Shining a light on the road towards conducting principle-based co-production research in rehabilitation.

Moving from participatory approaches incorporating co-design to co-production in health research involves a commitment to full engagement and partnership with people with lived experience through all stages of the research process-start to finish. However, despite the increased enthusiasm and proliferation of research that involves co-production, practice remains challenging, due in part to the lack of consensus on what constitutes co-production, a lack of guidance about the practical steps of applying this approach in respect to diverse research methods from multiple paradigms, and structural barriers within academia research landscape. To navigate the challenges in conducting co-produced research, it has been recommended that attention be paid to focusing and operationalising the underpinning principles and aspirations of co-production research, to aid translation into practice. In this article, we describe some fundamental principles essential to conducting co-production research (sharing power, relational resilience, and adopting a learning mindset) and provide tangible, practical strategies, and processes to engage these values. In doing so, we hope to support rehabilitation researchers who wish to engage in co-production to foster a more equitable, ethical, and impactful collaboration with people with lived experience and those involved in their circle of care.

Use and effectiveness of the arts for enhancing healthcare students' empathy skills: A mixed methods systematic review.

OBJECTIVE: To identify, critically appraise and synthesise evidence of the use and effectiveness of the arts for enhancing pre-registration/prelicensure healthcare students' empathy skills. DESIGN: A systematic review of mixed methods literature. DATA SOURCES: A search of six electronic databases was conducted. REVIEW METHODS: Articles describing English language, peer-reviewed, primary research studies reporting empathy as an outcome of an arts-based intervention with pre-registration/prelicensure healthcare students (years 1-7) and published between 2000 and 2024 were eligible for inclusion. The JBI Manual for Evidence Synthesis guided the review and a convergent segregated methodology was used to synthesise the results. Methodological rigour of included studies was examined using the Mixed Methods Appraisal Tool. RESULTS: Twenty studies from 12 countries described the use of the arts to develop empathy, with visual arts being the most common approach (n = 8). Other modalities included film, drama, digital stories, literature, creative writing, music, poetry, photography and dance. Studies included nursing, medicine and dental, pharmacy and/or health sciences students. Ten studies used quantitative methods, three qualitative, and seven used mixed methods designs. Of the studies that presented pre-post outcome measures, nine reported significant gains in empathy scores at post-test and two reported non-significant gains in empathy. In eight studies, empathy scores demonstrated a significant intervention effect with effect sizes ranging from moderate (d = 0.52) to large (d = 1.19). Findings from qualitative studies revealed that arts pedagogies support students to better understand the perspectives of people with a lived experience of suffering but that these approaches are sometimes perceived negatively by students. CONCLUSIONS: Arts interventions generally have a positive effect on healthcare students' empathy levels and enable a nuanced conceptual understanding of empathy. Arts modalities used as a stimulus for active learning and supported with facilitated group-based discussion and/or reflection, tend to be most effective.

The reported experiences of internationally qualified nurses in aged care: A scoping review.

AIM: To examine the experiences of internationally qualified nurses, including those from culturally and linguistically diverse backgrounds, transitioning to and working in the aged care sector of high-income countries. DESIGN: A scoping review. DATA SOURCES: CINAHL, MEDLINE and PSychINFO databases were searched to find eligible literature published from January 2010 onwards. REVIEW METHODS: This scoping review was based on the framework by Arksey and O'Malley and the PRISMA-ScR guidelines. The literature search was conducted by the first author, and all three authors reviewed the retrieved studies for eligibility and inclusion. RESULTS: Fourteen articles were eligible. Data was categorized into three broad themes: stress of migration and transition; miscommunication, racism and discrimination; and aged care specific challenges which included two sub-themes 'shock of aged care' and 'bottom care'. CONCLUSION: Internationally qualified nurses, particularly if they are culturally and linguistically diverse, face unique stresses and challenges in aged care and face barriers in the recognition of skills and qualifications. The under-utilization of skills is not only a loss in terms of patient care but is linked to fears of de-skilling, losing professional development and opportunities for career progression. IMPACT: Internationally qualified nurses are positioned as a solution to aged care shortages in high-income countries; however, there is a scarcity of research exploring their experiences. In the context of the global aged care staffing crisis, an understanding of the stresses and challenges faced by internationally qualified nurses will further strengthen efforts to recruit, support and retain skilled nurses in aged care.

Evaluation of a Culturally Adapted Online Basic Psychosocial Skills Training Program for International Frontline Workers in Under-Resourced Contexts During the COVID-19 Pandemic.

OBJECTIVE: Frontline workers report negative mental health impacts of being exposed to the risk of COVID-19, and of supporting people struggling with the effects of the virus. Uptake of psychological first-aid resources is inconsistent, and they may not meet the needs of frontline workers in under-resourced contexts. This study evaluates a culturally adapted basic psychosocial skills (BPS) training program that aimed to meet the needs of frontline workers in under-resourced settings. METHODS: A cross-sectional survey administered to frontline workers who completed the program between 2020 and 2022, investigated their perceived confidence, satisfaction, and skill development, as well as their views on relevance to context and accessibility of the program. RESULTS: Out of the 1000 people who had undertaken the BPS program, 118 (11.8%) completed the survey. Participants reported high levels of satisfaction and improved confidence in, and knowledge of, psychosocial skills. Participants reported that the BPS program was culturally and contextually relevant, and some requested expansion of the program, including more interactivity, opportunities for anonymous participation, and adaption to other cultural contexts, including translation into languages other than English. CONCLUSION: Findings indicate a need for free, online, and culturally adapted psychosocial skills training program that is designed with key stakeholders to ensure relevance to social and cultural contexts.

Co-design and evaluation of a multidisciplinary teaching resource on mental health recovery involving people with lived experience.

BACKGROUND: Students from a range of health disciplines need to learn from people with lived experience of mental distress and recovery to develop recovery capabilities for mental health practice. AIMS: The aims of this study are to describe the co-design of a teaching resource, to explore the experience of people with lived experience during the resource development, and to evaluate the outcome of the resource on student recovery capabilities. METHOD: Using a sequential mixed method, a project group consisting of six people with lived experience and 10 academics from five health disciplines was convened to co-develop teaching resources. People with lived experience met independently without researchers on several occasions to decide on the key topics and met with the research team monthly. The teaching resource was used in mental health subjects for two health professional programmes, and the Capabilities for Recovery-Oriented Practice Questionnaire (CROP-Q) was used before and after to measure any change in student recovery capabilities. Scores were compared using the Wilcoxon signed rank test. The people with lived experience were also interviewed about their experience of being involved in constructing the teaching resources. Interviews were audiotaped, transcribed, and analysed thematically. RESULTS: The finished resource consisted of 28 short videos and suggested teaching plans. Occupational therapy and nursing student scores on the CROP-Q prior to using the educational resource (n = 33) were 68 (median) and post scores (n = 28) were 74 (median), indicating a statistically significant improvement in recovery capability (P = 0.04). Lived experience interview themes were (i) the importance of lived experience in education; (ii) personal benefits of participating; (iii) co-design experience; and (iv) creating the resource. CONCLUSION: Co-design of teaching resources with people with lived experience was pivotal to the success and quality of the final product, and people with lived experience described personal benefits of participating in resource development. More evidence to demonstrate the use of the CROP-Q in teaching and practice is needed.

Learning that cannot come from a book: An evaluation of an undergraduate alcohol and other drugs subject co-produced with experts by experience.

Alcohol and other drugs (AOD) use is a significant public health issue and is associated with high mortality and morbidity rates. Despite this, people who use drugs are often reluctant to seek care due to the lack of trauma-informed treatment and harm reduction treatment options, as well as experiences of stigma and discrimination in health services. Arguably, AOD education that is co-produced with people who use alcohol and drugs can enhance future health professionals' ability to practice in ways that support the needs of this population. This paper reports on a qualitative co-evaluation of a co-produced undergraduate nursing AOD subject. The AOD subject was co-planned, co-designed, co-delivered, and co-evaluated with experts by experience, who have a lived experience of substance dependence and work as advocates and peer workers. Following the delivery of the subject in 2021 and 2022, focus groups were undertaken with 12 nursing students. Focus group data indicate that the co-produced subject supported participants to understand and appreciate how stigma impacts on nursing care and how to recognize and undertake 'good' nursing care that was oriented to the needs of service users. Student participants noted that being co-taught by people who use drugs was particularly powerful for shifting their nursing perspectives on AOD use and nursing care and took learning beyond what could be understood from a book. Findings indicate that co-produced AOD education can shift nursing students' perceptions of AOD use by providing access to tacit knowledge and embodied equitable and collaborative relationships with people who use drugs.

Towards epistemic justice doing: Examining the experiences and shifts in knowledge of lived experience researchers over the course of a mental health research training programme.

Participation of people with lived experience (LE) in mental health research is vital for improving the quality and relevance of research priorities, outcomes, and knowledge translation. Inclusion of people with LE is also recognized as central for achieving health service reform including commitments to human rights, social, and epistemic justice. Although a lack of research training is cited as a barrier to LE participation, few studies have examined the value of training for, or the specific requirements of, people with LE. This study seeks to address this gap. It reports on a longitudinal, qualitative study examining shifts in experience and knowledge, and unmet needs, of people with LE over the course of a coproduced research training programme. Findings indicate that the programme enabled participants to understand the role, value, and levels of LE participation in research. Participants also stressed the importance of the 'embodied lived expertise' of LE researchers who co-delivered the training programme. Nonetheless, participants indicated that they felt unprepared for the challenges of working in systems where LE knowledge is subordinated, and experiences of being silenced and powerless could mirror those previously experienced in mental health services and the community. Participants indicated a need for training that provided them with the epistemic resources to render such experiences intelligible. Findings also indicate that training in participatory research is required for conventional mental health researchers, to support them to navigate power asymmetries and value LE knowledge contributions.

Masculinities, emotions and men's suicide.

Men account for approximately 75% of the one million annual suicide deaths worldwide. Emerging research indicates a link between suicide and men's active pursuit of hegemonic masculinity via emotional restriction. However, little is known of the continuum of suicidal men's emotional practice, and particularly how men mobilise emotions to actively pursue or resist hegemonic masculine ideals. This theorised life-history study aimed to explore the emotional lives of 18 Australian men who had attempted suicide. Findings indicate that men in this study experienced a range of emotions. However, during childhood, they learned that expressing emotions such as sadness reduced masculine standing, whereas expressing emotions such as anger through acts of violence could enhance masculine status. Although the gendering of emotions offered participants multiple avenues of action to pursue or contest masculine ideals, they remained vulnerable to suicide. For some men, it became impossible to conceal escalating feelings of distress. For other men, displays of anger and violence resulted in job loss, relationship breakdown or criminal conviction. Many participants indicated that suicide presented a means of ending painful emotions. Paradoxically, suicide could also become an alternative means of demonstrating masculinity, whereby the body became both the vehicle and object of violence.

'Should it fit? Yes. Does it fit? No': Exploring the organisational processes of introducing a recovery-oriented approach to mental health in Australian private health care.

This article explores the implementation of an innovative approach to mental health care in a private health setting. Open Dialogue is a recovery-oriented approach to mental health that emerged in Finland, which emphasises family involvement, interdisciplinary collaboration and a flexible, needs-adapted approach. Early research is promising; however, little research has explored Open Dialogue outside Finland. This study aimed to explore the introduction of this approach at a private, inpatient young-adult mental health unit in Australia. Drawing on data from a long-term ethnographic field study that included 190 hours of observation and qualitative interviews, the findings show that despite staff members being inspired by and supportive of Open Dialogue, the existing ideology and organisational structures of the unit conflicted with the integration of Open Dialogue principles. Dialogical ways of working were challenged by medical dominance and emphasis on economic efficiencies. This study emphasises the importance of a 'good' fit between organisational cultures and innovations. It also highlights the challenges of moving towards recovery-oriented and family-focused models of care in the Australian neoliberal health care context. There is a need for organisational and ideological change in health services that is receptive to, and meaningfully supports, efforts to implement recovery-oriented care.

Us and them: The experience of international nursing students engaged in team based learning: A qualitative descriptive study.

BACKGROUND: International students report multiple challenges adjusting to educational settings. Instructional strategies such as Team Based Learning (TBL), could provide international students with opportunities that promote academic success, language skills and social connectedness. However, little is known about international students' experience of TBL. The aim of this study was to explore culturally and linguistically diverse (CALD) students' experiences of TBL. METHODS: This paper reports on a qualitative study that explored the experiences of 15 international students enrolled in an Australian university nursing program, where TBL is used. RESULTS: Findings indicate that TBL promotes language proficiency and respectful intercultural connections. It also uncovered an unintentional benefit of TBL in interrupting racism towards international students from domestic students. However, it is not enough to rely on TBL to mitigate the impact of racial and cultural power dynamics in educational settings. CONCLUSION: To improve international student experiences, educators must actively engage students in dialogue about privilege and structural racism as it relates to international students and other people of colour.

Verbatim Theater: Prompting Reflection and Discussion about Healthcare Culture as a Means of Promoting Culture Change.

Problem: The mistreatment of medical and nursing students and junior health professionals has been reported internationally in research and the media. Mistreatment can be embedded and normalized in hierarchical healthcare workplaces, limiting the effectiveness of policies and reporting tools to generate change; as a result, some of those who experience mistreatment later perpetuate it. We used a novel, creative approach, verbatim theater, to highlight the complexity of healthcare workplaces, encourage critical reflection, and support long-term culture change. Intervention: Verbatim theater is a theater-for-change documentary genre in which a playscript is devised using only the words spoken by informants. In 2017, 30 healthcare students and health professionals were recruited and interviewed about their experience of work and training by the multidisciplinary Sydney Arts and Health Collective using semi-structured interviews. Interview transcripts became the primary material from which the script for the verbatim theater play 'Grace Under Pressure' was developed. The performing arts have previously been used to develop the communication skills of health professional students; this esthetic expression of the real-life effects of healthcare workplace culture on trainees and students was implemented to stimulate consciousness of, and dialogue about, workplace mistreatment in healthcare work and training. Context: The play premiered at a major Sydney theater in October 2017, attended by the lay public and student and practicing health professionals. In November 2017, three focus groups were held with a sample of audience members comprising healthcare professionals and students. These focus groups explored the impact of the play on reflection and discussion of healthcare culture and/or promoting culture change in the health workplace. We analyzed the focus group data using theoretical thematic analysis, informed by Turner's theory of the relation between 'social' and 'esthetic' drama to understand the impact of the play on its audience. Impact: Focus group members recognized aspects of their personal experience of professionalism, training, and workplace culture in the play, Grace Under Pressure. They reported that the play's use of real-life stories and authentic language facilitated their critical reflection. Participants constructed some learning as 'revelation,' in which the play enabled them to gain significant new insight into the culture of health care and opened up discussions with colleagues. As a result, participants suggested possible remedies for unhealthy aspects of the culture, including systemic issues of bullying and harassment. A small number of participants critiqued aspects of the play they believed did not adequately reflect their experience, with some believing that the play over-emphasized workplace mistreatment. Lessons Learned: Verbatim theater is a potent method for making personal experiences of healthcare workplace and training culture more visible to lay and health professional audiences. In line with Turner's theory, the play's use of real-life stories and authentic language enabled recognition of systemic challenges in healthcare workplaces by training and practicing health professionals in the audience. Verbatim theater provides a means to promote awareness and discussion of difficult social issues and potential means of addressing them.

Stakeholder Perspectives on Using and Developing the MYPLAN Suicide Prevention Mobile Phone Application: A Focus Group Study.

The objective of this study was to explore different stakeholder perspectives on the MYPLAN app for suicide prevention safety planning. The study was a comparative analysis of 4 focus groups with Danish MYPLAN stakeholders, young users, adult users, relatives, and clinicians. The focus groups were audio recorded, transcribed, and subjected to a thematic analysis. The analysis contextualized the participants' experiences of the benefits and limitations of MYPLAN. While participants believed that MYPLAN could potentially interrupt early stages of a suicidal process, clinicians' involvement in safety planning was considered important. MYPLAN could potentially give users a sense of increased personal control but learning how to effectively safety plan was not perceived to be simple and additional support should be considered for MYPLAN users.

'Every single minute and hour is scrutinised': neoliberalism and Australian private mental health care.

There is little understanding of how recovery-oriented approaches fit within contemporary mental healthcare systems, which emphasise biomedical approaches to care, increased efficiency and cost-cutting. This article examines the established models of service delivery in a private, youth, mental health service and the impacts of the current system on staff. It explores whether the service is prepared or capable of adopting recovery-oriented approaches to care. Qualitative interviews were undertaken with staff and thematically analysed to understand the everyday practices on the unit. Data suggest that economic efficiencies and biomedical dominance largely shaped how health care was organised and delivered, which was perceived by staff as inflexible to change. Additionally, findings suggest that market-oriented principles associated with neoliberalism restricted the capacity of individuals to transform services in line with alternative models of care and lowered staff morale. These finding suggest that, while neoliberal ideologies and biomedical approaches remain dominant in organisations, there will be challenges to adopting alternative recovery-oriented models of care and promoting healthcare systems that understand mental health issues in broader socio-political contexts and can flexibly respond to the needs of service users.

User Involvement in Developing the MYPLAN Mobile Phone Safety Plan App for People in Suicidal Crisis: Case Study.

BACKGROUND: The effect of safety planning for people in suicidal crisis is not yet determined, but using safety plans to mitigate acute psychological crisis is regarded as best practice. Between 2016 and 2017, Australian and Danish stakeholders were involved in revising and updating the Danish MYPLAN mobile phone safety plan and translating the app into a culturally appropriate version for Australia. OBJECTIVE: The objective of this study was to examine the negotiation of stakeholders' suggestions and contributions to the design, function, and content of the MYPLAN app and to characterize significant developments in the emerging user-involving processes. METHODS: We utilized a case study design where 4 focus groups and 5 user-involving workshops in Denmark and Australia were subjected to thematic analysis. RESULTS: The analyses identified 3 consecutive phases in the extensive development of the app: from phase 1, Suggesting core functions, through phase 2, Refining functions, to phase 3, Negotiating the finish. The user-involving processes continued to prevent closure and challenged researchers and software developers to repeatedly reconsider the app's basic user interface and functionality. It was a limitation that the analysis did not include potentially determinative backstage dimensions of the decision-making process. CONCLUSIONS: The extended user involvement prolonged the development process, but it also allowed for an extensive exploration of different user perspectives and needs.

Masculinity, Social Connectedness, and Mental Health: Men's Diverse Patterns of Practice.

Men's mental health has remained undertheorized, particularly in terms of the gendered nature of men's social relations. While the importance of social connections and strong supportive networks for improving mental health and well-being is well documented, we know little about men's social support networks or how men go about seeking or mobilizing social support. An in-depth understanding of the gendered nature of men's social connections and the ways in which the interplay between masculinity and men's social connections can impact men's mental health is needed. Fifteen life history interviews were undertaken with men in the community. A theoretical framework of gender relations was used to analyze the men's interviews. The findings provide rich insights into men's diverse patterns of practice in regards to seeking or mobilizing social support. While some men differentiated between their social connections with men and women, others experienced difficulties in mobilizing support from existing connections. Some men maintained a desire to be independent, rejecting the need for social support, whereas others established support networks from which they could actively seek support. Overall, the findings suggest that patterns of social connectedness among men are diverse, challenging the social science literature that frames all men's social relationships as being largely instrumental, and men as less able and less interested than women in building emotional and supportive relationships with others. The implications of these findings for promoting men's social connectedness and mental health are discussed.

Peer work in Open Dialogue: A discussion paper.

Open Dialogue is a resource-oriented approach to mental health care that originated in Finland. As Open Dialogue has been adopted across diverse international healthcare settings, it has been adapted according to contextual factors. One important development in Open Dialogue has been the incorporation of paid, formal peer work. Peer work draws on the knowledge and wisdom gained through lived experience of distress and hardship to establish mutual, reciprocal, and supportive relationships with service users. As Open Dialogue is now being implemented across mental health services in Australia, stakeholders are beginning to consider the role that peer workers might have in this model of care. Open Dialogue was not, initially, conceived to include a specific role for peers, and there is little available literature, and even less empirical research, in this area. This discussion paper aims to surface some of the current debates and ideas about peer work in Open Dialogue. Examples and models of peer work in Open Dialogue are examined, and the potential benefits and challenges of adopting this approach in health services are discussed. Peer work in Open Dialogue could potentially foster democracy and disrupt clinical hierarchies, but could also move peer work from reciprocal to a less symmetrical relationship of 'giver' and 'receiver' of care. Other models of care, such as lived experience practitioners in Open Dialogue, can be conceived. However, it remains uncertain whether the hierarchical structures in healthcare and current models of funding would support any such models.

Experiences of giving and receiving care in traumatic brain injury: An integrative review.

AIMS AND OBJECTIVES: To synthesise the literature on the experiences of giving or receiving care for traumatic brain injury for people with traumatic brain injury, their family members and nurses in hospital and rehabilitation settings. BACKGROUND: Traumatic brain injury represents a major source of physical, social and economic burden. In the hospital setting, people with traumatic brain injury feel excluded from decision-making processes and perceive impatient care. Families describe inadequate information and support for psychological distress. Nurses find the care of people with traumatic brain injury challenging particularly when experiencing heavy workloads. To date, a contemporary synthesis of the literature on people with traumatic brain injury, family and nurse experiences of traumatic brain injury care has not been conducted. DESIGN: Integrative literature review. METHODS: A systematic search strategy guided by the PRISMA statement was conducted in CINAHL, PubMed, Proquest, EMBASE and Google Scholar. Whittemore and Knafl's (Journal of Advanced Nursing, 52, 2005, 546) integrative review framework guided data reduction, data display, data comparison and conclusion verification. RESULTS: Across the three participant categories (people with traumatic brain injury/family members/nurses) and sixteen subcategories, six cross-cutting themes emerged: seeking personhood, navigating challenging behaviour, valuing skills and competence, struggling with changed family responsibilities, maintaining productive partnerships and reflecting on workplace culture. CONCLUSIONS: Traumatic brain injury creates changes in physical, cognitive and emotional function that challenge known ways of being in the world for people. This alters relationship dynamics within families and requires a specific skill set among nurses. RELEVANCE TO CLINICAL PRACTICE: Recommendations include the following: (i) formal inclusion of people with traumatic brain injury and families in care planning, (ii) routine risk screening for falls and challenging behaviour to ensure that controls are based on accurate assessment, (iii) formal orientation and training for novice nurses in the management of challenging behaviour, (iv) professional case management to guide access to services and funding and (v) personal skill development to optimise family functioning.

Trends and socio-economic determinants of suicide in India: 2001-2013.

PURPOSE: To investigate trends and socio-economic determinants of suicide in India over the period of 2001-2013. METHOD: Suicide rates between 2001 and 2013 were calculated using suicide statistics provided by National Crime Records Bureau (NCRB) and census data provided by Census of India, stratified by sex, age group, and geographical region, to investigate trends in suicide over the study period. Multilevel negative binomial regression models were specified to investigate associations between state-level indicators of economic development, education, employment and religious factors and sex-specific suicide rates. RESULTS: Male suicide rates remained relatively steady (~ 14 per 100,000) while female suicide rates decreased over the study period (9 to 7 per 100,000). The age group of 45-59 years had the highest suicide rate among males while the age group of 15-29 years had the highest suicide rate among females. On average, higher male and female suicide rates were observed in states with: higher levels of development, higher levels of agricultural employment, higher levels of literacy, and higher proportions of people identifying with Hinduism. Higher male suicide rates were also observed in states with higher levels of unemployment. CONCLUSION: The process of modernization might be contributing towards higher suicide risk in more developed parts of India. Also, increase in farmer suicides since economic liberalization might be contributing towards higher suicide rates among more agricultural regions. Furthermore, ancient sanctions towards religious suicide are possibly still influencing modern Hindu suicides.

Convergent priorities and tensions: a qualitative study of the integration of complementary and alternative therapies with conventional cancer treatment.

PURPOSE: Demand for complementary and alternative medicine (CAM) is high among cancer patients. This, alongside growing evidence for the efficacy of some CAM therapies, is driving change within cancer centres, where evidence-based CAM therapies are increasingly provided alongside standard cancer treatments. In Australia, commitment to equitable access to healthcare is strong, and some cancer centres are now providing integrative services at no cost to the patient. This represents a significant shift in healthcare provision. This study aimed to examine health professional and patient dynamics in an integrated cancer service where CAM is provided at no cost to patients alongside standard cancer treatments. It specifically sought to understand what might drive or hinder further integration of CAM with standard treatment in the cancer context. METHODS: Qualitative interviews were undertaken with twenty key stakeholders-cancer patients, cancer nurses, and oncologists-who were delivering or receiving care in an Australian public hospital where acupuncture services are provided at no cost to patients alongside standard chemotherapy and radiation treatments. RESULTS: Findings point to key areas where the concerns and priorities of cancer patients, cancer nurses, and oncologists converge and diverge in ways that reflect core personal and professional interests regarding patient care needs, the evidence base for CAM efficacy and safety, and rising healthcare costs. CONCLUSIONS: Understanding points of convergence and divergence could assist clinicians and service providers in negotiating ways forward for integrative cancer services.