BACKGROUND: Natural disasters happen in an increased frequency, and telemental health interventions could offer easily accessible help to reduce mental health symptoms experienced by survivors. However, there are very few programs offered to natural disaster survivors, and no research exists on therapists\' experiences with providing blended interventions for natural disaster survivors.
OBJECTIVE: Our qualitative case study aims to describe psychologists\' experiences with an online, therapist-assisted blended intervention for survivors of the Fort McMurray wildfires in Alberta, Canada.
METHODS: The RESILIENT intervention was developed in the frames of a randomized controlled trial to promote resilience after the Fort McMurray wildfires by providing survivors free access to a 12-module, therapist-assisted intervention, aiming to improve post-traumatic stress, insomnia, and depression symptoms. A focus group design was used to collect data from the therapists, and emerging common themes were identified by thematic analysis.
RESULTS: Therapists felt they could build strong alliances and communicate emotions and empathy effectively, although the lack of nonverbal cues posed some challenges. The intervention, according to participating therapists, was less suitable for participants in high-stress situations and in case of discrepancy between client expectations and the intervention content. Moreover, the therapists perceived specific interventions as easy-to-use or as more challenging based on their complexity and on the therapist support needed for executing them. Client engagement in the program emerged as an underlying theme that had fundamental impact on alliance, communication, and ultimately, treatment efficiency. Therapist training and supervision was perceived as crucial for the success of the program delivery.
CONCLUSIONS: Our findings provided several implications for the optimalization of blended interventions for natural disaster survivors from our therapists\' perspective.

The prospect of automated vehicles (AVs) has generated excitement among the public and the research community about their potential to sustain the safe driving of people with dementia. However, no study to date has assessed the views of people with dementia on whether AVs may address their driving challenges.
This mixed-methods study included two phases, completed by nine people with dementia. Phase I included questionnaires and individual semistructured interviews on attitudes toward using different types of AVs (i.e., partially or fully automated). Interpretative phenomenological analysis was used to assess participants\' underlying reasons for and against AV use. The participants\' identified reasons against AV use informed the focus group discussions in Phase II, where participants were asked to reflect on potential means of overcoming their hesitancies regarding AV use.
The results showed that people with dementia might place higher levels of trust in fully automated compared to partially automated AVs. In addition, while people with dementia expressed multiple incentives to use AVs (e.g., regaining personal freedom), they also had hesitations about AV use. These hesitancies were based on their perceptions about AVs (e.g., cost), their own abilities (i.e., potential challenges operating an AV), and driving conditions (i.e., risk of driving in adverse weather conditions).
The findings of this study can help promote the research community\'s appreciation and understanding of the significant potential of AVs for people with dementia while elucidating the potential barriers of AV use by people with dementia.

Anastomotic leak (AL) is a severe complication after esophagectomy. Clinical presentation of AL is diverse and there is large practice variation regarding treatment of AL. This study aimed to explore different AL treatment strategies and their underlying rationale. This mixed-methods study consisted of an international survey among upper gastro-intestinal (GI) surgeons and focus groups with expert upper GI surgeons. The survey included 10 case vignettes and data sources were integrated after separate analysis. The survey was completed by 188 respondents (completion rate 69%) and 6 focus groups were conducted with 20 international experts. Prevention of mortality was the most important goal of primary treatment. Goals of secondary treatment were to promote tissue healing, return to oral feeding and safe hospital discharge. There was substantial variation in the preferred treatment principles (e.g. drainage or defect closure) and modalities (e.g. stent or endoVAC) within different presentations of AL. Patients with local symptoms were treated by supportive means only or by non-surgical drainage and/or defect closure. Drainage was routinely performed in patients with intrathoracic collections and often combined with defect closure. Patients with conduit necrosis were predominantly treated by resection and reconstruction of the anastomosis or by esophageal diversion. This mixed-methods study shows that overall treatment strategies for AL are determined by vitality of the conduit and presence of intrathoracic collections. There is large variation in preferred treatment principles and modalities. Future research may investigate optimal treatment for specific AL presentations and aim to develop consensus-based treatment guidelines for AL after esophagectomy.

BACKGROUND: The launch in 2017 of the Irish 10-year reform programme Sláintecare represents a key commitment in the future of the health system. An important component of the programme was the development of a health system performance assessment (HSPA) framework. In 2019, the Department of Health of Ireland (DoH) and Health Service Executive (HSE) commissioned the technical support of researchers to develop an outcome-oriented HSPA framework which should reflect the shared priorities of multiple stakeholders, including citizens. This study describes the method applied in the Irish context and reflects on the added value of using a citizen panel in the development of an HSPA framework.
METHODS: A panel of 15 citizens was convened, recruited by a third-party company using a sampling strategy to achieve a balanced mix representing the Irish society. Panellists received lay-language preparatory materials before the meeting. Panellists used a three-colour scheme to signal the importance of performance measures. An exit questionnaire was administered to understand how participants experienced being part of the panel. The citizen panel was the first in a series of three panels towards the development of the HSPA framework, followed by panels including representatives of the DoH and HSE, and representatives from professional associations and special interest groups.
RESULTS: The citizen panel generated 249 health performance measures ranging across 13 domains. Top-ranking domains to the citizen panel (people-centredness, coordination of care, and coverage) were less prioritized by the other panels; domains less prioritized by the citizen panel, such as accessibility, responsiveness, efficiency, and effectiveness, were of higher priority in the other panels. Citizen panellists shared a similar understanding of what a citizen panel involves and described their experience at the panel as enjoyable, interesting, and informative.
CONCLUSIONS: The priorities of the citizen panel were accounted for during all phases of developing the HSPA framework. This was possible by adopting an inclusive development process and by engaging citizens early on. Citizen engagement in HSPA development is essential for realizing citizen-driven healthcare system performance and generating trust and ownership in performance intelligence. Future research could expand the use of citizen panels to assess, monitor, and report on the performance of healthcare systems.

To anticipate future suffering due to dementia a growing number of people draft written advance euthanasia directives (AED). In actual practice the number of cases of euthanasia in advanced dementia is very limited. Dementia case managers are often closely involved since an early stage of the disease in the support and guidance of people with dementia and are well positioned to talk about the AED. This study aims to acquire insights into the way case managers deal with AEDs of people suffering from dementia. This qualitative study consists of two focus groups of ten case managers in total. Involvement of case managers was found to extend beyond discussing merely AEDs, to also the broader discussion of euthanasia and \'future euthanasia wishes\' of patients with dementia. A thematic analysis of how case managers proceed with future euthanasia wishes yielded five themes: 1) Scenarios in practice; 2) Introduction of a written euthanasia directive as a conversation topic; 3) Guidance and support of the client and caregiver; 4) Cooperation with other health care workers; 5) Experienced dilemmas. The insights, provided by this study, into the role of case managers regarding the guidance of people with dementia and a future euthanasia wish contributes to a further optimization of the multidisciplinary collaboration between general practitioners and dementia case managers. Further research into the added value of this collaboration in dealing with these complicated issues around euthanasia in dementia care, is recommended.
Om te anticiperen op mogelijk toekomstig lijden als gevolg van dementie stellen mensen steeds vaker een schriftelijke euthanasieverklaring op. In de praktijk is euthanasie bij mensen met gevorderde dementie en een schriftelijke euthanasieverklaring uitzonderlijk. Casemanagers dementie zijn vaak al vanaf het begin van het ziekteproces nauw betrokken bij mensen met dementie. Het onderzoeksdoel is om meer inzicht te krijgen in hoe casemanagers omgaan met schriftelijke euthanasieverklaringen van mensen met dementie. Deze kwalitatieve studie bestond uit twee focusgroepen met in totaal tien casemanagers. Betrokkenheid van casemanagers bleek zich niet te beperken tot gesprekken over schriftelijke euthanasieverzoeken, maar zich te verbreden naar gesprekken over euthanasie en ‘toekomstige euthanasiewensen’. Een thematische analyse naar hoe casemanagers omgaan met toekomstige euthanasiewensen leverde vijf thema’s op: 1) Scenario’s in de praktijk; 2) Introductie van de schriftelijke euthanasieverklaring als gespreksonderwerp; 3) Begeleiding en ondersteuning van de cliënt en mantelzorger; 4) Samenwerking met andere zorgverleners; 5) Ervaren dilemma’s. Het verkregen inzicht in de rol die casemanagers dementie op zich nemen bij de begeleiding van mensen met dementie en een toekomstige euthanasiewens draagt bij aan een verdere optimalisatie van de multidisciplinaire samenwerking tussen de huisarts en casemanager dementie. Nader onderzoek naar de meerwaarde van deze samenwerking bij de vaak complexe vraagstukken rondom euthanasie bij dementie wordt aanbevolen.

OBJECTIVE: To explore existential loneliness among older people in different healthcare contexts from the perspective of healthcare professionals.
BACKGROUND: Professionals meet and care for older people in most care contexts and need to be prepared to address physical, psychological, social and existential needs. Addressing existential loneliness can be both challenging and meaningful for professionals and is often not prioritised in times of austerity.
METHODS: A multiple case study design was used.
METHODS: Focus group interviews were conducted with healthcare professionals (n = 52) in home, residential, hospital and palliative care settings. The analysis was performed in two steps: firstly, a within-case analysis of each context was conducted, followed by a cross-case analysis.
RESULTS: Differences and similarities were observed among the care contexts, including for the origin of existential loneliness. In home care and residential care, the focus was on life, the present and the past, compared to hospital and palliative care, in which existential loneliness mainly related to the forthcoming death. The older person\'s home, as the place where home care or palliative care was received, helped preserve the older person\'s identity. In hospital and palliative care, as in institutional care, the place offered security, while in residential care, the place could make older people feel like strangers. Creating relationships was considered an important part of the professionals\' role in all four care contexts, although this had different meanings, purposes and conditions.
CONCLUSIONS: The context of care matters and influences how professionals view existential loneliness among older people and the opportunities they have to address existential loneliness.
CONCLUSIONS: Support for professionals must be tailored to their needs, their education levels and the context of care. Professionals need training and appropriate qualifications to address existential loneliness related to existential aspects of ageing and care.

BACKGROUND: A majority of nursing home residents have dementia, and many develop neuropsychiatric symptoms. These symptoms are often caused by neuropathological changes in the brain, but modifiable factors related to quality of care also have an impact. A team-based approach to care that include comprehensive geriatric assessments to facilitate clinical decision-making and structured case conference meetings could improve quality of care and quality of life for the residents. Despite recommendations to adopt this approach, dementia care does not reach standards of evidence-based practice. Better implementation strategies are needed to improve care. A cluster randomised controlled trial with a 12-month intervention was conducted, and the experiences of staff from the intervention nursing homes were explored in a qualitative study after the trial was completed. The aim of the present study was to describe: (i) staff\'s experiences with the intervention consisting of comprehensive geriatric assessments of nursing home residents and case conferencing, and (ii) enablers and barriers to implementing and sustaining the intervention.
METHODS: Four focus groups with a total of 19 healthcare staff were interviewed, representing four out of eight intervention nursing homes. Thematic content analysis was used to interpret the transcribed data.
RESULTS: Two major themes emerged: 1) learning experiences and 2) enablers and barriers to implementation. The participants had experienced learning both on an organisational level: improvements in care and an organisation that could adjust and facilitate change; and on an individual level: becoming more conscious of residents\' needs and acquiring skills in resident assessments. Participants described important enabling factors such as managerial support, drivers for change, and feasibility of the intervention for the local nursing home. Barriers to implementing and sustaining the intervention were time constraints, lack of staff training, unsuitable electronic patient record system for care planning and high complexities of care and instabilities that are present in nursing homes.
CONCLUSIONS: Quality improvements in nursing homes are difficult to sustain. In order to offer residents high quality of care that meet their individual needs, it is important for management and nursing home staff to be aware of and understand factors that enable or constrain change.

UNASSIGNED: The role of the community pharmacist has traditionally been a medication dispenser; however, community pharmacists\' responsibilities must expand to include more direct patient care services in order to transform primary care practice.
UNASSIGNED: Use case-based scenarios to (1) determine factors that contribute to positive and negative consumer perceptions of expanded community pharmacist patient care roles, (2) identify facilitators and barriers that contribute to consumer perceptions of the value of expanded community pharmacist patient care services, and (3) develop a successful approach and strategies for increasing consumer advocacy for the value of expanded community pharmacist patient care services.
UNASSIGNED: Two consumer focus groups used scenario-based guided discussions and Likert scale questionnaires to elicit consumer reactions, facilitators, and barriers to expanded community pharmacist services.
UNASSIGNED: Convenience, timeliness, and accessibility were common positive reactions across all 3 scenarios. Team approach to care and trust were viewed as major facilitators. Participant concerns included uncertainty about pharmacist training and qualifications, privacy, pharmacists\' limited bandwidth to accept new tasks, and potential increased patient costs. Common barriers to service uptake included a lack of insurance payment and physician preference to provide the services.
UNASSIGNED: Consumer unfamiliarity with non-traditional community pharmacist services is likely an influencer of consumers\' hesitancy to utilize such services; therefore, an opportunity exists to engage consumers and advocacy organizations in supporting expanded community pharmacist roles. This study can inform consumers, advocates, community pharmacists, primary care providers, and community-based organizations on methods to shape consumer perceptions on the value of community pharmacist expanded services.

Knowledge about slaughter of animals for human food is often perceived as controversial and therefore not made widely available. An open educational resource on the Internet about the slaughter of animals has created tension at launch but also resolved tension. Aiming to explore how this resource at the boundary between academia and society is perceived, a study was carried out with participants from slaughterhouses, universities, authorities and NGOs. Focus group sessions were video recorded and transcripts were coded using an interpretive thematic analysis. The results show that an open educational resource in addition to contributing to learning and awareness raising can also induce dialogue (and thus resolve tension) about animal welfare and contribute to animal welfare resilience. Our results also indicate that participants had diverse opinions about the influence of multimedia on attitudes towards animal slaughter. The use of additional instruments such as comment fields may lead to more knowledgeable citizens and socially robust knowledge, but has to be carefully weighed against the risk of false or fake data.

Objective Skull base tumors are associated with quality of life (QOL) changes. A qualitative case-study approach may help better understand patients\' experiences. Methods A total of 34 skull base surgery patients were selected into focus groups using a criterion-based maximum variation sampling strategy from a sampling frame of 138 patients. Eight groups were organized based on a factorial design of surgical approach (endoscopic/pen) and tumor location (anterior/central). Data were analyzed using a conceptual framework. Qualitative analysis was performed on focus group transcripts to identify major themes and determine if surgical approach or tumor location had differential effects on QOL. Concepts were quantitatively tallied from written workbooks. Results The 34 participants (19 men, 15 women; mean age: 48 years, standard deviation: 14 years) had mixed reactions to their diagnosis ranging from relief to fear. Participants reported physical and nonphysical changes in QOL with some variation in physical complaints by tumor location. Several major themes emerged from the analysis. Skull base tumors are associated with fear and frustration, loss of physical senses and self-identity, social isolation, and coping mechanisms. Conclusions Skull base surgery may impact patients\' lives. Qualitative study of patient experiences can provide rich information to better understand this disease.