIONS: This study is the first in-depth examination of the disability acceptance experiences of soldiers with disability. The insights gleaned from our in-depth interviews will help formulate psychological and physical support systems for such individuals.