The use of advance directives for autonomy in dementia care: A scoping meta-review and thematic synthesis.

Dementia may reduce individuals' capacity for autonomy and decision-making competence. Advance directives are subject to theoretical bioethical debate as tools to safeguard or extend autonomy in dementia. However, the extent and manner in which advance directives are actually used for these purposes in practice remain less examined. We aimed to examine how advance directives are used as tools for individual autonomy in dementia care. We systematically searched six databases and performed a thematic analysis and synthesis of included reviews based on an original model of six autonomy-relevant dimensions of advance directives. A total of 18 reviews met the inclusion criteria. We identified 12 themes across six dimensions. We found a lack of knowledge integration on the actual use of advance directives for autonomy in dementia care. Evidence suggests significant variation in the autonomy-relevant dimensions of advance directives, with a tendency towards an inconsistent or low level of implementation as a tool for autonomy. Further reviews and primary studies on all aspects of the use of advance directives for autonomy in dementia care would contribute significantly to dementia research and practice.

Development and prima facie validation of the Dementia-Specific Ethical Self-Efficacy scale for professional caregivers.

AIM: To develop and validate a scale for measuring professional caregivers' ethical self-efficacy in dementia care. BACKGROUND: Professional caregivers of people with dementia make ethical decisions on a day-to-day basis, and it is important that they feel confident when doing so. Moreover, confidence, or self-efficacy, influences caregivers' behaviour and well-being and may be a predictor of competence. However, there is no scale for measuring ethical self-efficacy. This study aims to fill this gap. METHODS: This study concerns the development and prima facie validation of the Dementia-Specific Ethical Self-Efficacy (DemESE) scale. During development, we identified dementia-specific ethical principles and generated items representing ethical conflicts of principles. In the subsequent validation, we administered the scale to experts and professional caregivers in dementia care. We assessed the relevance of the scale using a content validity index and tested validity and reliability using Cronbach's alpha. To further enhance validity, we compared the scale with analogous self-efficacy scales using Pearson's correlation coefficient. RESULTS: The quantitative testing of DemESE revealed that the scale exhibited acceptable levels of internal consistency and reliability. This finding was supported by Cronbach's alpha. In addition, the content validity index and Pearson correlation coefficient provided evidence of the scale's relevance and validity. CONCLUSION: The results suggest that DemESE is a promising tool for assessing professional caregivers' ethical self-efficacy in dementia care and may be used to measure ethical self-efficacy - that is, confidence in ethical decision-making in dementia care.

Caregivers' perceptions of lying to people with dementia in Denmark: a qualitative study.

OBJECTIVES: This study aims to examine caregivers' perspectives on and justifications for lying when caring for people with dementia. METHOD: The data consisted of interviews and observations of discussions among family and professional caregivers with various educational backgrounds. Thematic analysis was applied to identify key themes related to caregivers' perspectives on lying. RESULTS: The study revealed that lies were frequently employed by caregivers and were seen as effective tools in the caregivers' toolkit. These practices were often labelled 'white lies' and were rationalised based on their potential to enhance the well-being of people with dementia or to facilitate smooth interactions. The potential negative consequences of lying were also acknowledged. In addition, some caregivers suggested that the practice of 'stepping into the person with dementia's reality' might not constitute lying. CONCLUSION: The findings suggest that the caregivers perceived lying to be a legitimate strategy when caring for people with dementia; surprisingly, some did not recognize their practices as constituting acts of lying at all. This finding carries significant clinical relevance, as the varying perceptions of lying underscore the potential need for a consistent approach to deception. Addressing this complexity can lead to more ethical caregiving practices, ultimately enhancing the quality of care provided to people with dementia.

'We had conversations we wouldn't have had otherwise'-Exploring home-dwelling people with dementia and family members' experiences of deliberating on ethical issues in a literature-based intervention.

AIM: To explore home-dwelling people with dementia and family members' perceptions of the feasibility and acceptability of an intervention using dementia-related literature excerpts to facilitate conversations on ethical issues related to living with dementia. BACKGROUND: Ethical issues in dementia care emerge throughout the illness. In the early stages, they may involve decisions about disclosing the illness to the family, shifting roles and responsibilities, and considerations of transitioning to a nursing home. Addressing ethical issues and providing adequate support to home-dwelling people with dementia and their families are often lacking. DESIGN: An exploratory-descriptive qualitative study. METHODS: We conducted eight interviews with 14 home-dwelling persons with dementia and their family caregivers. Six were dyadic interviews, and two were individual interviews with family caregivers. We analysed the interview data using template analysis. We adhered to the COREQ checklist in reporting this study. RESULTS: Using excerpts from dementia-related literature was a feasible and acceptable way of initiating discussions on ethical issues among home-dwelling persons with dementia and family caregivers. However, engaging the families of newly diagnosed individuals was challenging due to emotional distress. The intervention provided peer support, including identifying with others and sharing experiences. Moreover, participating couples found intimacy and relational attunement through shared reflections. CONCLUSION: Based on the findings, it appears that the participants in this study felt that using excerpts from dementia-related literature to deliberate on ethical issues was feasible and acceptable. Deliberating on ethical issues with peers and family caregivers offers valuable social support and opportunities for strengthening relationships. IMPLICATIONS FOR PATIENT CARE: This study makes an important contribution by providing valuable insights into how ethical issues related to living with dementia can be addressed using related literature and suggests how the intervention can be integrated into existing care initiatives for home-dwelling people with dementia and their families. REPORTING METHOD: We have adhered to relevant EQUATOR guidelines with the COREQ reporting method. PATIENT OR PUBLIC CONTRIBUTION: A healthcare professional working as a so-called dementia coordinator (a title used in the Danish context) was involved in the conduct of this study by being responsible for the recruitment of home-dwelling people with dementia and their family members. Moreover, she had joint responsibility for facilitating the intervention along with the first author.

Developing the CARE intervention to enhance ethical self-efficacy in dementia care through the use of literary texts.

BACKGROUND: Dementia care is essential to promote the well-being of patients but remains a difficult task prone to ethical issues. These issues include questions like whether manipulating a person with dementia is ethically permissible if it promotes her best interest or how to engage with a person who is unwilling to recognize that she has dementia. To help people living with dementia and their carers manage ethical issues in dementia care, we developed the CARE intervention. This is an intervention focused on promoting the ethical self-efficacy of people living with dementia and carers, i.e., their confidence that they can manage ethical issues when they occur. The purpose of this paper is to explain and discuss how we have developed the CARE intervention to promote the ethical self-efficacy of people living with dementia, their family, and professional carers through a specific and, we believe, new use of literary texts. METHODS: The CARE intervention has been developed in two phases: First, we conducted a needs assessment of the occurrence of ethical issues in dementia care and the need for an intervention to support people living with dementia and their carers in managing such issues. Second, in a design phase, we developed the CARE intervention to meet identified needs. RESULTS: To address identified ethical issues in dementia care we designed the CARE intervention as a workshop format where people living with dementia and carers can meet, discuss literary texts, and deliberate on how to solve such issues. The workshop is structured by the following elements: An agenda of ethical issues, a collection of literary cases exemplifying ethical issues, a moderator with an understanding of dementia care, and an overview of the ethical principles relevant to the discussion of ethical issues. >This workshop concept is operationalized in three applications tailored to meet the specific ethical issues of each of the study´s three target groups: people living with dementia and family carers, professional and family carers, and professional carers. CONCLUSION: We conclude the paper by stating that it is possible to develop an intervention that promotes the ethical self-efficacy of people living with dementia and family and professional carers.

Why caregivers have no autonomy-based reason to respect advance directives in dementia care.

Advance directives (ADs) have for some time been championed by ethicists and patient associations alike as a tool that people newly diagnosed with dementia, or prior to onset, may use to ensure that their future care and treatment are organized in accordance with their interests. The idea is that autonomous people, not yet neurologically affected by dementia, can design directives for their future care that caregivers are morally obligated to respect because they have been designed by autonomous individuals. In this paper, we first criticize the idea that ADs can retain moral authority in severe dementia by arguing that it is paradoxical. Second, we consider two arguments that initially seem to refute this critique of ADs, but we eventually dismiss them. The first argument states that ADs retain moral authority in severe dementia because autonomously formed interests, for example, ADs, can only be appropriately discarded by autonomous persons. This we term the historical autonomy argument. We dismiss it by demonstrating how we, in analog cases, are not obligated to continue to respect autonomously formed interests even though they have been discarded under nonappropriate conditions. The second argument is that ADs can be justified by what we term external interests. While we agree that people with severe dementia plausible can be said to have external interests, we show that ADs cannot express such interests and hence cannot be justified by them. We conclude that none of the discussed arguments support the use of ADs and because of this, the idea of ADs should be reassigned.

Ethical issues in dementia guidelines for people with dementia and informal caregivers in Denmark: A qualitative thematic synthesis.

Numerous dementia-specific guidelines are offered to support people with dementia and their informal caregivers in dealing with dementia. However, the extent to which such guidelines address ethical issues and provide guidance for dealing with the issues has not yet been assessed. This study investigates the extent to which ethical issues are addressedin those guidelines, which ethical themes are considered and whatrecommendations are offered. We analysed Danish collected via onlinesearch engines and manual contact with relevant governmental, municipal and patient organisations from November 2020 to January 2021. To assess the scope of ethical issues in such guidelines, we devised an analytical framework using Beauchamp and Childress's four principles of biomedical ethics and a data-processing method inspired by systematic reviews. We collected a total 653 dementia guidelines and screened them using formal inclusion criteria, such as publication year, target group and public availability. The guidelines that satisfied these criteria were screened for content related to ethical issues and recommendations. The guidelines that addressed ethical issues were then coded in NVivo 12 and analysed using thematic text analysis. In total, 59 guidelines satisfied the formal inclusion criteria. Among these guidelines, 15 addressed ethical issues, which fell into four transversal themes: (1) being open about the disease, (2) accepting help, (3) the line between dignified behaviour and overstepping boundaries and (4) decision-making and autonomy. The ethical issues addressed in Danish dementia-specific guidelines were diverse. However, the addressed issues did not represent a comprehensive spectrum of ethical issues as identified in relevant literature, and only a few guidelines contained substantial ethical content. In conclusion, this study indicates that the need for guidance on ethical issues is not being met by dementia-specific guidelines and that further research is required to provide additional ethical guidance that benefits people with dementia and their informal caregivers.

Designing a conversational agent to promote teamwork and collaborative practices using design thinking: An explorative study on user experiences.

Appearance, voice features, and communication style affect users trust in conversational agents (chatbots), but few studies have assessed what features users like and dislike. Using design thinking, we developed Susa, a conversational agent, to help workplaces promote teamwork and collaborative practices. Design thinking prioritizes co-creation and multidisciplinary teamwork to develop innovative solutions to complex problems. The aim of this qualitative study was to explore users' interactions with and reactions toward Susa and explain how we used user inputs to adapt and refine the first prototype. The employees and managers from four workplaces participated in three workshops to test and refine the agent. We applied an explorative thematic analysis of data collected via video recordings of the workshops. The results of the analyses revealed that visual identity, communication style and personality was important for acceptability. Users favored a more human like agent that primarily communicated with the team via text messages. Users disliked emoticons and humor because these features clashed with the seriousness of the topic. Finally, users highlighted that Susa helped structure organizational change processes, develop concrete action plans, and stay on track. It is a weakness that Susa is a simple robot based on a preprogrammed script that does not allow users to adapt the process.

The workings of an action learning program for building mental health promotion capacity - A realist evaluation.

Action learning is a promising approach for building mental health promotion (MHP) capacity. The aim of this study is to explore how action learning processes can strengthen MHP capacity within and across organizations in a community setting. We applied an embedded case study design and a realist evaluation framework to explore key combinations of mechanisms and contextual factors that generated the emergent MHP capacity outcomes of an action learning program, i.e. context-mechanism-outcome-configurations (CMO-configurations). Data consisted of 18 semi-structured face-to-face interviews, 10 telephone interviews, two group interviews, observations, and documents. Interviewees (n = 21) were participants and management employees. Our analytical provision of CMO-configurations provides insights into how contextual factors, such as participant motivation, organizational support, and existing task descriptions, in combination with certain program mechanisms, such as legitimization of specific agendas, learning-by-doing, and collaborations across organizational boundaries, explain the identified outcomes. Outcomes ranged across implementation of MHP initiatives, personal development among participants, and relational and collaborative development. Taken together, our results strengthen the notion that mechanisms of action learning hold the potential to build MHP capacity on an individual, organizational, and community level. This study, also, illustrates that realist evaluation offers a relevant methodology for investigating the underlying workings of capacity building programs.

Implementing a peer-to-peer, self-management intervention for young people with depression and anxiety in Denmark.

BACKGROUND: Depressive and anxiety disorders share major risk factors and can often be effectively prevented or treated with similar interventions. However, less than half of young people with mental health problems seek professional help and hence innovative approaches to support this group are needed. To this end Coping with Anxiety and Depression shows promise. The aim of this paper was to evaluate the implementation of Coping with Anxiety and Depression for young people aged 15-25 years showing symptoms of anxiety and/or depression in a Danish community setting. METHODS: The programme was implemented in 39 Danish municipalities. To evaluate the implementation of the programme, we collected quantitative and qualitative data simultaneously and subsequently we triangulated it in the data analysis. The qualitative data collection comprised semi-structured interviews in seven case municipalities. In each municipality we conducted interviews with a local municipality coordinator of the program, a group interview with two voluntary instructors facilitating the program and a group interview with two to seven participants in the programme. In total, seven local coordinators, 14 voluntary instructors and 23 participants (8 men and 15 women) were interviewed. We also carried out a baseline and post-intervention survey. Interview data was coded via an inductive and deductive analysis approach. Survey data was analysed via descriptive statistics in the statistical software programme STATA 16. RESULTS: The evaluation showed that the implementation of the programme is feasible, and that most participants (83%) were satisfied with the programme to a high/very high extent. In total, 84% of the participants strongly agreed/agreed that it was advantageous that instructors themselves had experience with anxiety and depression. Qualitative data showed that the participants were very positive about the group format. It also showed that recruitment and retention of participants and especially young instructors were challenging but doable. Thus our findings suggest that the programme can be implemented in a way that is perceived as useful and satisfying to young people. CONCLUSIONS: Coping with Anxiety and Depression constitutes a feasible peer-to-peer, group-based community programme that is well-received by its target group. Recruitment and retention of participants and instructors is challenging but doable.

A multicomponent psychosocial intervention among people with early-stage dementia involving physical exercise, cognitive stimulation therapy, psychoeducation and counselling: Results from a mixed-methods study.

BACKGROUND: There is increasing awareness of the benefits of both physical and psychosocial interventions to empower and benefit people with dementia and their caregivers. However, the potential additional benefits of combining physical and psychosocial interventions have only been sparsely explored. The aim of this pilot study was to investigate the acceptability and potential impact of a multicomponent intervention comprising physical exercise, cognitive stimulation therapy (CST), psychoeducation and counselling for people with early-stage dementia. DESIGN: A 15-week multicomponent group-based intervention was offered to people with early-stage dementia in Denmark (N = 44). A mixed-methods design combining interviews, observations, tests of cognitive and physical functioning and an interviewer-assisted questionnaire on quality of life was applied to (1) investigate acceptability of the intervention, including whether people with dementia and their caregivers found the intervention meaningful and (2) to explore and assess changes in participants' physical and cognitive functioning and quality of life. The study was conducted between June 2018 and August 2019. RESULTS: The pilot study demonstrated that the multicomponent intervention was acceptable for people with early-stage dementia and their caregivers. Test results did not show significant changes in measures of participants' physical and cognitive functioning or quality of life. However, qualitative data revealed that participants perceived the intervention as meaningful and found that it had a positive influence on their physical and social well-being. In addition, interaction and support from peers and staff members was considered important and rewarding. CONCLUSION: This multicomponent intervention constitutes a meaningful and beneficial activity for people with early-stage dementia and their caregivers. It provides an opportunity to engage in social interactions with peers and experience professional support. The study also underlines the importance of providing prolonged and sustainable interventions for people with dementia to maintain personal and social benefits.

Practice-guided public health philosophy.

Although highly relevant, philosophical theory and philosophical competences are rarely integrated in empirical public health research. We suggest a variant of applied philosophy that is valuable for the development and improvement of public health research. We call it practice-guided public health philosophy because: (i) research questions derive from public health challenges, i.e. real-life concerns that relate to the prevention of disease or the promotion of health and well-being, (ii) the ultimate test of success lies within an empirical framework aiming to improve public health practices and (iii) philosophers collaborate very closely with different kinds of empirical researchers in the different stages of the research process. Using examples from current public health projects at the National Institute of Public Health at the University of Southern Denmark, we outline three paradigmatic cases of practice-guided public health philosophy: (i) by using philosophy as an idea generator of empirical research, (ii) by using philosophy as a frame of reference for interpreting ethnographic data and (iii) by using philosophy as an explanatory resource for discussing survey and register data.

Does meaning protect against loneliness? Exploring empirical studies and theory.

Research indicates that meaning in life is a protective factor for physical and mental health. Although loneliness is increasingly recognized as an important public health concern, no studies have investigated the potential of meaning in life to protect against loneliness. Based on an explorative interdisciplinary research strategy that comprises data from a cohort study, a strategic review of empirical literature and a conceptual analysis of the concept of meaning in life we explore the support for potential links between meaning in life and the protection against loneliness. We propose three different explanatory mechanisms; (i) that meaning in life promotes a positive orientation toward others, (ii) that meaning in life enhances interpersonal appeal and (iii) that meaning in life promotes a better ability to cope with loneliness. Theoretically, we explore the idea that the value of meaning in life ultimately concerns a social need to contribute to the realization of value that, at least in principle, can be shared and recognized by others. When people realize the value of meaning in life, they partake in a community of shared values, which links them to a social world in a way that may protect against the feeling of loneliness. Jointly the analyses point to the need for prospective studies on the role of meaning in life as a protective factor against loneliness and a potential novel focus for loneliness interventions.

Emergency care, triage, and fairness.

Triage is a widespread principle for prioritizing patients in emergency departments. The purpose of triage is to ensure that in emergency situations, whenever medical demand exceeds medical supply, limited resources should be directed to the case with the greatest clinical need. Triage fulfills this purpose by ranking patients according to how acute their condition is and then giving priority to the most acute ones. In this paper, I argue that this current practice of triage needs to be supplemented. Contemporary triage is based on a principle of preserving patients' core capabilities, which is relevant when it comes to prioritizing acute patients above sub-acute ones, but not for prioritizing among sub-acute patients, which is the largest group of emergency patients. Henceforth, I propose to supplement triage with what I term the real dialogue model, a framework that, when combined with enhanced professional autonomy for clinical decision-makers, enables fair prioritizing among sub-acute patients.

Exploring Perceptions of Continuity of Care Among People With Long-Term Mental Disorders in Denmark.

Continuity of mental health care is central to improve the treatment and rehabilitation of people with mental disorders. While most studies on continuity of care fail to take the perspectives of service users into account, the aim of this study was to explore the perceived meanings of continuity of care among people with long-term mental disorders. Fifteen service users participated in semi-structured in-depth interviews. We used template analysis to guide the analysis. The main transversal themes of continuity were "Navigating the system" and "Connecting to people and everyday life." While the first theme related to the participants' experiences of their interaction with the mental health care system, the latter related to their hopes and perceived opportunities for a good life as desired outcomes of mental health care. We conclude that efforts to improve continuity of mental health care should be tailored to the priorities of service users.

Implementing internet-delivered cognitive behavior therapy for common mental health disorders: A comparative case study of implementation challenges perceived by therapists and managers in five European internet services.

OBJECTIVE: Internet-delivered cognitive behavior therapy programs have been developed and evaluated in randomized controlled trials during the past two decades to alleviate the rising demand for effective treatment of common mental health disorders such as anxiety and depression. While most of the research on internet-based cognitive behavior therapy (iCBT) has focused on efficacy and effectiveness only little attention has been devoted to the implementation of iCBT. The aim of this study was to identify the main implementation challenges perceived by therapists and managers involved in the practical operation of iCBT services in routine care settings in five European countries. METHOD: The study was designed as a multiple comparative case study to explore differences and similarities between five different iCBT services in Sweden, Norway, Denmark, The Netherlands and Scotland. Field visits were carried out to each of the five services including interviews with the management of the service (n = 9), focus group interviews with key staff (n = 15) and demonstration of online programs. The data material was processed through thematic, comparative analysis. RESULTS: The analysis generated four transversal themes: 1) integration in the mental health care system; 2) recruitment of patients; 3) working practice of therapists; and 4) long-term sustainability of service. The main results concerned the need to address the informal integration in the health care systems related to the perceived skepticism towards iCBT from GPs and face-to-face therapists, the role of referral models and communication strategies for the stable recruitment of patients, the need for knowledge, standards and material for the training of therapists in the provision of online feedback, the need to improve the possibilities to tailor programs to individual patients, and the need for considerate long-term sustainability planning of the transitions from local projects to permanent regional or national services. CONCLUSION: The present study gives an overview of the main implementation challenges regarding the practical operation of iCBT services perceived by the therapists and managers of the iCBT services. Future studies into specific details of each challenge will be important to strengthen the evidence base of iCBT and to improve uptake and implementation of iCBT in routine care.

Using action learning to reduce health inequity in Danish municipalities.

Purpose The aim of this study is to clarify how action learning can be used as a vehicle for promoting equal access to municipal health services for socially disadvantaged groups in a Danish context. It is the purpose of this paper to describe the methods for reducing health inequity developed in the study and to discuss how action learning methodologically contributed to achieving these results. Design/methodology/approach In the study, the front-line staff from 19 health and social service units in six different municipalities, in Denmark, each formed an action learning group to develop methods for reducing health inequity in a municipal health setting. Each group was guided by an external facilitator, according to an Action Learning Action Research phase model (ALAR-model), which structured the cyclical development of methods into four phases: diagnosing, planning action, taking action and evaluating action. Findings Two types of results of the study are reported in the paper. First, the authors present an overview of the results the 19 participating municipal units have achieved in their action learning processes, as well as two case examples of how two units have worked with action learning and the concrete methods and tools they have developed in this process. Second, they report the challenges and dilemmas the 19 units faced when working with action learning in the study. Originality/value With its use of action learning techniques and the ALAR-model, this study contributes to the development of practice-based methods to reduce unequal access to municipal health services for socially disadvantaged groups. Through the study, the front-line staff in the health and social service units has been involved in the problem-solving process, to a much greater extent than it has previously been adopted in a Danish municipal health setting.

A cross-sectional national survey assessing self-reported drug intake behavior, contact with the primary sector and drug treatment among service users of Danish drug consumption rooms.

BACKGROUND: Drug consumption rooms (DCRs) have been implemented worldwide as a harm-reducing strategy. In 2012, Denmark passed legislation allowing establishment of DCRs. The aim of this study was to identify characteristics and gain knowledge of the way service users use the DCRs including bridge building to specialized health care. Associations between nationality, opioid substitution treatment (OST), drug intake method, and response to staff advice on harm-reducing education was investigated, as well as service user's reasons for using the DCRs, and their perceptions of safety and trust in the DCRs. METHODS: A survey questionnaire sampled 154 participants of DCRs. Convenience sampling was used. Key variables covered demographics, drug intake mode, educational advice received in the DCR, and opinions about and role of the DCRs for the service users. RESULTS: Only 10 % of the participants were under the age of 30, 30 % between 30 and 39 years, 36 % between 40 and 49 years, and 24 % age 50 or more. A total of 60 % of the participants had encountered drugs before they were 19 years old. Female participants were 25 %, and 73 % were Danish citizens, 8 % were non-Danish EU citizens, and 18 % were non-EU citizens. As drug intake method, 63 % injected drugs in a vein, 7 % sniffed, and 37 % smoked. Of drugs used in the DCR, 49 % used cocaine, 41 % heroin, 16 % a mix of heroin and cocaine, and 16 % used methadone. Participants who smoked drugs made significantly less use of drug rehabilitation than participants who sniffed or injected drugs. There was a similar rate of advice on OST across nationality. Participants accepted staff education on hygienic measures and safe injection practices and found it useful. Participants felt safe and trusted staff and bridge building to specialized health care took place in the DCR. CONCLUSIONS: Staff of Danish DCRs educate service users on health related issues and harm-reducing interventions. A subgroup who smoke and a subgroup of nationality other than Danish are underserved and have less likely been in OST. More research on these groups is needed.

A qualitative study of how Danish drug consumption rooms influence health and well-being among people who use drugs.

BACKGROUND: Drug use contributes to higher rates of morbidity and mortality among people who use drugs compared to the general population. In 2012, Danish politicians passed a law that allowed drug consumption rooms (DCRs) to operate; among the objectives were to improve the well-being of vulnerable citizens and to reduce the number of overdoses. Five Danish DCRs are currently being operated. This article presents results from a national investigation focused on assessing the impact of Danish drug consumption rooms on the health and well-being of DCR clients and factors facilitating the acceptance of DCR clients in order to improve their health and refer them onward to social and health service providers. METHODS: We conducted 250 h of participant observation in the DCRs, followed by in-depth qualitative interviews with 42 DCR clients and 25 staff members. Field notes and interviews were analysed and coded, and themes have been developed. RESULTS: DCR clients experienced a sense of social acceptance while inside DCRs. Members of staff conveyed a welcoming, non-judgemental attitude, and DCR clients were predominantly satisfied with the facilities. They prioritized forging relations with drug users so as to foster a sense of social acceptance within DCRs. The primary goal of staff members is to prevent overdoses by informing clients about strong drugs and by intervening in cases of intoxication. DCRs provide security to clients. In cases of health-related problems, DCR clients were referred to local health clinics. Members of the staff build bridges for DCR clients by guiding them towards drug treatment programmes and services in the social and the health sectors. CONCLUSIONS: The study reveals a consistency between DCR clients and staff members with respect to appraisal of the importance of DCRs. Both clients and staff agreed that DCRs provide a safe haven in the environment in which DCR clients often live and that staff members' approach to clients with the intention of promoting acceptance clears the path for the prevention and treatment of overdoses and providing referrals to healthcare facilities, to drug treatment centres and to social services.