BACKGROUND: Virtual patients (VPs) are widely used in health professions education. When they are well integrated into curricula, they are considered to be more effective than loosely coupled add-ons. However, it is unclear what constitutes their successful integration. The aim of this study was to identify and synthesise the themes found in the literature that stakeholders perceive as important for successful implementation of VPs in curricula.
METHODS: We searched five databases from 2000 to September 25, 2023. We included qualitative, quantitative, mixed-methods and descriptive case studies that defined, identified, explored, or evaluated a set of factors that, in the perception of students, teachers, course directors and researchers, were crucial for VP implementation. We excluded effectiveness studies that did not consider implementation characteristics, and studies that focused on VP design factors. We included English-language full-text reports and excluded conference abstracts, short opinion papers and editorials. Synthesis of results was performed using the framework synthesis method with Kern\'s six-step model as the initial framework. We appraised the quality of the studies using the QuADS tool.
RESULTS: Our search yielded a total of 4808 items, from which 21 studies met the inclusion criteria. We identified 14 themes that formed an integration framework. The themes were: goal in the curriculum; phase of the curriculum when to implement VPs; effective use of resources; VP alignment with curricular learning objectives; prioritisation of use; relation to other learning modalities; learning activities around VPs; time allocation; group setting; presence mode; VPs orientation for students and faculty; technical infrastructure; quality assurance, maintenance, and sustainability; assessment of VP learning outcomes and learning analytics. We investigated the occurrence of themes across studies to demonstrate the relevance of the framework. The quality of the studies did not influence the coverage of the themes.
CONCLUSIONS: The resulting framework can be used to structure plans and discussions around implementation of VPs in curricula. It has already been used to organise the curriculum implementation guidelines of a European project. We expect it will direct further research to deepen our knowledge on individual integration themes.

BACKGROUND: Stigma is a social attribute that links a person to an undesirable characteristic and leads to actions that increase the social distance from that person. This includes different or discriminatory treatment. Stigma is common in healthcare, particularly in people with persistent physical symptoms (PPS) and functional disorders (FD). The aim of this study is to create a new actionable framework to aid understanding of stigmatisation in consultations about PPS/FD and to improve the consultation experiences.
METHODS: This framework development used the Best Fit Framework approach to data collected for a scoping review of stigma in functional disorders. The stages included selection of an initial framework from existing conceptual models, mapping quote data from published papers to the framework and an iterative process of revision and re-mapping. The final framework was tested by re-mapping all the quote data to the framework following classification rules.
RESULTS: 253 quotes were obtained from the results sections of qualitative studies from a previous scoping review. The framework comprises of prejudice, stereotypes and actions to increase social distance. Stereotype refers to the focus of stigma: this may be the condition, the patient, or their behaviour. Actions that increase social distance include: othering; denial; non-explanation; minimising, norm-breaking; and psychologising. By breaking down stigma into recognisable components, the framework provides a way to understand the difficulties that patients and clinicians face during consultations and a way to develop intervention materials.
CONCLUSIONS: This new framework for stigma in clinical consultations for PPS/FDs provides a useful tool for the study of stigma in clinical consultations.

BACKGROUND: Shared decision-making facilitates collaboration between patients and health care providers for informed health decisions. Our review identified interventions to support Indigenous Peoples making health decisions. The objectives were to synthesize evidence and identify factors that impact the use of shared decision making interventions.
METHODS: An Inuit and non-Inuit team of service providers and academic researchers used an integrated knowledge translation approach with framework synthesis to coproduce a systematic review. We developed a conceptual framework to organize and describe the shared decision making processes and guide identification of studies that describe interventions to support Indigenous Peoples making health decisions. We conducted a comprehensive search of electronic databases from September 2012 to March 2022, with a grey literature search. Two independent team members screened and quality appraised included studies for strengths and relevance of studies\' contributions to shared decision making and Indigenous self-determination. Findings were analyzed descriptively in relation to the conceptual framework and reported using guidelines to ensure transparency and completeness in reporting and for equity-oriented systematic reviews.
RESULTS: Of 5068 citations screened, nine studies reported in ten publications were eligible for inclusion. We categorized the studies into clusters identified as: those inclusive of Indigenous knowledges and governance (\"Indigenous-oriented\")(n = 6); and those based on Western academic knowledge and governance (\"Western-oriented\")(n = 3). The studies were found to be of variable quality for contributions to shared decision making and self-determination, with Indigenous-oriented studies of higher quality overall than Western-oriented studies. Four themes are reflected in an updated conceptual framework: 1) where shared decision making takes place impacts decision making opportunities, 2) little is known about the characteristics of health care providers who engage in shared decision making processes, 3) community is a partner in shared decision making, 4) the shared decision making process involves trust-building.
CONCLUSIONS: There are few studies that report on and evaluate shared decision making interventions with Indigenous Peoples. Overall, Indigenous-oriented studies sought to make health care systems more amenable to shared decision making for Indigenous Peoples, while Western-oriented studies distanced shared decision making from the health care settings. Further studies that are solutions-focused and support Indigenous self-determination are needed.

We conducted a systematic review of qualitative evidence to improve understanding of the processes and outcomes of redress and reconciliation following a life-changing event from the perspectives of individuals experiencing the event and their families.
We searched six bibliographic databases for primary qualitative evidence exploring the views of individuals who have experienced a life-changing event, and/or their family or carers, of redress or reconciliation processes. This was supplemented with targeted database searches, forward and backward citation chasing and searches of Google Scholar and relevant websites. Title and abstract and full-text screening were undertaken independently by two reviewers. Data extraction and quality appraisal were conducted by one reviewer and checked by a second. We used a best-fit framework synthesis approach, drawing upon procedural and restorative justice concepts.
Fifty-three studies (61 papers) were eligible for inclusion. Forty-one studies (47 papers) were included in the synthesis, from which we identified four themes. Three themes \'Transparency\', \'Person-centered\' and \'Trustworthy\' represent the procedural elements required to support a fair and objective process. The fourth, \'Restorative justice\' encapsulates how a fair process feels to those who have experienced a life-changing event. This theme highlights the importance of an empathic relationship between the different parties involved in the redress-reconciliation process and the significance of being able to engage in meaningful action.
Our findings highlight the procedural aspects and context of redress-reconciliation processes required to ensure that the process and outcomes are experienced as fair. These criteria may be applied to the processes used to investigate both recent and historical patient safety events.
One member of the public affiliated with the Exeter Policy Research Programme Evidence Review Facility helped develop the review protocol. Two people with experience of medically life-changing events provided insight which corroborated our findings and identified important limitations of the evidence included in this review.

Opioid misuse is a nationwide issue and is of particular concern with regard to military readiness. The 2017 National Defense Authorization Act charges the Military Health System with greater oversight of opioid use and mitigation of misuse.
We synthesized published articles using secondary analysis of TRICARE claims data, a nationally representative database of 9.6 million beneficiaries. We screened 106 articles for inclusion and identified 17 studies for data abstraction. Framework analysis was conducted, which assessed prescribing practices, patient use, and optimum length of opioid prescriptions after surgery, trauma, and common procedures, as well as factors leading to sustained prescription opioid use.
Across the studies, sustained prescription opioid use after surgery was low overall, with <1% of opioid-naïve patients still receiving opioids more than 1 year after spinal surgery or trauma. In opioid-exposed patients who had undergone spine surgery, sustained use was slightly lower than 10%. Higher rates of sustained use were associated with more severe trauma and depression, as well as with prior use and initial opioid prescriptions for low back pain or other undefined conditions. Black patients were more likely to discontinue opioid use than were White patients.
Prescribing practices are well correlated with degree of injury or intensity of intervention. Sustained prescription opioid use beyond 1 year is rare and is associated with diagnoses for which opioids are not the standard of care. More efficient coding, increased attention to clinical practice guidelines, and use of tools to predict risk of sustained prescription opioid use are recommended.

OBJECTIVE: To identify how peer support interventions, for self-management of chronic pain, support basic psychological needs from a self-determination theory (SDT) perspective, using a systematic review.
METHODS: Ten databases were searched for studies reporting qualitative research about peer interactions in pain management interventions. \'Best fit\' framework synthesis methodology was applied to identify strategies that support the satisfaction of competence, autonomy and motivation. These were matched to definitions of strategies provided by standardised taxonomies.
RESULTS: 18 studies were selected for inclusion. The synthesis resulted in a conceptual model, identifying 12 peer strategies that support psychological needs for self-management of chronic pain; 10 overlapped with existing taxonomies.
CONCLUSIONS: This was the first known attempt to synthesise evidence about peer support strategies for people living with pain, using SDT as an a priori framework. The model demonstrates commonality between the motivation-promoting processes of peer support and those of other behaviour change interventions and identifies additional unique strategies provided by peers. This systematic classification of peer support strategies provides a means for future study of the efficacy and comprehensiveness of peer interventions.
CONCLUSIONS: The model could assist healthcare professionals and support groups to optimise the potential of peer processes.

Despite consistent international guidelines for osteoarthritis (OA) management, evidence-based treatments are underutilised. OA management programmes (OAMPs) are being implemented internationally to address this evidence-practice gap. An OAMP is defined as a \'model of evidence-based, non-surgical OA care that has been implemented in a real-world setting\'. Our objective is to identify, synthesise and appraise qualitative research identifying anticipated or experienced micro (individual/behavioural), meso (organisational) or macro (context/system) level barriers or facilitators to the implementation of primary or community care-based OAMPs. Five electronic databases will be searched for papers published between 2010 and 2021. Qualitative or mixed-methods studies that include qualitative data on the anticipated or experienced barriers or facilitators to the implementation of primary or community care-based OAMPs, from the perspective of service users or service providers, will be included. The review will be reported using the PRISMA and ENTREQ guidelines. A data extraction form will be used to provide details of the included studies. Data will be analysed and identified barriers and facilitators will be mapped onto an appropriate implementation framework, such as the Theoretical Domains Framework. The appropriate JBI critical appraisal tools will be used to assess methodological quality, while the GRADE-CERQual approach will be used to assess confidence in the findings. Translation of evidence-based guidelines into practice is challenging and reliant on the quality of implementation. By comparing and contrasting anticipated and experienced barriers, this review will determine the extent of congruence between the two, and provide valuable insights into the views and experiences of key stakeholders involved in the implementation of OAMPs. The mapping of identified barriers and facilitators to behaviour change theory will enhance the applicability and construct validity of our findings and will offer significant utility for future development and implementation of OAMPs. Registration: This protocol was registered with PROSPERO (CRD42021255698) on 15/07/21.

Cervical cancer is the fourth most common cancer affecting women worldwide, with 85% of the burden estimated to occur among women in low and middle-income countries (LMICs). Recent developments in cervical cancer screening include a novel self-collection method for the detection of oncogenic HPV strains in the collected samples. The purpose of this review is to synthesise qualitative research on self-collection for HPV-based testing for cervical screening and identify strategies to increase acceptability and feasibility in different settings, to alleviate the burden of disease.
This review includes qualitative studies published between 1986 and 2020. A total of 10 databases were searched between August 2018 and May 2020 to identify qualitative studies focusing on the perspectives and experiences of self-collection for HPV-based cervical screening from the point of view of women, health care workers and other key stakeholders (i.e., policymakers). Two authors independently assessed studies for inclusion, quality, and framework thematic synthesis findings. The Socio-Ecological Model (SEM) was used to synthesize the primary studies.
A total of 1889 publications were identified, of which 31 qualitative studies were included. Using an adapted version of SEM, 10 sub-themes were identified and classified under each of the adapted model\'s constructs: (a) intrapersonal, (b) interpersonal, and (c) health systems/public policy. Some of the themes included under the intrapersonal (or individual) construct include the importance of self-efficacy, and values attributed to self-collection. Under the intrapersonal construct, the findings centre around the use of self-collection and its impact on social relationships. The last construct of health systems focuses on needs to ensure access to self-collection, the need for culturally sensitive programs to improve health literacy, and continuum of care.
This review presents the global qualitative evidence on self-collection for HPV-based testing and details potential strategies to address socio-cultural and structural barriers and facilitators to the use of self-collection. If addressed during the design of an HPV-based cervical cancer screening testing intervention program, these strategies could significantly increase the acceptability and feasibility of the intervention and lead to more effective and sustainable access to cervical screening services for women worldwide.

Personal recovery, living a satisfying, hopeful life alongside symptoms, has become an increasingly valued aim across mental health care agendas internationally. However, there is little understanding of how people experience personal recovery alongside the mood challenges characteristic of a bipolar disorder diagnosis. Personal recovery frameworks have been developed for populations with mixed psychiatric diagnoses, predominantly psychotic disorders.
This systematic review of qualitative data used the widely adopted personal recovery processes Connectedness, Hope and optimism, Identity, Meaning and purpose, Empowerment (CHIME) in a \"best fit\" framework synthesis to understand personal recovery experiences in bipolar disorder. Included studies were coded with deductive framework analysis based on the CHIME processes and inductive thematic analysis for aspects beyond the a priori framework.
A comprehensive search of six literature databases led to inclusion of twelve articles published 2010-2020. Deductive coding supported the fit with the CHIME framework but revealed difficulties, losses, and tensions within and across recovery processes. The proposed framework for personal recovery in bipolar disorder, Purpose and meaning, Optimism and hope, Empowerment, Tensions, Identity, Connectedness (POETIC), organises all CHIME processes around these tensions.
Diversity among study participants was limited with majority middle-aged, female, Western participants.
The compact POETIC personal recovery framework tailored for bipolar disorder is directly applicable to clinical practice with personal recovery objectives. It highlights the need for professionals to introduce personal recovery in a realistic and balanced way to address recent criticism by service user organisations of personal recovery as overly optimistic.

OBJECTIVE: To critically review and synthesize qualitative research pertaining to the establishment of early caregiver-infant relationships in the neonatal care unit (NCU).
BACKGROUND: It is well-established that bonding and attachment, established across the prenatal and early childhood periods, affect child cognitive and behavioural development. Proximity, reciprocity, and commitment are key to the formation of these early relationships. It is intuitively likely that an admission to the NCU may affect early reciprocal caregiver-infant relationships.
METHODS: A qualitative best-fit framework synthesis.
METHODS: A systematic search of four databases (PsycINFO, MEDLINE, British Nursing Index and CINAHL) was conducted, from January 2000-December 2018.
METHODS: The RATS quality appraisal tool was used to evaluate study quality. To ensure reliability, 20% of studies were randomly selected for independent rating. A \"best-fit\" synthesis approach using an existing framework of early parent-infant attachment and bonding was adopted to synthesize the review findings.
RESULTS: Twenty studies, from an original 3,526 unique articles, were included in the review. Studies varied in the extent to which they demonstrated transparency of procedures and in the quality of recruitment information provided. The meta-synthesis demonstrated that proximity, reciprocity, and commitment were affected by admission to a NCU and identified that parental reflections on bonding and the role of staff in this process, were important factors to consider.
CONCLUSIONS: Caregiver-infant relationships are affected by admission to the NCU. The review theoretically supports moves to Family Integrated Care. Units should evaluate caregiver emotional state and consider the role of peer support.
CONCLUSIONS: The synthesis revealed that areas typically implicated in the formation of attachment and bonds were affected by admission to a NCU. Results have implications on the clinical care delivered as part of neonatal care.
目的: 为了严格审查和汇总有关在新生儿监护病房(NCU)建立早期护理者与婴儿关系的定性研究 背景: 众所周知,在产前和幼儿期建立的纽带和依恋关系会影响儿童的认知和行为发展。亲近、相互作用和承诺是形成这些早期关系的关键。直观地看,入住新生儿监护病房可能会影响早期相互作用的护理者与婴儿的关系。 设计: 最佳拟合的定性综合框架。 数据来源: 2000年1月至2018年12月期间,对4个数据库(PsycINFO、MEDLINE、British Nursing Index和CINAHL)进行了系统检索。 审查方法: 采用RATS质量评价工具对研究质量进行评估。为确保可靠性,随机选择20%的研究进行独立评级。采用“最佳拟合”综合方法,利用现有的父母-婴儿早期依恋和纽带框架,对审查结果进行汇总。 调查结果: 审查中包括了20项研究(来自最初的3526篇独特文章)。各项研究在表明程序的透明度和提供的招聘信息的质量方面各不相同。荟萃综合研究表明,入住新生儿监护病房会对亲近、相互作用和承诺造成一定影响,并确定“父母对纽带关系的反思以及工作人员在这一过程中的角色”是需要考虑的重要因素。 结论: 入住新生儿监护病房会对护理者与婴儿的关系造成一定影响。审查从理论上支持转向家庭综合护理。监护病房应评估护理者的情绪状态,并考虑同伴支持的作用。 影响: 综合显示,通常牵涉到依恋和纽带关系形成的区域受到入住新生儿监护病房的影响。这些结果对作为新生儿护理的一部分而提供的临床护理具有影响。.