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Abstract: Background: The psychosocial consequences of stroke are complex and comprehensive and include substantial and longlasting impacts on mood, identity, social relationships, return to work and quality of life. Many studies have explored possible interventions to prevent or treat psychosocial problems, but the results have generally been disappointing. Very few studies have provided adequate theoretical accounts of the mechanisms assumed to contribute to positive outcomes. Objectives: To describe the development of a psychosocial nursing intervention aimed at promoting psychosocial health and well-being and to stimulate dialogue about how to develop and report theoretically and empirically sound complex interventions in nursing. Design: A systematic, stepwise approach was used, consistent with the framework recommended for developing and evaluating complex interventions by the UK Medical Research Council. Data sources: Systematic reviews of empirical studies regarding the psychosocial consequences and needs of patients following stroke; qualitative, experiential studies of stroke and stroke recovery; theories of psychosocial well-being, coping, life skills, narrative approaches to rehabilitation and guided self-determination. Review methods: Each systematic review was examined to determine the major psychosocial challenges and needs experienced by stroke survivors, focusing on how these challenges and needs developed over the illness trajectory, how previous interventions had sought to address them and the effective mechanisms assumed to affect the level of success of interventions. Qualitative studies were examined to reveal the subjective experiences of stroke and stroke recovery, paying particular attention to the development of needs across time and context. A qualitative synthesis of the major characteristics of the trajectory of stroke rehabilitation and recovery during the first year was developed. Theories were examined to illuminate possible effective mechanisms and actions aimed at promoting psychosocial well-being during the stroke recovery process. Results: A dialogue-based intervention comprising eight encounters between stroke survivors and trained health care workers was designed, based on narrative theories, empowerment philosophy and guided self determination. Worksheets and a guiding topical outline were developed to support the dialogue. Conclusions: The UK Medical Research Council framework facilitated the systematic development of an empirically and theoretically informed complex nursing intervention aimed at promoting post-stroke psychosocial well-being. [Copyright &y& Elsevier]

Objectives : In Norwegian aquaculture, safer technology and better safety management systems have been developed during the last decade. Safety commitment and safe behavior are still vital to ensure a safe working environment. The objective of this paper is to explore what factors might influence the reporting of hazardous situations in aquaculture. The significance of factors on both the individual (work experience, position) and company/organizational level (company size, safety climate) was studied. It was hypothesized that reporting of hazardous situations was positively predicted by work experience, having the position as operational manager, company size, and safety climate. Methods : The study is based on a quantitative questionnaire study involving 428 fish farmers, operational managers, and service vessel employees in the Norwegian aquaculture industry, interviewed by telephone. A purposive sampling procedure was employed. Correlation and hierarchical regression analyses were applied. The data quality was considered satisfactory. Results : Individual factors had no significant relationship with the reporting of hazardous situations. Company size and safety climate factors had positive associations with reporting. Larger companies might have more resources for safety management and the development of practical reporting solutions. A positive safety climate might increase the motivation for reporting. Conclusion : Efforts by management to improve the safety climate can contribute to the reporting of hazardous events, continuous improvement of safety management and improvement of the safety level.

Background: Large-scale, national eHealth services, such as the summary care record (SCR) and electronic prescriptions (e-prescriptions), have been implemented by project managers as Norwegian health authority initiatives. Few studies have been conducted on the large-scale implementation of eHealth services and the relationship between the implementers' work and the use of the tools in healthcare practices. Hence, there was a need to determine the project work with a focus on changes in practice. This study explores the implementation of the SCR and e-prescriptions from the perspective of project managers; how does the implementation work by project managers relate to institutional practices in large-scale initiatives?, Methods: Twenty-two semi-structured interviews were held with project managers in 2016 and 2018 and were recorded, transcribed, and coded according to the content. The analytical concepts of the "project" and "practice" were used to focus on tensions between the dimensions of time connecting historically established social practice and in situ actions., Results: The eHealth initiatives were demonstrated to have been implemented as a part of the national strategy and achieved through close collaboration with the Norwegian Directorate of eHealth (NDE). Tensions arose in relation to task-oriented actions during the implementation of the project and the daily management thereafter. Further, the work tasks of the project managers were related to the dissemination of the tools while, in practice, the tools were related to actual use by professionals. The implementation of several projects simultaneously created tensions between the implementation of a tool and a specific practice, as well as between tools., Conclusion: The objectives set out by the project managers in relation to their work should be viewed as temporary, whereas a long-term objective should apply to the use of the tools. Hence, the work of implementing eHealth initiatives might call for a renewed definition of the empirical object. Identifying factors that affect uptake, such as gaps between the intended use of an object and in situ actions or historically established activities, might expedite the future success of national eHealth initiatives. The social aspect of institutional practice has a direct bearing on the potential of a project to be implemented successfully.

Objectives: The aim of this study was to provide recommendations to hospital owners and employee unions about developing efficient, sustainable and safe work-hour agreements. Employees at two clinics of a hospital, one a non-intensive care and the other a newborn intensive care unit (ICU), trialled 12-hour shifts on weekends for 1 year., Methods: We systematically recorded the experiences of 24 nurses' working 12-hour shifts, 16 in the medical unit and 8 in the ICU for 1 year. All were interviewed before, during and at the end of the trial period. The interview material was recorded, transcribed to text and coded systematically., Results: The experiences of working 12-hour shifts differed considerably between participants, especially those in the ICU. Their individual experiences differed in terms of health consequences, effects on their family, appreciation of extra weekends off, perceived effects on patients and perceived work task flexibility., Conclusions: The results indicate that individual preference for working 12-hour shifts is a function of own health situation, family situation, work load tolerance, degree of sleep problems, personality and other factors. If the goal is to recruit and retain nurses, nurses should be free to choose to work 12-hour shifts., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The Norwegian government recently implemented a new management system to regulate salmon farming in Norway, aiming to promote environmentally sustainable growth in the aquaculture industry. The Norwegian coast has been divided into 13 production zones and the volume of salmonid production in the zones will be regulated based on salmon lice effects on wild salmonids. Here we present a model for assessing salmon louse-induced mortality of seaward-migrating post-smolts of Atlantic salmon. The model quantifies expected salmon lice infestations and louse-induced mortality of migrating post-smolt salmon from 401 salmon rivers draining into Norwegian coastal waters. It is assumed that migrating post-smolts follow the shortest path from river outlets to the high seas, at constant progression rates. During this migration, fish are infested by salmon lice of farm origin according to an empirical infestation model. Furthermore, louse-induced mortality is estimated from the estimated louse infestations. Rivers draining into production zones on the West Coast of Norway were at the highest risk of adverse lice effects. In comparison, rivers draining into northerly production zones, along with the southernmost production zone, were at lower risk. After adjusting for standing stock biomass, estimates of louse-egg output varied by factors of up to 8 between production zones. Correlation between biomass adjusted output of louse infestation and densities of farmed salmon in the production zones suggests that a large-scale density-dependent host-parasite effect is a major driver of louse infestation rates and parasite-induced mortality. The estimates are sensitive to many of the processes in the chain of events in the model. Nevertheless, we argue that the model is suited to assess spatial and temporal risks associated with farm-origin salmon lice., (Copyright © 2017 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Despite extensive publication of clinical guidelines on how to manage musculoskeletal pain and back pain in particular, these efforts have not significantly translated into decreases in work disability due to musculoskeletal pain. Previous studies have indicated a potential for better outcomes by formalized, early referral to allied healthcare providers familiar with occupational health issues. Instances where allied healthcare providers of comparable professional characteristics, but with differing practice parameters, can highlight important social and organisational strategies useful for informing policy and practice. Currently, Norwegian chiropractors have legislated sickness certification rights, whereas their Danish and Swedish counterparts do not. Against the backdrop of legislative variation, we described, compared and contrasted the views and experiences of Scandinavian chiropractors engaging in work disability prevention and sickness absence management., Methods: This study was embedded in a two-phased, sequential exploratory mixed-methods design. In a comparative qualitative case study design, we explored the experience of chiropractors regarding sickness absence management drawn from face-to-face, semi-structured interviews. We subsequently coded and thematically restructured their experiences and perceptions., Results: Twelve interviews were conducted. Thematically, chiropractors' capacity to support patients in sickness absence management revolved around four key issues: issues of legislation and politics; the rationale for being a sickness absence management partner; whether an integrated sickness absence management pathway existed/could be created; and finally, the barriers to service provision for sickness absence management., Conclusion: Allied health providers, in this instance chiropractors, with patient management expertise can fulfil a key role in sickness absence management and by extension work disability prevention when these practices are legislatively supported. In cases where these practices occur informally, however, practitioners face systemic-related issues and professional self-image challenges that tend to hamper them in fulfilling a more integrated role as providers of work disability prevention practices., Competing Interests: All authors are certified chiropractors from one of the three Scandinavian countries described in this study, and either work or have worked in chiropractic settings. They have intimate knowledge about the daily life and routines in chiropractic clinics, and have themselves faced the challenges of WDP and SAM of patients.In Sweden, the regional ethics committee evaluated the project and found that the study did not need ethical permission (advisory statement 2016/3:1). In Denmark, the Regional ethics of Southern Denmark gave approval for the study and declared that the study does not fall within the scope of the Medical Research Involving Human Subject Act (§14). Approval for data handling and storage covering both Denmark and Norway under the EEA-collaboration was granted from the Danish Data Protection agency. Prior to the interviews, written and oral information about the study were provided to the participants. Written informed consent was obtained from all participants. All participants were advised that conversations were to be audio or video recorded, and assured of confidentiality and anonymity in reporting of the results.IA is an associate editor and MJS is a society representatives of Chiropractic and Manual Therapies, but had no influence over the review assignment or process. The authors declare that they have no further competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

It is known that if one partner wants to talk after the loss of a child, while the other does not, the less satisfied they are with the relationship. The aim of this study was to increase our understanding of parental relationships following the loss of a child. A questionnaire on various aspects of the relationship was sent to 1,027 members of bereavement support organizations for parents who have lost children in Norway. The studied sample ( N = 285) consisted of 169 women (59.3%) and 116 men (40.7%), representing 175 couples. Although the participants were generally satisfied with their relationship and felt that it was strengthened, there were challenges of communication and interaction. The loss made the relationship special, and they felt they had learned to know each other on a deeper level. The importance of talking together and communicating thoughts and feelings was emphasized by the parents. Women initiated talk more often and evidenced a greater need to talk. A deterioration of the relationship tended to be related to a lack of understanding, communication, and care. Communication, respect, and understanding were underlined as core factors for perceiving a relationship as positive.

Objective: It is logical that tailoring implementation strategies to address identified determinants of adherence to clinical practice guidelines should improve adherence. This study aimed to identify and prioritize determinants of adherence to six recommendations for elderly patients with depression., Design and Setting: Group and individual interviews and a survey were conducted in Norway., Method: Individual and group interviews with healthcare professionals and patients, and a mailed survey of healthcare professionals. A generic checklist of determinants of practice was used to categorize suggested determinants., Participants: Physicians and nurses from primary and specialist care, psychologists, researchers, and patients., Main Outcome Measures: Determinants of adherence to recommendations for depressed elderly patients in primary care., Results: A total of 352 determinants were identified, of which 99 were prioritized. The most frequently identified factors had to do with dissemination of guidelines, general practitioners' time constraints, the low prioritization of elderly patients with depression, and the patients' or relatives' wish for medication. Approximately three-quarters of the determinants were from three of the seven domains in the generic checklist: individual healthcare professional factors, patient factors, and incentives and resources. The survey did not provide useful information due to a low response rate and a lack of responses to open-ended questions., Implications: The list of prioritized determinants can inform the design of interventions to implement recommendations for elderly patients with depression. The importance of the determinants that were identified may vary across communities, practices. and patients. Interventions that address important determinants are necessary to improve practice.

Background: There has been an increased interest in recruiting health professionals with a clinical background to management positions in health care. We know little about the factors that influence individuals' decisions to engage in management. The aim of this study is to explore clinicians' journeys towards management positions in hospitals, in order to identify potential drivers and barriers to management recruitment and development., Methods: We did a qualitative study which included in-depth interviews with 30 clinicians in middle and first-line management positions in Norwegian hospitals. In addition, participant observation was conducted with 20 of the participants. The informants were recruited from medical and surgical departments, and most had professional backgrounds as medical doctors or nurses. Interviews were analyzed by systemic text condensation., Results: We found that there were three phases in clinicians' journey into management; the development of leadership awareness, taking on the manager role and the experience of entering management. Participants' experiences suggest that there are different journeys into management, in which both external and internal pressure emerged as a recurrent theme. They had not anticipated a career in clinical management, and experienced that they had been persuaded to take the position. Being thrown into the position, without being sufficiently prepared for the task, was a common experience among participants. Being left to themselves, they had to learn management "on the fly". Some were frustrated in their role due to increasing administrative workloads, without being able to delegate work effectively., Conclusions: Path dependency and social pressure seems to influence clinicians' decisions to enter into management positions. Hospital organizations should formalize pathways into management, in order to identify, attract, and retain the most qualified talents. Top managers should make sure that necessary support functions are available locally, especially for early stage clinician managers.

Background: Insight in parental energy balance-related behaviours, their determinants and parenting practices are important to inform childhood obesity prevention. Therefore, reliable and valid tools to measure these variables in large-scale population research are needed. The objective of the current study was to examine the test-retest reliability and construct validity of the parent questionnaire used in the ENERGY-project, assessing parental energy balance-related behaviours, their determinants, and parenting practices among parents of 10-12 year old children., Findings: We collected data among parents (n = 316 in the test-retest reliability study; n = 109 in the construct validity study) of 10-12 year-old children in six European countries, i.e. Belgium, Greece, Hungary, the Netherlands, Norway, and Spain. Test-retest reliability was assessed using the intra-class correlation coefficient (ICC) and percentage agreement comparing scores from two measurements, administered one week apart. To assess construct validity, the agreement between questionnaire responses and a subsequent interview was assessed using ICC and percentage agreement.All but one item showed good to excellent test-retest reliability as indicated by ICCs > .60 or percentage agreement ≥ 75%. Construct validity appeared to be good to excellent for 92 out of 121 items, as indicated by ICCs > .60 or percentage agreement ≥ 75%. From the other 29 items, construct validity was moderate for 24 and poor for 5 items., Conclusions: The reliability and construct validity of the items of the ENERGY-parent questionnaire on multiple energy balance-related behaviours, their potential determinants, and parenting practices appears to be good. Based on the results of the validity study, we strongly recommend adapting parts of the ENERGY-parent questionnaire if used in future research.

Aims and Objectives: To analyse the relationships between depressive symptoms, sense of coherence and emotional and social loneliness among nursing home residents without cognitive impairment., Background: Depression symptoms and loneliness are major health problems for older people. Sense of coherence, which is based on a salutogenic theoretical framework, is a strong determinant of positive health and successful coping and is associated with well-being and depression among older people. Few studies have explored the relationships between depression symptoms, sense of coherence and emotional and social loneliness among nursing home residents., Design: A cross-sectional, descriptive, correlational design., Methods: Sample - 227 residents 65-102 years old from 30 nursing home residing ≥ six months. All had a Clinical Dementia Rating ≤ 0·5 and could converse. Residents were interviewed using the Social Provisions Scale, Geriatric Depression Scale and Sense of Coherence Scale (SOC-13). Possible relationships between these were analysed, controlled for sex, age, marital status, education, length of stay and comorbidity., Results: Before adjustment, Geriatric Depression Scale was associated with attachment and social integration. After adjustment, Geriatric Depression Scale was still associated with attachment and social integration. Further adjusting for Sense of Coherence Scale reduced the association between Geriatric Depression Scale and attachment and even more so for the association between Geriatric Depression Scale and social integration. Sense of coherence and Geriatric Depression Scale did not interact, and SOC-13 was associated with attachment and social integration., Conclusions: Depression symptoms contribute to emotional and social loneliness. Independent of sense of coherence, depression symptoms are associated with emotional loneliness, sense of coherence influence emotional and social loneliness., Relevance to Clinical Practice: Clinical nurses should observe residents closely for signs of depression and loneliness and support their sense of coherence to reduce emotional and social loneliness., (© 2012 Blackwell Publishing Ltd.)

Background: Implementation researchers have attempted to overcome the research-practice gap in e-health by developing tools that summarize and synthesize research evidence of factors that impede or facilitate implementation of innovation in healthcare settings. The e-Health Implementation Toolkit (e-HIT) is an example of such a tool that was designed within the context of the United Kingdom National Health Service to promote implementation of e-health services. Its utility in international settings is unknown., Methods: We conducted a qualitative evaluation of the e-HIT in use across four countries--Finland, Norway, Scotland, and Sweden. Data were generated using a combination of interview approaches (n = 22) to document e-HIT users' experiences of the tool to guide decision making about the selection of e-health pilot services and to monitor their progress over time., Results: e-HIT users evaluated the tool positively in terms of its scope to organize and enhance their critical thinking about their implementation work and, importantly, to facilitate discussion between those involved in that work. It was easy to use in either its paper- or web-based format, and its visual elements were positively received. There were some minor criticisms of the e-HIT with some suggestions for content changes and comments about its design as a generic tool (rather than specific to sites and e-health services). However, overall, e-HIT users considered it to be a highly workable tool that they found useful, which they would use again, and which they would recommend to other e-health implementers., Conclusion: The use of the e-HIT is feasible and acceptable in a range of international contexts by a range of professionals for a range of different e-health systems.

Background: One Norwegian medical school introduced A-type MCQs (best one of five) to replace more traditional assessment formats (e.g. essays) in an undergraduate medical curriculum. Quality assurance criteria were introduced to measure the success of the intervention., Method: Data collection from the first four year-end examinations included item analysis, frequency of item writing flaws (IWF) and proportion of items testing at a higher cognitive level (K2). All examinations were reviewed before after delivery and no items were removed., Results: Overall pass rates were similar to previous cohorts examined with traditional assessment formats. Across 389 items, the proportion of items with >or=5% of candidates marking two or more functioning distracters was >or=47.5%. Removal of items with high p-values (>or=85%), this item distracter proportion became >75%. With each successive year in the curriculum the proportion of K2 items used rose steadily to almost 50%. 31/389 (7%) items had IWFs. 65% items had a discriminatory power, >or=0.15., Conclusions: Five item quality criteria are recommended: (1) adherence to an in-house style, (2) item proportion testing at K2 level, (3) functioning distracter proportion, (4) overall discrimination ratio and (5) IWF frequency.

The new standard of cause of death classification is an automated selection of the underlying cause of death using the international software Automated Classification of Medical Entities (ACME). Norwegian mortality rates are, however, based on manual classification of deaths. The aim of this study was to investigate how the use of ACME would influence Norwegian prostate cancer mortality rates. A previously described cohort of Norwegian prostate cancer patients deceased during 1996 was applied. Multiple causes of death data based on information from death certificates, autopsies and queries was coded according to ACME specifications, thereby ACME selected the underlying cause of death. In addition, the underlying cause of death that originally was manually classified for the official mortality statistics was retrieved from Statistics Norway in all cases. Age-standardized prostate cancer mortality rates (world population) per 100,000 person-years were calculated. A total of 2012 cases were included. On the basis of ACME classification, the age-standardized prostate cancer mortality rate in Norway for 1996 would have been 24.4 (95% confidence interval: 22.9-26.0) as compared with the rate based on manual classification for the official mortality statistics of 24.9 (95% confidence interval: 23.4-26.5). Thus, automated classification by ACME does not significantly influence the age-adjusted Norwegian prostate cancer mortality rate for the year 1996. There is reason to assume that the use of manual classification of deaths is not a major explanation of the high prostate cancer mortality rates in Norway.

This study illuminates the role and significance of music listening in everyday life for the long-term ill. Twenty-two participants, aged 34-65 from Oslo and Akershus in Norway, were recruited as a strategic sample and took part in eight in-depth interviews over a 1-year period, from 2004 to 2005. Four double CD compilations from different genres, part of the project, were used as devices to discover whether participants could learn to use music as a 'technology' for self-help, with regard to health, healing and recovery, through exposure to and exchange of new musical materials and practices. A novel Participatory CD design was developed, and the beneficial experiences of taking part in the project resulted in an increase in self-awareness and self-consciousness. Listening to and discussing music was considered to be an important tool in the process of change, sense of agency and self-development, through enhancing well-being and 'wellness', a vital factor in the process of recovery and sustaining quality of life, despite of illness.

This qualitative study aims to interpret the results of a randomized controlled trial comparing two educational programs (directed learning and self-directed learning) in evidence-based medicine (EBM) for medical students at the University of Oslo from 2002 to 2003. There is currently very little comparative educational research in this field. In the trial, no statistically significant differences between the study groups were shown for any outcomes considered (EBM knowledge, skills, and attitudes). Further analysis suggests that main reason for the negative trial results was that the majority of students learned equally effectively, whichever program they received, although implementation of the educational programs was not complete because of varying attendance. This study illustrates a stepwise evaluation model that might be useful in evaluating other socially complex interventions.

The objective of the study was to validate the model of empathic opportunity (EO) and potential empathic opportunity (PEO) using the Roter Interaction Analysis System (RIAS) in a sample of cancer patients. Thirty-nine audio taped consultations at an outpatient oncology clinic performed by four oncologists were previously coded with the Roter Interaction Analysis System for another purpose. These consultations were also coded by two raters with the empathic and potential empathic opportunity method (E-PE-O method). The reliability of EO and PEO coding was satisfactory. Most of the EOs were found within the RIAS category "showing concern". The PEOs were found in both the socio-emotional and the instrumental categories of the RIAS. We conclude that the E-PE-O method is a good starting point for studying the empathy process in oncology consultations., (Copyright 2003 Elsevier Ireland Ltd.)

In a pilot project, telemedicine was used to conduct retinal examinations of diabetic patients in the Alta municipality of Norway. All health-care workers who were involved in the project were interviewed. The ophthalmologists found that the grading of the level of retinopathy was quicker with digital images than with slit-lamp examinations. Fifty patients with type II diabetes were invited to attend a telemedicine check-up and 42 did so. Patients were asked to complete a questionnaire after the telemedicine examination and we received 32 replies (a 76% response rate), of which 12 were from men and 20 from women. The patients expressed a high degree of satisfaction with the telemedicine examination. The results of the evaluation also clearly showed that trust between health personnel was of major importance in engendering positive attitudes. Confidence is the basis of good collaboration between the various professions in the health-care sector, between health-care levels and between patients and treatment providers - in terms not only of individuals' confidence but also of routines, procedures and the system as a whole.

The World Health Report 2000 presents a set of indicators and global indices by which different countries' goal attainment and performance in health care may be compared. The paper explains the methods employed in some detail and raises a number of critical points. The WHO has gone too far in compressing the results of potentially useful primary measurements in summary indices with unclear meaning, dubious validity and little practical relevance to decision makers facing specific tasks and problems. The WHO has also gone too far in applying the same measuring rods to countries with different histories and values and different stages of development, and in encouraging international comparisons that are of little use to policy makers. The WHO needs to add an indicator of equality in access to its present indicator of fairness in financing.

Objectives: To evaluate the implementation of clinical guidelines for diabetes mellitus in general practice with a specific computer-based clinical decision support system (CDSS) as part of the intervention., Methods: Randomized study with health center as unit. General practice in Sør- and Nord-Trøndelag counties in Norway, 380,000 inhabitants. Seventeen health centers with 24 doctors and 499 patients with diabetes mellitus were in the intervention group and 12 health centers with 29 doctors and 535 patients were in the control group. Main outcome measures were group differences in fractions of patients without registrations (process evaluation) and mean group differences for the same variables (patient outcome evaluation)., Results: Statistically significant group differences were experienced for fractions of patients without registration of cigarette smoking (intervention group, 82.6%; control group 94.5%), body mass index (78.2% vs. 93.0%), and sufficient registrations for calculation of risk score for myocardial infarction (91.1% vs. 98.3%); all during 18 months. Large center variations were shown for all variables. The only statistically significant group difference was -2.3 mm Hg (95% CI, -3.8, -0.8) in diastolic blood pressure in favor of the intervention group. Statistically insignificant differences in favor of the intervention group were HbA1c, -0.1% (95% CI, -0.4, 0.1), systolic blood pressure, -1.2 mm Hg (95% CI, -4.4, 2.0). Statistically insignificant differences in favor of the control group were fractions of smokers, +3.0% (95% CI, -4.0, 10.0), body mass index, +0.3 kg/m2 (95% CI, -0.8, 1.4), risk score in female +0.1 (95% CI, -5.1, 5.2), and risk score in male +2.6 (95% CI, -14.2, 19.5)., Conclusions: Implementation of clinical guidelines for diabetes mellitus in general practice, by means of a CDSS and several procedures for implementation, did not result in a clinically significant change in doctors' behavior or in patient outcome.

Background: Final-year medical students at the University of Bergen take a 16-hour consultation course. The students are trained in an educational setting focusing on structured elements of the patient-centred consultation method, self evaluation and peer evaluation. The course has a strong emphasis on learning by doing. The objective of this study was to evaluate the learning process and the subjective outcome of the course. We used a focus group technique and a self-administered free text based questionnaire., Material and Methods: Transcriptions from the focus groups and free text from the questionnaires were analysed using qualitative methods., Results: The qualitative analysis revealed three main categories of statements about the learning process: about the process of selfchange in the consultations; about the pain of self evaluation; and about insufficiency faced with clinical uncertainty., Interpretation: We conclude that the course seems to initiate changes in consultation strategies. The students' evaluation also underline the need to take care of the students during a process of change in which they are vulnerable.

Background: Electronic result reporting from two laboratories to physicians in primary health care through electronic data interchange (EDI) has been used as a supplement to the printed reports. The aim of the study was to see if the quality of the electronic reporting could be improved so that the printed reporting could be cut out without any loss of data., Material and Methods: Staff members in 20 selected offices were interviewed and error messages on file in the computer systems were studied., Results: During a period of four months, the laboratories sent 10,740 electronic messages to the selected offices. Error messages arose from 71 of these messages (0.7%). 49 of the errors were discovered and corrected by the staff, but 22 errors were not noticed, and the result reports were lost., Interpretation: If electronic result reporting should become the only reporting routine, it would be necessary to change several routines both in the laboratories and in the physician's offices. Patients must be identified by using official identifiers. The physicians must control in the computer system that all requested results are received, and the programs used for controlling the messages before they are entered into the electronic patient journal, must be improved.

Background: Bicycle helmets prevent head injury in bicycle riders. Still, only a portion of bicycle riders in Norway use bicycle helmets. The aim of this study was to estimate the number of head injuries among bicycle riders that might be prevented by increased helmet use in Norway., Material and Methods: We used data from the Norwegian National Injury Register for the years 1995 and 1996 to estimate the number of bicycle injuries in Norway. In order to estimate the number of bicycle users and helmet users in different age groups, we used data from earlier surveys of bicycle use. Data on the effectiveness of helmet promotion interventions have been obtained from a systematic review of the literature., Results: The overall annual incidence rate was 92 injuries per 100,000 bicycle users. The incidence varied with age and was highest among children. If every rider used a helmet, about 1,600 head injuries would be avoided every year, of these, 800 among children aged 0-14. Currently available helmet promotion interventions may improve the use among children by about 40%, thus preventing about 1,500 head injuries over a period of three years. Successful helmet promotion interventions use a combination of health education and helmet distribution strategies., Interpretations: There is a significant health improvement potential in promoting bicycle helmets in Norway by implementation of evaluated modes of intervention.

Background: Information and communication technology may represent unique opportunities as well as challenges for persons who are socially isolated due to serious mental disorders., Material and Methods: In order to explore how such persons use and experience Internet technology, a pilot project was conducted in collaboration with eight subjects. These accepted a PC with Internet access in their homes for a period of one year. The experiences reported are based on self-reports, and observations made by clinical and project personnel., Results: Three of the eight subjects reported little or no use of the Internet. For the five active users, Internet opened up for social contact and support without provoking the same degree of social anxiety as face-to-face interaction. Four of the five subjects wish to use e-mail contact as a supplement to face-to-face contact with their therapist., Interpretation: Internet can represent a lifeline to society for persons isolated due to mental disorders. Electronic based interaction between patients and health care professionals will provide unique opportunities as well as challenges in efforts towards improving the quality of and access to health care services.

Background: Our aim was to evaluate one year of operation of a newly established teleradiology service for people in Mid- and North Gudbrandsdalen (30,000 inhabitants). In Otta, one radiographer works with digital pictures (phosphorus plate technology). Pictures are sent to the local hospital in Lillehammer (115 kilometres away) by a broadband network (for health services only) for radiological evaluation., Material and Methods: We have measured the scope of the service, patient satisfaction, management stability and efficiency, and financial aspects (the latter are not included in this article)., Results: Over one year we have examined 3,081 persons (skeleton, thorax, sinuses). A majority of patients (90%) thought it was better for them to be examined at Otta. Waiting time was short, rarely more than one week. No re-examinations due to insufficient picture quality were required. Some expected and some unexpected problems occurred. Pictures from 37 patients were lost and could not be radiologically evaluated. The lead time from when pictures were taken to when the requisitioning doctor received the report, was too long (one to three weeks). The digital pictures are not easily available to hospital physicians. Copies must be made on film., Interpretation: Our experience is positive. Most problems will be solved by storing copies at Otta, by better organisation of the radiologic service, and by establishing a digital picture archiving and communication system (PACS) at the hospital.

Background: Two thirds of the young women who want induced abortions have not used contraception, and it is likely that improved education in contraception will lead to a decline in induced abortions. The Norwegian Medical Association sees this as its responsibility, and in 1995 proposed a campaign to improve the quantity and quality of physicians' advice on contraceptive use. A booklet was produced and mailed with a poster to all general practitioners in May 1997., Material and Methods: Before the distribution of the information package a questionnaire on how contraception was taught was sent to a representative sample of 211 general practitioners. Six months later the same 211 received a similar questionnaire with a few questions added on the possible effect of the information package., Results: 132 physicians responded the first time and 105 the second. Four out of five general practitioners have consultations where they advise on contraception at least weekly. 70% had attended courses on sexology or contraception. 80% found the booklet useful, and 12% had changed their routines as a consequence of the campaign. Routine examinations before prescription of contraceptives were more extensive than the booklet advises. There was no measurable difference in reported practice before and after the campaign, but by using the more than 20,000 potential annual consultations as the unit instead of the physicians, there were significant moves in the right direction., Interpretation: Even if the evaluation cannot document improved contraception as a result of the campaign, the quality of the physicians' advice on contraception has improved.

Introduction: Postnatal care of the healthy term newborn and the mother has, in modern times, taken place in the hospital setting. As a result of tightened hospital budgets as well as maternal preferences the duration of hospital stay has successively been shortened. Most women in Scandinavia today leave the hospital within four days after delivery. Postnatal care in a hotel like setting has emerged as an alternative to the well-baby nursery unless medical conditions makes this option inappropriate., Material and Methods: To evaluate the safety of postnatal care a study was undertaken to investigate whether correct criteria were being used for referral of the newborn to the hotel. We also wanted to document the duration of stay, unexpected medical complications, and weight development of the infants. Data from 865 infants were used for analysis., Results: Ten (1.1%) newborns had to be readmitted to the hospital due to medical complications. 488 (56%) of the mothers went home within 96 hours, and only 23 (2.6%) stayed more than 120 hours. The weight of the infants reached a nadir on the fourth day post partum (-5.2% of birth weight)., Interpretation: The patient hotel is a medically safe alternative to the traditional well-baby nursery, provided that appropriate criteria for referral are used.

Background: In medical education, using literary texts as a starting point for discussion and reflection, is now quite common. Lectures and seminars in literature and medicine have been given at the University of Oslo since 1996. We describe our pedagogical approach as a "thematic interpretation and discussion of literary texts", theoretically grounded in reader-oriented criticism and problem-based learning (PBL). This article describes the kind of learning taking place during analysis and discussion of literary texts among medical students., Material and Methods: We evaluated a series of four elective seminars for first and second year students in the autumn 1998. We used qualitative approaches based on analysis of material from observations during seminars, reflections written by participants, and notes from a group interview at the end of the seminars., Results: Analysis and discussion of literary texts may give medical students: A better understanding of communicative aspects in the doctor-patient-relationship. Experience with interpretation of narratives and insight into how differently we may interpret a story. Awareness of aspects and dilemmas related to being a doctor. Understanding of how people may experience illness and health., Interpretation: Lectures and seminars on literary texts might be an important supplement to other practical or theoretical teaching for medical students.

Background: We studied reports of clinical neurological status in patients referred from primary and secondary health service to a neurological department., Material and Method: We evaluated referrals consecutively during 6 months. By using parametric and categorical statistical methods, we studied characteristics in examined patients compared with others., Results: Of a total of 912 patients, 431 (47%) had been examined neurologically. Among the women, 267 women (51%) had been examined; among the 164 men (43%). Patients with musculoskeletal disorders were more often examined, p = 0.0001, while those with faint or seizure disorders were significantly less frequently examined compared with other patients, p = 0.009. Clinical neurological examinations were performed more often in women compared with men, p = 0.03. The mean age was higher in the examined group (49.7 years) compared with others (46.5 years), p = 0.006., Interpretation: Clinical neurological examination in patients referred to a neurological department had more often been performed in women, in higher age groups, and in those with musculoskeletal symptoms. In more than half of the patients, the decision of referring patients to the department of neurology was not based on results obtained from clinical neurological examination.

Background: In 1993 a list patient system was introduced in four Norwegian municipalities: Trondheim, Tromsø, Lillehammer and Asnes., Material and Methods: Questionnaire surveys were conducted among all GPs in these four municipalities in 1996 and 1999 for the purpose of examining changes in their assessment of the list patient system., Results: The number of GPs generally satisfied with the list patient system declined over the three-year period. Doctors found their workload heavier in 1999 than in 1996, but their confidence in the list patient system as a tool for enhancing quality in general practice did not change over the period. GPs with too long patient lists were the most dissatisfied. The decline in confidence in the new system was strongest in Trondheim, the largest of the four municipalities and that in which the average patient list is longest. In Tromsø, the second largest municipality, with moderate to average patient lists, there were no changes in GP attitudes., Interpretation: The study demonstrates some important consequences of a shortage of medical manpower in a list patient system. Local authorities will have to deal with these challenges.

Background: A list patient system will be introduced in Norway from 2001. In England and Holland, countries with long experience with this system, the average consultation is much shorter than in the present Norwegian system. Research reports indicate a significant association between longer consultations and patient satisfaction with service as well as quality. The challenge in these countries has been to find mechanisms that reduce list size in order to enhance the quality of care., Material and Methods: On the basis of the author's own data and a summary of relevant literature, a model for estimating average list size in Norway is developed., Results: The model shows the impact of various time-consuming factors in general practice on the workload associated with a patient list., Interpretation: The article describes some objective criteria for calculating a list size which corresponds to a full normal medical man-year, with due consideration for quality of care.

Rehabilitation programmes for patients suffering from chronic obstructive pulmonary diseases are established in many countries. In this paper a new rehabilitation programme at Ullevål University Hospital is described and evaluated. We compared patients' (N = 80) use of hospital inpatient services the year before and the year after attending a rehabilitation course. We also compared patients' self-assessed health status before and six and 12 months after rehabilitation using the St. George's Respiratory Questionnaire and the Hospital Anxiety and Depression scale. The percentage of patients needing hospitalization per year was reduced from 45% before the programme to 22% afterwards. There was no change in the total number of hospitalizations or in the number of days spent in hospital. Self-assessed health status had improved. The results are in accordance with reports from similar rehabilitation programmes in other countries.

After a project period from 1994 to 1997, all hospital-based psychogeriatric services in the Norwegian county of Telemark have been located to one department in the central hospital. The department has three differentiated bed units and one out-patient unit. This article describes the psychogeriatric department before and after the project, and includes an evaluation of the quality of service. The changes following the reorganization have been evaluated with an internal analysis, questionnaires to primary health care personnel and an examination of medical and psychiatric records. In 1995 and 1997, questionnaires were sent to general practitioners and district nurses in Telemark County. An independent consultant examined 40 medical and psychiatric records in 1995 and 1997, evaluating them according to selected quality standards. The response rates among doctors were 59% in 1995 and 48% in 1997. The responses show that primary health care doctors and nurses make use of the department's services and that they are increasingly satisfied with the quality of these services. The examination of medical and psychiatric records shows insufficient documentation of psychiatric symptoms and activities of daily life in 1995, but significant improvements by 1997. There are drawbacks to the evaluation method employed. However, we find it warranted to conclude that the reorganization has been functional and that the quality of services has improved.

Objective: To investigate prospectively which medical, psychosocial or treatment-related factors predicted treatment satisfaction and to evaluate the adequacy of a preceding retrospective study which had examined the same factors. Furthermore, to examine the predictors and the stability of the major determinants of patient treatment satisfaction., Design: Assessments made before admission, at discharge and 2 and 4 months after discharge were used to predict both the level and the rate of change in satisfaction with different aspects of treatment., Setting: Three surgical departments at a University Hospital., Study Participants: Four-hundred and eighty-two patients electively admitted for several surgical conditions., Results: The central treatment-related measures were the same in the retrospective and prospective studies: global satisfaction with treatment (GS), perceived quality of contact with the nursing (QCN) and medical staff (QCM) and provision of adequate treatment information (INF). More of the variance in GS was explained in the prospective study (48.7% versus 36.3%). GS was most influenced by treatment-related factors with QCN as the strongest predictor in both studies. Only a small portion of the variance in QCN and QCM could be accounted for by the characteristics of the patients. INF was predicted by characteristics of the patients, their illness and life situation and by treatment-related factors. QCN was the strongest predictor of INF. The relationships with the nursing and medical personnel appear to be the major determinants of both patient treatment satisfaction and patients' reception of adequate information about their condition and its treatment.

RELIS Vest provides drug information by answering questions from mainly physicians and pharmacists. In the present paper we evaluated this service. All questions to RELIS Vest during the 1995-98 period were systematically categorized and analysed. The quality of the service was assessed by evaluation forms. Of a total of 875 queries, 393 came from physicians and 370 from pharmacists. 42% were about psychoactive drugs; the most frequent types of queries concerned documentation and adverse effects. Analysis of 180 evaluation forms showed that 79% of the physicians and 56% of the pharmacists found the answers fast enough, relevant, adequately comprehensive and with valuable references while 16% of the physicians and 29% of the pharmacists found that the answers satisfied three of these four criteria. We conclude that problem-oriented drug information based on actual cases of prescribing is highly appreciated.

In the international Drug Education Project, a new educational program for peer groups of doctors was developed and tested to improve the treatment of asthma patients in The Netherlands, Norway, Sweden, and Slovakia. Individualized feedback on prescribing and the underlying decision strategy was presented and discussed within the group of doctors, in relation to existing guidelines. In a parallel, randomized controlled design the effect on competence and actual prescribing was tested. Results were related to national guidelines. In general, the program improved the doctors' attitudes as well as some of their prescribing behavior. The proportion of patients treated with inhaled corticosteroids significantly improved in The Netherlands (effect size 1.27), and the proportion of oral corticosteroid use for exacerbation treatment increased both in The Netherlands and in Norway (effect sizes 1.99 and 0.87, respectively). Overall attitudes of Dutch and Norwegian doctors also improved significantly (effect sizes 1.06 and 0.87, respectively), as did both knowledge (effect size 1.06) and attitudes (effect size 1.49) concerning exacerbation treatment in Slovakia. In Sweden no significant improvements could be measured. Conclusively, improvements in asthma treatment are possible with an educational program based on self-learning in small peer groups, although effects in one health care setting may not occur in another health care setting. Possible explaining factors may be different attitudes to and experiences with guidelines as well as with continuing medical education programs, and differences in the opportunities for change, including prevailing trends in prescribing behavior.

This article presents and evaluates 105 project proposals submitted for review by a regional committee for medical research ethics in Norway from 1987 to 1997. The committee's review practice is presented in a historical and international perspective. Until recently, no serious objections seem to have been raised to the suitability of children as research subjects. Abuse of children in research has been uncovered; as a result, strict criteria for including children in research have been developed. Our regional research ethics committee has reviewed project proposals on this background. Over a ten-year period the regional committee reviewed 105 project proposals with children as subjects, advising against implementation in only nine cases. Most projects were approved with changes. 16 approved projects were invasive and non-therapeutic. We present the committee's reasons for allowing research on children and discuss some pertinent problems in research ethics. Recently it has been shown that protective caution excludes children from research. As a result, medical services for children are not of the same quality as those for adults. There is a need for a change of practice towards including children in research unless there are scientific or ethical reasons to exclude them. The new guidelines of the National Institutes of Health attest to this change.

The Journal of the Norwegian Medical Association performs regular reader surveys. 1,643 readers, (74%), i.e. 245 medical students (62%), 1,276 active physicians (78%) and 122 retired physicians (66%), responded in 1999 to a questionnaire on their use of and satisfaction with the journal. Two out of three had read or browsed through the six most recent issues of the journal. Two out of three readers seldom had time to read all the articles they wanted to read, and a quarter of the readers felt that the issues were published with too short intervals (30 per year). Clinical reviews were most frequently read, by all categories of readers. Female readers were interested in news and debates, while male readers were more interested in organisational matters. Nine out of ten said that the journal gave valuable information, and two out of five thought there should be more articles on ethics and legal issues. Time spent on each issue has declined throughout the 1990s, parallel to a general tendency for Norwegians to spend less time reading various publications, and the increased quest for physicians' time and attention from various publishers and producers. The majority of readers are content with the journal in its present form, but there seems to be a potential for improvement, particularly with regard to stimulating clinical research and excellence, and to promoting health policy issues. In its 119th year of existence, the journal still plays a major role in the professional update of Norwegian physicians.

January 1st 1998 Norwegian health authorities introduced a standard referral form to be used for all referrals to specialists. The form had been developed by a working group in the Norwegian Board of Health. The group also was responsible for testing out the form. One test was performed by use of a medical audit method in Sør-Trøndelag County in September 1997. The evaluation from the specialists who received the referrals was positive with regard to the information needed for appraisal of the referral. The general practitioners who participated had a more varied evaluation; in 90% of the cases the form was evaluated as good or serviceable, but only in 30% of the cases was it considered an improvement. At the closing workshop the participating doctors had many proposals for changes and improvements of the form. The most important conclusion of the pilot study is that efforts to improve communication between doctors must be closely linked to developments in computer software for medical practice.

The goal of this study was to evaluate the Injury Severity Score (ISS) in an alpine area. Hafjell Alpine Centre was the 1994 Winter Olympic Alpine arena in Lillehammer. A total of 2,044,484 lift transportations and 183 injuries were registered in the two winter seasons 1991 and 1992. The injury rate was 1.8 injuries per 1000 skier days. The mean ISS was 3.6 per injury for this particular alpine area. Thirty-six per cent of the injured were women and 35.5% were between 15 and 19 years of age. There was no difference in mean ISS between male and female skiers, but mean ISS was higher in adolescents than in the other age groups. Injuries to the knee represented the single most frequently injured body region, but injuries to the abdomen had the highest mean ISS. Alpine skiers suffered more severe injuries than telemark and snowboard skiers. Severe injuries (ISS > 16) were recorded when unexpected objects, such as a grooming machine, a net, a root, etc., appeared on the slope. The Abbreviated Injury Scale (AIS) and ISS give us additional information about the condition of the slopes, and their use as a tool in preventing skiing injuries is recommended.

We wanted to assess how much additional information could be gained from the results of tympanometry after first performing a clinical hearing examination at a mother and child clinic. 182 children aged from six months up to four years, had their hearing first examined clinically and afterwards by tympanometry. Pathological tympanograms were seen in 39% of the ears we examined, but most of them reverted to normal spontaneously at a later stage. There was little concordance between tympanometry and BOEL test in children aged six months and one year. Concordance between tympanometry and audiometry was fairly good in four-year old children. 27 children were referred to an ear, nose and throat specialist for evaluation, 11 of them as a result of tympanometry. Operative treatment was recommended for 17 of the children. In the anamnesis there was a connection between the parents perception of their child's hearing and the child having a cold and referral to an ear, nose and throat specialist. Tympanometry contributes to an early diagnosis of secretory otitis media, as well as being a means of helping parents understand the periodically poor middle ear function of their child.

The patient's expectations, wishes, judgments, and opinions have recently become a topic of interest in medical research. This is partly due to the physician's increasing awareness of an inadequate impact of medical measures, be they preventive, informative, or even curative, on the patient and the general public. It may also be partly due to an increasing criticism on the part of the patient and the general public of the failure of the medical service to respond adequately to the information provided. Consequently, there has recently been increased interest in gaining knowledge about the social aspects of human life relevant to medicine. The measures for securing validity, however, are the traditional rules of reductionist methodology. The author argues that by exploring the domain of culturally constructed meaning with tools based on naturalistic epistemology, the knowledge obtained will be invalid.

Efficient continuing education for experienced physicians should build upon and reflect doctors' concrete everyday experiences and self-defined learning needs. Reciprocal practice visits among general practitioners, afford excellent opportunities for colleagues to see and be seen, to reflect, discuss, learn from each other and develop networks, using commonly experienced consultations as a starting point. Practice visits have been credited within the Norwegian continuing medical education system since 1989, but very few practitioners have made use of the method. We have developed a course where groups of 10-12 experienced general practitioners conduct four whole day practice visits over a 2-month period. Group sessions, totalling 20 hours, are used to develop cohesion and trust among colleagues through discussions and exercises. In the later stages, plenary sessions are used to present and discuss experiences from all of the practice visits, and participants are encouraged to develop ideas and strategies concerning their professional future. The participants in the three courses arranged so far (n = 31) were general practitioners with, on average, ten years of experience. Evaluations were positive, and emphasized the value of the course as an opportunity to break the relative isolation of general practice, and share experiences, insights, frustrations and ideas with colleagues.

In just a few years C-reactive protein (CRP) has become an important test in the rapid elucidation of infections in Norwegian general practice. 33 general practitioners in the southern part of Vestfold county, continuously registered 546 consultations where a CRP analysis was performed. The protein was analyzed in 10% of all the consultations (range 3-31%). The general practitioners stated that the CRP analysis has great diagnostic impact in the elucidation of acute infections, but significantly less impact in routine examinations. The result contributed to a change in diagnosis in 30% of the patients where a diagnosis involving infection was considered. C-reactive protein contributed to a reduction in the prescribing of antibiotics in a quarter of the consultations. C-reactive protein is an important supplement to clinical investigation in the elucidation of infections in Norwegian general practice.