Lost in translation : Mental health professional`s understanding of care pathways and its implications for policy construction and implementation

Denne avhandlingen har som siktemål å undersøke profesjonelle aktører innen psykisk helse sin forståelse av pakkeforløp, og hvordan denne forståelsen påvirket konstruksjonen samt implementering av pakkeforløp til bruk i poliklinisk behandling innen psykisk helse og rus. Et pakkeforløp er et standard pasientforløp som beskriver organisering av utredning og behandling, kommunikasjon/dialog med pasient og pårørende, samt ansvarsplassering og konkrete forløpstider. I 2015 annonserte daværende statsminister Erna Solberg at pakkeforløp skulle iverksettes innen psykisk helse og rus. Kort tid etter annonseringen oppstod det en betent mediedebatt. Kronikker og innlegg var primært fra profesjonelle som arbeider innenfor psykisk helsetjenester og som mente at denne formen for organisering ville sette korrekt pasientbehandling på spill. Til tross for disse reaksjonen, har psykisk helsefeltet i flere rapporter vist store svakheter i henhold til bruken av standardiserte verktøy, lange ventelister, høy ventetid samt for høy bruk av ulike tvangsmidler. Introduksjonen av pakkeforløp I 2016 var initiert av helsedirektoratet som involverte fagfeltet, brukere og pårørende gjennom ulike konferanser og arbeidsgrupper. Målet var å produsere 22 ulike forløp basert på diagnose og evidensbasert praksis. Pakkeforløpet ble implementert 1. januar 2019. Avhandlingens avgrenser seg til to forskningsområder relatert til pakkeforløp. Første område ser nærmere på konstruksjonen av et pakkeforløp til bruk i poliklinisk behandling. Andre studie undersøker implementeringen av dette pakkeforløpet ved fire ulike sykehus. Avhandlingen ser dermed på pakkeforløp fra flere innfallsvinkler og nivå og består av tre artikler samt kappen. Den første artikkelen omhandler konstruksjonen av pakkeforløpet og har som teoretisk innfallsvinkel hvordan de ulike aktørene i feltet sine meninger relatert til pakkeforløp delvis påvirkes av deres institusjonelle logikker. Som en konsekvens av e oppstår en dynamikk hvor debatten omkring pakkeforløp og nytteverdi innen psykisk helse og rus sirkulerer som et slags polariseringsideal hvor effektivitet og korrekt pasientbehandling blir motpoler. Denne polariseringen har også et politisk, retorisk formål hvor målet med den skriftlige debatten i forkant er å diskreditere ideen om pakkeforløps overførbarhet til det psykiske helsefeltet. Konstruksjonen ledes av Helsedirektoratet med god kjennskap til de ulike logikkene. Sluttresultat ender opp med å bli et forhandlet produkt hvor man har tatt bekymringene til helsepersonell på alvor gjennom å produsere et logistikkforløp som bringer med seg målepunkter, men uten å røre profesjonelt skjønn og autonomi som kjennetegner pasientbehandling. Artikkel to undersøker implementeringen av pakkeforløpet innen poliklinisk behandling ved 4 ulike poliklinikker. Resultatet viser fire ulike, dog distinkte reaksjoner knyttet til implementeringen av pakkeforløpet. 1) ambivalens knyttet til overordnede mål og innhold I pakkeforløpet, 2.) økt administrativt arbeid knyttet til koder og registeringer av og i et forløp 3.) Et IT-system som ikke korresponderer med pakkeforløpets koder 4.) Et falskt skille mellom diagnostisering og behandling. Artikkelen opererer med Sense Making teori for å vise hvordan aktørene finner ulike «hint» i omgivelsene som brukes aktivt for å unngå videre involvering i pakkeforløpet. Videre diskuterer artikkelen hvorledes mistillit mot myndighetene samt opplevd mistillit til dem som behandlere, farger implementeringen og delvis forklarer det svake implementeringsutfallet. Den siste artikkelen undersøker hvordan det overordnende målet om økt brukermedvirkning (ikke) blir tatt i bruk. Videre analyseres operasjonaliseringen av fenomenet «brukermedvirkning» fra helseprofesjonelle i deres rolle som bakkebyråkrater. Denne analysen viser hvordan helseprofesjonelle tolker brukermedvirkning som innlemmet i profesjonell praksis gjennom å ha et overordnet blikk på pasientene til enhver tid. Andre del av artikkelen ser på hvilke utfordringer og barrierer som oppstår når man (som pakkeforløpet anbefaler), skal involvere pasienter i behandlingsvalg. Analysen her viser at to ulike «coping»-mekansimer oppstår for å håndtere målet om pasientinvolvering i behandlingsrommet. Mekanismene forståes som handlinger som tolkes av behandlerne som enten er til fordel for pasientene, eller dem selv og fungerer som elementer som gjør at de kan mestre en arbeidshverdag med stor pågang av pasienter, men lite ressurser. I spennet mellom idealet om brukermedvirkning slik det er formulert i pakkeforløpet og praksis oppstår et paradoks hvor ulike normative forståelser av individ/pasient kommer i skvis. Overordnet sett finner avhandlingen at det er stor diskrepans mellom ulike politiske ideal og ideer om pakkeforløp og dets overordnede mål om økt brukermedvirkning, og hvordan disse endres i møte med helseprofesjonene. Denne avhandlingen presenterer implementering og utfall av pakkeforløp i kreftbehandling, og bruker dette som et komparativt case for å bedre belyse og diskutere utvikling og implementering av pakkeforløp innen psykisk helsetjenester.This main aim of this thesis is to research the understanding of care pathways among professionals in the Norwegian mental health services, and how this understanding has influenced the construction and implementation of care pathways that are then utilised in outpatient clinics within the specialist health care services. A care pathway is a complex intervention for the mutual decision-making and organisation of care processes for a group of patients during a specific period. An explicit statement of the goals and key elements of care based on evidence, best practices, and patients’ expectations and their characteristics recognises the CP approach. In 2015, the Norwegian government decided to reorganise its mental health services into care pathways (CPs). Shortly after the above announcement by the state, mental health professionals reacted by publishing numerous articles and chronicles where they stated that the organisation of mental health care through the utilising of CPs has been a large failure and something that will jeopardise patient treatment. Despite these reactions, mental health services in numerous reports have shown several weaknesses related to the use of standardised diagnostic practices, treatment facilitation, a high degree of coercive measures and an imminent capacity issue with long waiting list and times. The emergence of CPs in 2016 was initiated by the Norwegian Directorate of Health, that made work groups with different professionals to produce different CPs, with the aim of producing 22 care pathways with a diagnostic outlook and evidence-based best practices. The CPs were put into effect on 1 January 2019. Furthermore, this thesis delineates to two research areas related to care pathways. The first area will focus on research related to the construction of a care pathway designed to be utilised in outpatient clinics. The second area of engagement research revolves around the implementation of this care pathway at four different hospitals. The thesis thus seeks to get an overview and understanding of the care pathway from multiple levels, and will consist of three articles and the kappa. The first article asks how mental health professionals’ interpretation of a CP influences the construction of a CP for use in outpatient clinics. When understanding the concept of a care pathway (CP), the two main actor groups – mental health professionals and politicians – are guided by the values associated with a specific logic. Compared to mental health services, actors in the political arena are guided by values of discretion and autonomy, as opposed to those in the political field, who value control and efficiency. During this discussion, a polarisation between patient and efficiency concerns then emerge. The pathway is formulated by the Norwegian Directorate of Health, with the input of health professionals, who have knowledge of the values of both types of logic – of which were part of the consideration process during a CP formulation – that operate in the political domain. The above factor explains how CPs have become a negotiation process between the two logics, where both actors are able to maintain their core values. The result is a logistic pathway aiming for more transparency and control but without affecting professionals’ autonomy and discretion. The purpose of the second article is to examine how mental health professionals make sense of CPs and, furthermore, how issues of trust affects the implementation process. Case studies are conducted in four community mental health centres (CMHCs) in different regions of Norway. Individual and focus group interviews are conducted to collect qualitative data. There are four distinct themes or reactions to CPs and their implementation that arose from these interviews: 1) ambiguity concerning the overall goals and content of the CPs; 2) an increased burden in terms of coding, registration, and administrative work that then causes stress among the health care professionals; 3) an IT system and medical records that do not match the coding in the CPs; and 4) an unrealistic distinction between assessment and treatment. The process where sense is made of the care pathway implementation by professionals encourages health professionals to reduce the importance that they associate with the CP system. Distrust of and resistance to the CP system overshadows some of the overall quality goals, a view that is shared by many mental health professionals. The third article examines how mental health professionals involve themselves in the care pathways’ overall goal regarding increased user participation (UP) and contributes to an understanding around the lack of research on the professional roles played by street-level bureaucrats (SLBs) in mental health care. The introduction of increased UP and patient involvement in treatment facilitation is crucial for CP implementation. Throughout this article, we see how SLBs emphasise UP as part of their practice, influenced by professional institutional logics. When using the policy's measure on involving patients in treatment, certain implications arise. In addition to analysing the political trend of construing shared decision-making (SDM) in mental health care as a form of UP, this article questions its transferability. The overall concern of this thesis is related to how mental health professionals’ understanding of CPs influences their construction and implementation. The conclusion is that mental health professionals have an overall negative postponement of CPs, as they believe that the use of CPs would take away their discretion and autonomy and therefore lead to poorer patient treatment outcomes. However, these concerns are considered by the authorities responsible for the design, and construction of the CP, and the final approach to be implemented by the professionals is a logistic pathway that aims for more control around how their time is utilised. Furthermore, even though the pathway does not take away their discretion and autonomy, a belief of distrust towards those responsible for its designation produces a sense-making process that encourages professionals not to involve themselves in matters related to CPs. When examining how the overall goal concerning increased UP and the involvement of patients in treatment facilitation, two issues emerge. The first issue is that the notion of UP is interpreted as integrated into professional practice by providing correct patient treatment. Involving patients in matters of treatment facilitation is, at certain times, regarded as poor patient treatment. Additionally, the ideal of the medical professionals and the patients as two equal partners regarding treatment facilitation is not agreed on by these professionals, as they believe that there should be a professional reason to meet patients in terms of their treatment requests. Furthermore, this thesis elaborates on the care pathway approach in cancer treatment, and discuss this as a case to be compared to the care pathways in mental health care.Doktorgradsavhandlin

Satellite detection of volcanic ash from Eyjafjallajökull and the threat to aviation

Earth orbiting satellites provide an excellent means for monitoring and measuring emissions from volcanic eruptions. The recent eruption of Eyjafjallajökull in Iceland on 14 April, 2010 and the subsequent movement of the ash clouds were tracked using a variety of satellite instruments as they moved over Europe. Data from the rapid sampling (every 15 minutes) SEVIRI on Meteosat Second Generation were especially useful during this event as the thermal channels between 10–12 micron could be used to detect the ash signal and perform quantitative ash retrievals of mass loadings, optical depths and effective particle size. Higher-spatial resolution ( 1 km2) information from the MODIS sensors on NASA’s Terra and Aqua platforms were also analysed to determine ash microphysics and also to provide ash cloud top height. High-spectral resolution data from the IASI and AIRS sensors showed that initially quantities of ice, potentially with ash cores, were present, and that multi-species retrievals could be performed by exploiting the spectral content of the data. Vertically resolved ash layers were detected using the Caliop lidar on board the Calipso platform. Ash was clearly detected over Europe using the infra-red sensors with mass loadings typically in the range 0.1–5 gm-2, which for layers of 500–1000 m thickness, suggests ash concentrations in the range 0.1–10 mg m-3, and therefore represent a potential hazard to aviation.Little SO2 was detected at the start of the eruption, although both OMI and AIRS detected upper-level SO2 on 15 April. By late April and early May, 0.1–0.3 Tg (SO2) could be detected using these sensors. The wealth of satellite data available, some in near real-time, and the ability of infrared and ultra-violet sensors to detect volcanic ash and SO2 are emphasised in this presentation. The ash/aviation problem can be addressed using remote sensing measurements, validated with ground-based and air-borne, and combined with dispersion modelling. The volcanic ash threat to aviation can be ameliorated by utilising these space-based resources

Satellite detection of volcanic ash from Eyjafjallajökull and the threat to aviation

Earth orbiting satellites provide an excellent means for monitoring and measuring emissions from volcanic eruptions. The recent eruption of Eyjafjallajökull in Iceland on 14 April, 2010 and the subsequent movement of the ash clouds were tracked using a variety of satellite instruments as they moved over Europe. Data from the rapid sampling (every 15 minutes) SEVIRI on Meteosat Second Generation were especially useful during this event as the thermal channels between 10–12 micron could be used to detect the ash signal and perform quantitative ash retrievals of mass loadings, optical depths and effective particle size. Higher-spatial resolution ( 1 km2) information from the MODIS sensors on NASA’s Terra and Aqua platforms were also analysed to determine ash microphysics and also to provide ash cloud top height. High-spectral resolution data from the IASI and AIRS sensors showed that initially quantities of ice, potentially with ash cores, were present, and that multi-species retrievals could be performed by exploiting the spectral content of the data. Vertically resolved ash layers were detected using the Caliop lidar on board the Calipso platform. Ash was clearly detected over Europe using the infra-red sensors with mass loadings typically in the range 0.1–5 gm-2, which for layers of 500–1000 m thickness, suggests ash concentrations in the range 0.1–10 mg m-3, and therefore represent a potential hazard to aviation.Little SO2 was detected at the start of the eruption, although both OMI and AIRS detected upper-level SO2 on 15 April. By late April and early May, 0.1–0.3 Tg (SO2) could be detected using these sensors. The wealth of satellite data available, some in near real-time, and the ability of infrared and ultra-violet sensors to detect volcanic ash and SO2 are emphasised in this presentation. The ash/aviation problem can be addressed using remote sensing measurements, validated with ground-based and air-borne, and combined with dispersion modelling. The volcanic ash threat to aviation can be ameliorated by utilising these space-based resources

Gridded global surface ozone metrics for atmospheric chemistry model evaluation

The concentration of ozone at the Earth's surface is measured at many locations across the globe for the purposes of air quality monitoring and atmospheric chemistry research. We have brought together all publicly available surface ozone observations from online databases from the modern era to build a consistent data set for the evaluation of chemical transport and chemistry-climate (Earth System) models for projects such as the Chemistry-Climate Model Initiative and Aer-Chem-MIP. From a total data set of approximately 6600 sites and 500 million hourly observations from 1971-2015, approximately 2200 sites and 200 million hourly observations pass screening as high-quality sites in regionally representative locations that are appropriate for use in global model evaluation. There is generally good data volume since the start of air quality monitoring networks in 1990 through 2013. Ozone observations are biased heavily toward North America and Europe with sparse coverage over the rest of the globe. This data set is made available for the purposes of model evaluation as a set of gridded metrics intended to describe the distribution of ozone concentrations on monthly and annual timescales. Metrics include the moments of the distribution, percentiles, maximum daily 8-hour average (MDA8), sum of means over 35 ppb (daily maximum 8-h; SOMO35), accumulated ozone exposure above a threshold of 40 ppbv (AOT40), and metrics related to air quality regulatory thresholds. Gridded data sets are stored as netCDF-4 files and are available to download from the British Atmospheric Data Centre (doi:10.5285/08fbe63d-fa6d-4a7a-b952-5932e3ab0452). We provide recommendations to the ozone measurement community regarding improving metadata reporting to simplify ongoing and future efforts in working with ozone data from disparate networks in a consistent manner

Elemental and Organic Carbon in PM10: a One Year Measurement Campaign within the European Monitoring and Evaluation Programme EMEP

In the present study, ambient aerosol (PM10) concentrations of elemental carbon (EC), organic carbon (OC), and total carbon (TC) are reported for 12 European rural background sites and two urban background sites following a one-year (1 July 2002¿1 July 2003) sampling campaign within the European Monitoring and Evaluation Programme, EMEP (http://www.emep.int/). The purpose of the campaign was to assess the feasibility of performing EC and OC monitoring on a regular basis and to obtain an overview of the spatial and seasonal variability on a regional scale in Europe. Analyses were performed using the thermal-optical transmission (TOT) instrument from Sunset Lab Inc., operating according to a NIOSH derived temperature program. The annual mean mass concentration of EC ranged from 0.17±0.19µgm-3 (mean ± SD) at Birkenes (Norway) to 1.83±1.32µgm-3 at Ispra (Italy). The corresponding range for OC was 1.20±1.29µgm-3 at Mace Head (Ireland) to 7.79±6.80µgm-3 at Ispra. On average, annual concentrations of EC, OC, and TC were three times higher for rural background sites in Central, Eastern and Southern Europe compared to those situated in the Northern andWestern parts of Europe. Wintertime concentrations of EC and OC were higher than those recorded during summer for the majority of the sites. Moderate to high Pearson correlation coefficients (rp) (0.50¿0.94) were observed for EC versus OC for the sites investigated. The lowest correlation coefficients were noted for the three Scandinavian sites: Aspvreten (SE), Birkenes (NO), and Virolahti (FI), and the Slovakian site Stara Lesna, and are suggested to reflect biogenic sources, wild and prescribed fires. This suggestion is supported by the fact that higher concentrations of OC are observed for summer compared to winter for these sites. For the rural background sites, total carbonaceous material accounted for 30±9% of PM10, of which 27±9% could be attributed to organic matter (OM) and 3.4±1.0% to elemental matter (EM). OM was found to be more abundant than SO2- 4 for sites reporting both parametersJRC.H.2-Climate chang

The Global Atmosphere Watch reactive gases measurement network

Long-term observations of reactive gases in the troposphere are important for understanding trace gas cycles and the oxidation capacity of the atmosphere, assessing impacts of emission changes, verifying numerical model simulations, and quantifying the interactions between short-lived compounds and climate change. The World Meteorological Organization’s (WMO) Global Atmosphere Watch (GAW) program coordinates a global network of surface stations some of which have measured reactive gases for more than 40 years. Gas species included under this umbrella are ozone, carbon monoxide, nitrogen oxides, and volatile organic compounds (VOCs). There are many challenges involved in setting-up and maintaining such a network over many decades and to ensure that data are of high quality, regularly updated and made easily accessible to users. This overview describes the GAW surface station network of reactive gases, its unique quality management framework, and discusses the data that are available from the central archive. Highlights of data use from the published literature are reviewed, and a brief outlook into the future of GAW is given. This manuscript constitutes the overview of a special feature on GAW reactive gases observations with individual papers reporting on research and data analysis of particular substances being covered by the program. - See more at: http://elementascience.org/article/info:doi/10.12952/journal.elementa.000067#sthash.cHvHu0T6.dpu

Arctic smoke ? record high air pollution levels in the European Arctic due to agricultural fires in Eastern Europe

International audienceIn spring 2006, the European Arctic was abnormally warm, setting new historical temperature records. During this warm period, smoke from agricultural fires in Eastern Europe intruded into the European Arctic and caused the most severe air pollution episodes ever recorded there. This paper confirms that biomass burning (BB) was indeed the source of the observed air pollution, studies the transport of the smoke into the Arctic, and presents an overview of the observations taken during the episode. Fire detections from the MODIS instruments aboard the Aqua and Terra satellites were used to estimate the BB emissions. The FLEXPART particle dispersion model was used to show that the smoke was transported to Spitsbergen and Iceland, which was confirmed by MODIS retrievals of the aerosol optical depth (AOD) and AIRS retrievals of carbon monoxide (CO) total columns. Concentrations of halocarbons, carbon dioxide and CO, as well as levoglucosan and potassium, measured at Zeppelin mountain near Ny Ålesund, were used to further corroborate the BB source of the smoke at Spitsbergen. The ozone (O3) and CO concentrations were the highest ever observed at the Zeppelin station, and gaseous elemental mercury was also enhanced. A new O3 record was also set at a station on Iceland. The smoke was strongly absorbing ? black carbon concentrations were the highest ever recorded at Zeppelin ?, and strongly perturbed the radiation transmission in the atmosphere: aerosol optical depths were the highest ever measured at Ny Ålesund. We furthermore discuss the aerosol chemical composition, obtained from filter samples, as well as the aerosol size distribution during the smoke event. Photographs show that the snow at a glacier on Spitsbergen became discolored during the episode and, thus, the snow albedo was reduced. Samples of this polluted snow contained strongly enhanced levels of potassium, sulphate, nitrate and ammonium ions, thus relating the discoloration to the deposition of the smoke aerosols. This paper shows that, to date, BB has been underestimated as a source of aerosol and air pollution for the Arctic, relative to emissions from fossil fuel combustion. Given its significant impact on air quality over large spatial scales and on radiative processes, the practice of agricultural waste burning should be banned in the future

D3.4 : Report on observations, measurements and gaps in observation systems reported by the communities

Report on the list of observations, measurements, gaps, sensors, procedures, and practices used currently or expected in the future in observation systems reported by the communities. It also includes the Citizen science workshop report (WS4). D6.2 will contain more elaborated material based on this document and the other methodologies of the project

Biomass burning in eastern Europe during spring 2006 caused high deposition of ammonium in northern Fennoscandia

High air concentrations of ammonium were detected at low and high altitude sites in Sweden, Finland and Norway during the spring 2006, coinciding with polluted air from biomass burning in eastern Europe passing over central and northern Fennoscandia. Unusually high values for throughfall deposition of ammonium were detected at one low altitude site and several high altitude sites in north Sweden. The occurrence of the high ammonium in throughfall differed between the summer months 2006, most likely related to the timing of precipitation events. The ammonia dry deposition may have contributed to unusual visible injuries on the tree vegetation in northern Fennoscandia that occurred during 2006, in combination with high ozone concentrations. It is concluded that long-range transport of ammonium from large-scale biomass burning may contribute substantially to the nitrogen load at northern latitudes. (C) 2013 Elsevier Ltd. All rights reserved

Influence of water uptake on the aerosol particle light scattering coefficients of the Central European aerosol

The influence of aerosol water uptake on the aerosol particle light scattering was examined at the regional continental research site Melpitz, Germany. The scattering enhancement factor f(RH), defined as the aerosol particle scattering coefficient at a certain relative humidity (RH) divided by its dry value, was measured using a humidified nephelometer. The chemical composition and other microphysical properties were measured in parallel. f(RH) showed a strong variation, e.g. with values between 1.2 and 3.6 at RH=85% and λ=550 nm. The chemical composition was found to be the main factor determining the magnitude of f(RH), since the magnitude of f(RH) clearly correlated with the inorganic mass fraction measured by an aerosol mass spectrometer (AMS). Hysteresis within the recorded humidograms was observed and explained by long-range transported sea salt. A closure study using Mie theory showed the consistency of the measured parameters