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Additional file 1. Appendix 1: Questionnaire translated from the original Norwegian into English.

Additional file 2.

Background In several countries, district medical officers (DMOs) are public health experts with duties including infection control measures. The Norwegian DMOs have been key actors in the local handling of the COVID-19 pandemic. Methods The aim of the study was to explore the ethical challenges experienced by Norwegian DMOs during the COVID-19 pandemic, and how the DMOs have handled these challenges. 15 in-depth individual research interviews were performed and analyzed with a manifest approach. Results Norwegian DMOs have had to handle a large range of significant ethical problems during the COVID-19 pandemic. Often, a common denominator has been the need to balance burdens of the contagion control measures for different individuals and groups. In another large set of issues, the challenge was to achieve a balance between safety understood as effective contagion prevention on the one hand, and freedom, autonomy and quality of life for the same individuals on the other. Conclusions The DMOs have a central role in the municipality’s handling of the pandemic, and they wield significant influence. Thus, there is a need for support in decision-making, both from national authorities and regulations, and from discussions with colleagues.

Additional file 1. [45–47].

Background Advance care planning (ACP) is a way of applying modern medicine to the principle of patient autonomy and ensuring that patients receive medical care that is consistent with their values, goals and preferences. Robust evidence supports the benefits of ACP, but it remains an underutilized resource in most countries. This paper goes from the naïve point of view, and seeks to identify the barriers and facilitators to implementation in unfamiliarized contexts and in a whole system approach involving the clinical, institutional and policy level to improve the implementation of ACP. Methods Qualitative interviews were chosen to enable an explorative, flexible design. Qualitative interviews were conducted with 40 health care professionals and chief physicians in hospitals and in municipalities. The thematic analysis was done following Braun and Clarke’s strategy for thematic analysis. Results The main reported barriers were the lack of time and space, a lack of culture and leadership legitimizing ACP, lack of common communication systems, and unclear responsibility about who should initiate, resulting in missed opportunities and overtreatment. Policy development, public and professional education, and standardization of documentation were reported as key to facilitate ACP and build trust across the health care system. Conclusions Progressively changing the education of health professionals and the clinical culture are major efforts that need to be tackled to implement ACP in unfamiliarized contexts, particularly in contexts where patient's wishes are not legally binding. This will need to be tackled through rectifying the misconception that ACP is only about death, and providing practical training for health professionals, as well as developing policies and legislation on how to include patients and caregivers in the planning of care.

The main task of mental health care services is to provide good quality of care. Despite this, users are sometimes treated badly by staff. The purpose of this study was to investigate violations and infringements towards users in mental health care services, from the perspectives of both staff and users. Data were gathered through an anonymous online questionnaire sent to staff and users in Norway. Staff were recruited in collaboration with professional organisations and users in collaboration with user-organisations.

Additional file 2. Interview Guides.

Background The uptake of family involvement in health care services for patients with psychotic disorders is poor, despite a clear evidence base, socio-economic and moral justifications, policy, and guideline recommendations. To respond to this knowledge-practice gap, we established the cluster randomised controlled trial: Implementation of guidelines on Family Involvement for persons with Psychotic disorders in community mental health centres (IFIP). Nested in the IFIP trial, this sub-study aims to explore what organisational and clinical barriers and facilitators local implementation teams and clinicians experience when implementing family involvement in mental health care for persons with psychotic disorders. Methods We performed 21 semi-structured focus groups, including 75 participants in total. Implementation team members were interviewed at the initial and middle phases of the intervention period, while clinicians who were not in the implementation team were interviewed in the late phase. A purposive sampling approach was used to recruit participants with various engagement in the implementation process. Data were analysed using manifest content analysis. Results Organisational barriers to involvement included: 1) Lack of shared knowledge, perceptions, and practice 2) Lack of routines 3) Lack of resources and logistics. Clinical barriers included: 4) Patient-related factors 5) Relative-related factors 6) Provider-related factors. Organisational facilitators for involvement included: 1) Whole-ward approach 2) Appointed and dedicated roles 3) Standardisation and routines. Clinical facilitators included: 4) External implementation support 5) Understanding, skills, and self-efficacy among mental health professionals 6) Awareness and attitudes among mental health professionals. Conclusions Implementing family involvement in health care services for persons with psychotic disorders is possible through a whole-ward and multi-level approach, ensured by organisational- and leadership commitment. Providing training in family psychoeducation to all staff, establishing routines to offer a basic level of family involvement to all patients, and ensuring that clinicians get experience with family involvement, reduce or dissolve core barriers. Having access to external implementation support appears decisive to initiate, promote and evaluate implementation. Our findings also point to future policy, practice and implementation developments to offer adequate treatment and support to all patients with severe mental illness and their families. Trial registration ClinicalTrials.gov Identifier NCT03869177. Registered 11.03.19.

Additional file 4. Example excerpts illustrating facilitator subcategories.

Additional file 3. Example excerpts illustrating barrier categories.

Additional file 1. Standards for Reporting Qualitative Research (SRQR): 21-item checklist.

Additional file 1: Table A1. Demographic characteristics of respondents.

Additional file 2. Fidelity scale for Basic Family Involvement and Support (BFIS).

Additional file 1. STROBE Statement—Checklist of items that should be included in reports of cross-sectional studies.

La pandemia de COVID-19 ha generado en todo el mundo una amenaza sin precedentes que no solo impone la urgente necesidad de reflexionar críticamente y de producir nuevo conocimiento, sino que también exige la acción inmediata, a pesar de las lagunas de información que aún prevalecen y la incertidumbre existente a múltiples niveles. En cuanto al papel de la ética de la investigación en estos tiempos de pandemia, algunos defienden el excepcionalismo mientras que otros, incluidos los autores de este artículo, hacen énfasis en la urgente necesidad de mantener el compromiso con los principios éticos fundamentales y con las obligaciones de derechos humanos más fundamentales, que se reflejan en las pautas y directrices para la investigación que han sido cuidadosamente elaboradas a lo largo del tiempo. En este artículo analizamos algunos de los argumentos que se plantean en el debate actual sobre los estudios de desafío humano o estudios de infección humana controlada (EIHC) y el papel concomitante de la ética de la investigación en temas de salud en épocas de pandemia. Sugerimos que resultaría útil pensar la cuestión a partir de la diferenciación entre riesgo, incertidumbre en sentido estricto y la ignorancia. Presentamos algunos ejemplos de casos en los que se causó daño en nombre de la investigación científica y discutimos la relevancia de este legado en la situación actual.

Additional file 1. The IFIP Intervention. Detailed description of the trial’s intervention.