Exploring the contexts, mechanisms and outcomes of a torture, abuse and dental anxiety service in Norway: a realist evaluation.

BACKGROUND: Torture, abuse and dental anxiety (TADA) are often precursors to developing a pathological relationship with dental care due to elevated anxiety. Consequently, patients who suffer from one or more of these tend to avoid dental services. This could leave them with severe tooth decay, which could affect their general and psychosocial health. Norwegian dental services have implemented the TADA service to specifically alleviate dental anxiety and restore oral health for the TADA patient group. However, the service has not been evaluated, and there is a need to understand how and why this service works, for whom, under what circumstances. Therefore, this study aimed to develop theories on how the service's structure alleviates dental anxiety and restores these patients' oral health. Although developed in a Norwegian context, these theories may be applicable to other national and international contexts. METHODS: This realist evaluation comprised multiple sequential methods of service and policy documents (n = 13), followed by interviews with service developers (n = 12). RESULTS: The analysis suggests that, by subsidising the TADA service, the Norwegian state has removed financial barriers for patients. This has improved their access to the service and, hence, their service uptake. National guidelines on service delivery are perceived as open to interpretation, and can hereby meet the needs of a heterogeneous patient group. The services have become tailored according to the available regional resources and heterogeneous needs of the patient population. A perceived lack of explicit national leadership and cooperative practices has resulted in regional service teams becoming self-reliant and insular. While this has led to cohesion within each regional service, it is not conducive to interservice collaborations. Lastly, the complexity of migration processes and poor dissemination practices is presumed to be the cause of the lack of recruitment of torture survivors to the service. CONCLUSIONS: Policy documents and service developers described the TADA service as a hybrid bottom-up/top-down service that allows teams to practise discretion and tailor their approach to meet individual needs. Being free of charge has improved access to the service by vulnerable groups, but the service still struggles to reach torture survivors.

Seeing the person before the teeth: A realist evaluation of a dental anxiety service in Norway.

Patients with a trauma history, whether sexual abuse or torture, or dental phobia, tend to avoid dental services due to severe dental anxiety. Subsequently, they experience poor oral health, lower quality of life, and poorer general health. In Norway, a specific service (torture, abuse, and dental anxiety [TADA]) targets these patients' dental anxiety through cognitive behavioural therapy (CBT) prior to dental restoration. By exploring patients' experiences with TADA services using a realist evaluation approach, this paper aims to increase our understanding of how this type of service addresses patients' dental anxiety in terms of its mechanisms and contextual factors. Interviews with TADA patients (n = 15) were analysed through a template analysis driven by context-mechanism-outcome heuristics. The analysis revealed that patients value a dental practitioner who provides a calm and holistic approach, positive judgements and predictability elements that lean towards a person-centred care approach. Provided this, patients felt understood and cared for, their shame was reduced, self-esteem emerged, and control was gained, which led to alleviation of dental anxiety. Therefore, our findings suggest that combining CBT with a person-centred care approach helps alleviate patients' dental anxiety. This provides insights into how dental services could be executed for these patients.

Organizational dynamics of interprofessional practice in the Norwegian prison system.

Reoffending rates may be reduced through efforts to rehabilitate prisoners. A more nuanced understanding is needed of how front-line prison and health care services collaborate during the rehabilitation process. We report an investigation of the organizational dynamics of interprofessional practice among prison, mental health, and welfare services in two Norwegian prison case studies. First, a high security (closed) prison where a coordination network was implemented among prison management, front-line staff, and external service personnel to enhance the prisoners' life management skills. Second, an (open) transitional residence, where interprofessional practice was facilitated by front-line prison staff to increase prisoners' ability to reintegrate into society through their socialization and access to external services. The study demonstrates the demands on prisoners as they move from passive service receivers to active service users/organizer, and how interprofessional practice and models of service integration support them in this process.

Exploring Norwegian prison frontline workers' perceptions of inter professional collaboration - a pilot study.

PURPOSE: Interprofessional collaboration is necessary for handling the complex psychosocial needs of prisoners. This collaboration must be addressed to avoid high recidivism rates and the human and societal costs linked to them. Challenges are exacerbated by a linear approach to handling prisoners' problems, silo working between welfare agencies and professional boundaries between frontline workers. There are few adequate theoretical frameworks and tools to address these challenges in the prison context. The purpose of this study is to explore the perceptions that frontline staff working in Norwegian prison facilities have regarding interprofessional collaboration in providing mental health services for prisoners. DESIGN/METHODOLOGY/APPROACH: This study had a non-experimental, cross-sectional design to explore perceptions of interprofessional collaboration in a prison context. Descriptive and multifactorial analyses (exploratory factor analysis and confirmatory factor analysis) were used to explore the data. FINDINGS: The analysis showed that three factors, communication, organizational culture and domain, explained 95% of the variance. Results are discussed using relational coordination, as well as the conceptual PINCOM model, as a theoretical framework. ORIGINALITY/VALUE: Few studies explicitly explore collaboration between professionals in mental health and prison services despite its being a prerequisite to achieving sufficient services for prisoners. To our knowledge, this current study is one of the first in Norway to explore collaboration in a prison context by analysing quantitative data and focusing on frontline workers perception of the phenomenon.

More than just a dental practitioner: A realist evaluation of a dental anxiety service in Norway.

Patients with dental phobia or a history of trauma tend to avoid dental services, which may, over time, lead to poor oral health. In Norway, a specific service targets these patients by providing exposure therapy to treat their fear of attendance and subsequently enable oral restoration. Dental practitioners deliver the exposure therapy, which requires a role change that deviates from their traditional practice. This paper explores how - and under what circumstances - dental practitioners manage this new role of alleviating dental anxiety for patients with a history of trauma or dental phobia. Using a realist evaluation approach, this paper develops theory describing which contexts promote mechanisms that allow practitioners to alleviate dental anxiety for patients with trauma or dental phobia. A multi-method approach, comprising service documents (n = 13) and stakeholder interviews (n = 12), was applied. The data were then analysed through a content analysis and context-mechanism-outcome heuristic tool. Our findings reveal that dental practitioners must adopt roles that enable trust, a safe space, and gradual desensitisation of the patient to their fear triggers. Adopting these roles requires time and resources to develop practitioners' skills - enabling them to adopt an appropriate communication style and exposure pace for each patient.

A conceptual model on reintegration after prison in Norway.

PURPOSE: Many offenders struggle when attempting to reintegrate into society after release from prison, and the conditions they face after release often lead to reoffending. The purpose of this paper is to present a conceptual model on reintegration after prison. The model has the potential to guide practitioners in their understanding of the relationships between welfare services and the agency of the offender. DESIGN/METHODOLOGY/APPROACH: The model was developed from a small-scale study in the Norwegian Criminal Justice system, which is well known for its emphasis on rehabilitation and crime prevention. Data collection aimed to explore the reintegration process from the perspective of the hard-to-reach and vulnerable population of serial offenders. Nine prisoners in two different prisons were interviewed. A thematic analysis identified two main themes that related, first, to the personal challenges the offenders faced in the rehabilitation and reintegration process and, second, to the factors in the welfare services that interacted with the prisoners' psychosocial issues in the reintegration process. FINDINGS: Findings suggest that the interaction between the psychosocial needs of the prisoners and the organization of the welfare services is complex and does not harmonize. The findings underpin the argument that the current reintegration strategies for certain groups of inmates need to be questioned and challenged. RESEARCH LIMITATIONS/IMPLICATIONS: The model is a conceptual model intended to provide a lens from which to reinterpret offenders' experiences of reintegration and applied to only the small and exploratory study described in this paper. As such, it requires further testing and substantiation, and the model and the study's findings should be regarded as tentative and cannot be generalized to a larger population. The prisoners were selected by the first author for convenience, and it is possible that this also influenced the findings. Other inmates may have presented other experiences. ORIGINALITY/VALUE: There are few studies looking into reintegration from the reoffenders' perspective, and this study also presents a model that serves as a reflective and analytical tool to developing new approaches to supporting offenders in their reintegration into society from prison in the future.

Making sense of interactions between mental health and criminal justice services: the utility of cultural historical activity systems theory.

Purpose Effective collaboration between mental health services (MHS) and criminal justice services (CJS) impacts on mental illness and reduces reoffending rates. This paper proposes the change laboratory model (CLM) of workplace transformation as a potential tool to support interagency collaborative practice that has potential to complement current integration tools used in this context. The purpose of this paper is to focus specifically on the theoretical dimension of the model: the cultural historical activity systems theory (CHAT) as a theoretical perspective that offers a framework with which interactions between the MHS and CJS can be better understood. Design/methodology/approach The structure and rationale behind future piloting of the change laboratory in this context is made. Then CHAT theory is briefly introduced and then its utility illustrated in the presentation of the findings of a qualitative study of leaders from MHS and CJS that explored their perspectives of the characteristics of collaborative working between MHS and prison/probation services in a Norwegian context and using CHAT as an analytical framework. Findings Leaders suggested that interactions between the two services, within the Norwegian system at least, are most salient when professionals engage in the reintegration and rehabilitation of the offender. Achieving effective communication within the boundary space between the two systems is a focus for professionals engaging in interagency working and this is mediated by a range of integration tools such as coordination plans and interagency meetings. Formalised interagency agreements and informal, unspoken norms of interaction governed this activity. Key challenges limiting the collaboration between the two systems included resource limitations, logistical issues and differences in professional judgments on referral and confidentiality. Originality/value Current tools with which MHS/CJS interactions are understood and managed, fail to make explicit the dimensions and nature of these complex interactions. The CLM, and CHAT as its theoretical underpinning, has been highly successful internationally and in other clinical contexts, as a means of exploring and developing interagency working. It is a new idea in prison development, none as yet being applied to the challenges facing the MHS and CJS. This paper addresses this by illustrating the use of CHAT as an analytical framework with which to articulate MHS/CJS collaborations and the potential of the CLM more widely to address current challenges in a context specific, bottom-up and fluid approach to interagency working in this environment.

The contribution of theory to the design, delivery, and evaluation of interprofessional curricula: BEME Guide No. 49.

BACKGROUND: Interprofessional curricula have often lacked explicit reference to theory despite calls for a more theoretically informed field that illuminates curricular assumptions and justifies curricular practices. AIM: To review the contributions of theory to the design, delivery, and evaluation of interprofessional curricula. METHODS: Four databases were searched (1988-2015). Studies demonstrating explicit and a high-quality contribution of theory to the design, delivery or evaluation of interprofessional curricula were included. Data were extracted against a comprehensive framework of curricular activities and a narrative synthesis undertaken. RESULTS: Ninety-one studies met the inclusion criteria. The majority of studies (86%) originated from the UK, USA, and Canada. Theories most commonly underpinned "learning activities" (47%) and "evaluation" (54%). Theories of reflective learning, identity formation, and contact hypothesis dominated the field though there are many examples of innovative theoretical contributions. CONCLUSIONS: Theories contribute considerably to the interprofessional field, though many curricular elements remain under-theorized. The literature offers no "gold standard" theory for interprofessional curricula; rather theoretical selection is contingent upon the curricular component to which theory is to be applied. Theories contributed to interprofessional curricula by explaining, predicting, organizing or illuminating social processes embedded in interprofessional curricular assumptions. This review provides guidance how theory might be robustly and appropriately deployed in the design, delivery, and evaluation of interprofessional curricula.

The etemic model of Gypsy Roma Traveller community vulnerability: is it time to rethink our understanding of vulnerability?

AIMS AND OBJECTIVES: To present a new etemic model of vulnerability. BACKGROUND: Despite vulnerability being identified as a core consequence of health and health experiences, there has been little research exploring the meaning of vulnerability as a concept. Yet, being vulnerable is known to have dire physical/mental health consequences. It is therefore a fundamental issue for nurses to address. To date, the meaning of the term vulnerability has been influenced by the work of Spiers (Journal of Advanced Nursing, 31, 2000, 715, The Essential Concepts of Nursing: Building Blocks for Practice, 2005, Elsevier, London). Spiers identified two aspects of vulnerability: the etic (external judgment of another persons' vulnerability) and the emic (internal lived experience of vulnerability). This approach has led to a plethora of research which has explored the etic (external judgment) of vulnerability and rendered the internal lived (or emic) experience invisible. Consequences of this, for marginalised communities such as Gypsy Roma Travellers include a lack of culturally sensitive services compounding health inequalities. DESIGN: Position paper. METHOD: Drawing upon a qualitative phenomenological research study exploring the lived experience of vulnerability from a Gypsy Roma Travelling community (published previously), this paper presents a new model of vulnerability. This etemic model of vulnerability values both external and internal dimensions of vulnerability and argues for a fusion of these two opposing perspectives. CONCLUSIONS: If nurses and other health- and social care professionals wish to develop practice that is successful in engaging with Gypsy Roma Travellers, then there is a need to both understand and respect their community. This can be achieved through an etemic approach to understanding their vulnerability achieved by eliciting lived experience alongside the appreciation of epidemiological studies. RELEVANCE TO CLINICAL PRACTICE: If nurses and health practitioners used this etemic approach to practice then it would enable both the development and delivery of culturally sensitive services facilitating health access to this community. Only then, will their poor health status be successfully addressed.

Improving collaboration between professionals supporting mentally ill offenders.

Purpose Interprofessional collaboration is necessary when supporting mentally ill offenders but little is understood of these interactions. The purpose of this paper is to explore prison officers' perceptions of current and desirable levels of interprofessional collaboration (relational coordination (RC)) to understand how collaboration between these systems can be improved. Design/methodology/approach Gittell's RC scale was administered to prison officers within the Norwegian prison system ( n=160) using an adaptation of the instrument in which actual and desired levels of RC are evaluated. This differentiates between prison officers' expectations of optimum levels of collaboration with other professional groups, dependent on the role function and codependence, vs actual levels of collaboration. Findings Prison officers reported different RC levels across professional groups, the lowest being with specialist mental health staff and prison doctors and highest with nurses, social workers and other prison officers. Significant differences between desired and actual RC levels suggest expertise of primary care staff is insufficient, as prison officers request much greater contact with mental health specialists when dealing with the mentally ill offender. Originality/value The paper contributes to limited literature on collaborative practice between prison and health care professionals. It questions the advisability of enforcing care pathways that promote the lowest level of effective care in the prison system and suggest ways in which mental health specialists might be better integrated into the prison system. It contributes to the continued debate on how mental health services should be integrated into the prison system, suggesting that the current import model used in Norway and other countries, may not be conducive to generating the close professional relationships required between mental health and prison staff.

Collaborative practices between correctional and mental health services in Norway: Expanding the roles and responsibility competence domain.

Internationally, mental illness is high in prison populations. Collaboration between the correctional services (CS) and mental health services (MHS) is required to address this. Little is known of the collaborative processes in this context, however. This article presents the findings of a study exploring the characteristics of collaborative practices between the MHS and CS in a Norwegian context. A purposeful sample (n = 12) of MHS and CS leaders was recruited from one region in Norway. Taking a generic qualitative approach, semi-structured interviews with each participant explored specific structures that promoted collaboration, the nature of collaborative relationships, and factors that facilitated or constrained these. The study indicated that leaders are exercised by one dimension of collaborative practice in particular, namely the distribution of responsibility for the care of the offender across systems. This activity is mediated by highly complex external structures as well as the individual characteristics of the professionals involved. They speculate that professionals and organisations who fail to take responsibility for the offender as expected may be constrained from doing so by resource limitations, logistical issues, and poor attitudes towards the offender population. Based on these findings, this study suggests that the MHS and CS workforce would benefit from a great knowledgeability of the roles and responsibility domains of collaborative practice. Improving competence in the workforce in this area would achieve this. However, competency frameworks that address this domain are currently limited. Recommendations on how to extend the remit of this domain in light of the current findings are provided.

Lived experience of vulnerability from a Gypsy Roma Traveller perspective.

AIMS AND OBJECTIVES: To describe the lived experience of vulnerability of individuals within a Gypsy Roma Travelling community. BACKGROUND: People experience vulnerability whenever their health or usual functioning is compromised. This may increase when they enter unfamiliar surroundings, situations or relationships. One's experience of vulnerability can also be heightened through interactions between the individual and the society within which they live. Gypsy Roma Travellers are often identified as vulnerable owing to increased morbidity and mortality as well as their marginalised status within society. Yet little is known of the experiences of vulnerability by the individuals themselves. Without their stories and experiences, health professionals cannot effectively develop services that meet their needs. DESIGN: This descriptive phenomenological study sought to explore the lived experience of vulnerability in a Gypsy Roma Travelling community. METHODS: Seventeen Gypsy Roma Travellers were interviewed in 2013-2014 about their experiences of feeling vulnerable. This paper reports on the findings from the depth phase in which 13 individuals were interviewed. The interviews were conducted and analysed using Giorgi's descriptive phenomenological approach. FINDINGS: Six constituents of the phenomenon of vulnerability were identified as feeling: defined and homogenised as a group; pressurised to conform to live in a particular way; split in one's identity; a loss of one's heritage; discriminated, persecuted and threatened; and powerlessness. RELEVANCE TO CLINICAL PRACTICE: There is a wealth of evidence that Gypsy Roma Travellers experience high levels of morbidity and mortality, which has led to them being identified by health professionals and policy makers as a vulnerable community. Exploring their lived experience of vulnerability presents a different perspective regarding this concept and can help explain why they may experience poorer levels of physical and mental health.

Reviews of theoretical frameworks: Challenges and judging the quality of theory application.

BACKGROUND: Rigorous reviews of available information, from a range of resources, are required to support medical and health educators in their decision making. AIM: The aim of this article is to highlight the importance of a review of theoretical frameworks specifically as a supplement to reviews that focus on a synthesis of the empirical evidence alone. Establishing a shared understanding of theory as a concept is highlighted as a challenge and some practical strategies to achieving this are presented. This article also introduces the concept of theoretical quality, arguing that a critique of how theory is applied should complement the methodological appraisal of the literature in a review. METHOD: We illustrate the challenge of establishing a shared meaning of theory through reference to experiences of an on-going review of this kind conducted in the field of interprofessional education (IPE) and use a high scoring paper selected in this review to illustrate how theoretical quality can be assessed. FINDINGS: In reaching a shared understanding of theory as a concept, practical strategies that promote experiential and practical ways of knowing are required in addition to more propositional ways of sharing knowledge. Concepts of parsimony, testability, operational adequacy and empirical adequacy are explored as concepts that establish theoretical quality. CONCLUSIONS: Reviews of theoretical frameworks used in medical education are required to inform educational practice. Review teams should make time and effort to reach a shared understanding of the term theory. Theory reviews, and reviews more widely, should add an assessment of theory application to the protocol of their review method.

The experiences of older people who live with a long-term condition.

AIM: The aim of this study was to gain insight into the experiences of people aged 65 and older who have learned to live with a pre-existing long-term condition. METHOD: A qualitative approach and the principles of narrative research were used to learn as much as possible about the individuals' stories. A focus group of five men was interviewed and two women were interviewed as a pair. FINDINGS: Existing skills in condition management and interactions with professionals are transferable to new health needs that older people develop, but additional, age-related problems can affect management of long-term conditions. Progressive long-term conditions may become more difficult to manage with age, and it is difficult to distinguish between ageing processes and deterioration of pre-existing long-term conditions. Age-related social and financial changes and society's perception of older people may also present challenges to condition management. CONCLUSION: Nurses who care for older people should take into account the effects of the person's long-term condition and the ageing process when assessing their needs; understand that people may be reluctant to ask for practical assistance; explore existing support mechanisms that people have in place and their sustainability; and advocate with people to secure appropriate choices related to their health needs.

A nurse's role in promoting social capital in children and young people.

Enabling children's wellbeing by supporting their social networks is an important role of children's nurses. This article presents the concept of social capital as a cognitive tool to help nurses reflect on why and how supporting these networks is important. Through three case studies the authors introduce the attributes of social capital and how these may be applied and inform practice in hospital and community healthcare settings.

A top-down approach impedes the use of theory? Interprofessional educational leaders' approaches to curriculum development and the use of learning theory.

International policy has emphasized the development of interprofessional education (IPE) to reinforce interprofessional practice. This study explored the extent to which IPE initiatives in the UK are based on sound theoretical frameworks. Findings from semi-structured interviews with lead IPE curriculum developers at eight higher education institutions are presented which identified curriculum developers' developmental approaches to IPE. The findings reveal a notable lack of explicit theoretical basis for models of IPE. In many cases, senior managers determined the institutional approach to IPE which academic staff then needed to deliver. Curriculum developers reported adopting a largely practical approach to IPE curriculum development. However, questioning that focused on learning and teaching methods revealed that a range of learning theories was used implicitly. The significance of these findings is discussed with recommendations to inform future curriculum development of IPE initiatives.

Testing theory in interprofessional education: social capital as a case study.

Theory is essential to understand our interprofessional educational (IPE) practice. As a discipline, IPE has moved from being widely atheoretical to having a plethora of theories imported from the psychosocial disciplines that have utility to understand, articulate and improve IPE practice and evaluation. This paper proposes that when taking this deductive approach to theoretical development in IPE, a greater focus must now be placed on the rigorous testing of these theories within the IPE context. It synthesizes two approaches to achieving this, using the social capital theory as a case study, and focuses on the first two stages of this synthesis: first, the identification of the concepts and propositions that make up a theory within the study context and second, the value-based judgments made by the researcher and other stakeholders on the utility of these propositions. The interprofessional student group is chosen as a possible exemplar of a social network and theory-derived concepts and propositions are identified and classified within this context. With a focus on physical network characteristics, validation of these propositions with a sample of IPE educationalists is described. We present a range of propositions specifically related to the size and mix of IPE student groups, the frequency and level with which students participate in these as well as some of the existing evidence that have explored these propositions to date. Refined propositions and the way forward in the future application and empirical testing of social capital theory in IPE are presented.

IN-2-THEORY--Interprofessional theory, scholarship and collaboration: a community of practice.

Theoretical awareness is essential in the development and delivery of effective interprofessional education and collaborative practice (PECP). The objective of this paper was to explain the origins and purpose of an international network, IN-2-THEORY--interprofessional theory, scholarship and collaboration: a community of practice (CoP) that aims to build theoretical rigor in IPECP. It explains why the network is viewed as a CoP and lays out the way forward for the community based on the principles for developing a CoP outlined by Wenger, McDermott, and Snyder (2002).

The impact of the economic recession on well-being and quality of life of older people.

The importance of economic well-being is recognised in the recent UK Government policy. Older people may be particularly vulnerable to economic fluctuations as they are reliant on fixed incomes and assets, which are reducing in value. Within the literature, little is understood about the impact of the current economic downturn on people's general quality of life and well-being and, in particular, there is little research on the financial experiences and capability of the older age group, a concern in light of the ageing UK population. This article reports a qualitative research study into the nature of older peoples' vulnerability by exploring their perceptions of the impact of the economic recession on their well-being and quality of life. It explores specifically a group of older people who are not the poorest within the ageing population, but who may be described as the 'asset rich-income poor' group. Key themes relate to the impact of the recession on the costs of essential and non-essential items and dimensions of mental, physical and social well-being. Implications for health and social care practice in meeting the needs of older people during times of economic recession are then explored. The paper adds to the debate by demonstrating that the recession is having adverse consequences for older people's quality of life in terms of economic, mental and social well-being, although there is also evidence that some of them are equipped with certain resilience factors due to their money management and budgeting skills.