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Background: There are several strategies used to assess involvement in their healthcare across service providers. However, there is no consensus on the most appropriate measurement tool to use when evaluating patient involvement initiatives. This qualitative study aimed to explore the perspectives of stakeholders from micro, meso, and macro levels within the Danish healthcare system on measuring patient involvement in their healthcare., Methods: This descriptive, explorative study employed semi-structured interviews with open-ended questions to elicit participants' views and experiences of patient involvement and measurement tools. A purposeful sample of participants was identified, to include decision makers, researchers, and health professionals (n = 20) with experiences of measuring patient involvement in healthcare at micro, meso, and macro levels across Danish organizations. Data underwent reflexive thematic analysis., Results: Three main themes were identified: 1) Determining the purpose of patient involvement practices and measurement alignment; 2) Reflecting on the qualities, fit, and usefulness of measures; 3) Recognizing conflicting stakeholder paradigms. Despite the interest in and positive attitudes toward patient involvement innovations, views on the meaning and value of evaluating involvement varied; in part, this was attributable to challenges in selecting criteria, methods, and measures for evaluation., Conclusion: The findings indicate the need to integrate the perspectives of all key stakeholders in designing the evaluation of patient involvement initiatives. The application of a multiple stakeholder approach and co-production of a multidimensional evaluation may provide some common ground for selecting evaluation criteria and measurement tools in the healthcare setting., Trial Registration: Danish Data Protection Agency (1-16-02-400-21) 15 October 2021., Competing Interests: Declarations Ethics approval and consent to participate The study was registered with the Danish Data Protection Agency, Central Denmark Region (1–16-02–400-21) on 15 October 2021. The Research Ethics Committee waivered approval of the study as interview studies according to Danish law (Denmark Committees on Health Research Ethics, §14, 2) are exempted from registration. The principles of the Declaration of Helsinki were followed [52], and written informed consent was obtained from all participants. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Illness trajectories are particularly characterised by the temporal dimension of human existence. In the area of low back pain, patients often have challenging temporal experiences such as unproductive waiting time and fragmented, repetitive consultations over many years. This study seeks to investigate relationships between digital technologies, temporal agency, and illness, through describing how users experienced a new digital solution, BackTrace, targeting patients with low back pain. The study builds on six months of ethnographic fieldwork, including semi-structured interviews, participant observation and a workshop. The study shows how the introduction of the digital solution could facilitate new possibilities of temporal actions for individuals living with and receiving care for low back pain. For many research participants, the use of BackTrace facilitated a useful visualisation of their past and present low back pain state; BackTrace could assist participants in navigating different external temporal demands; and it allocated time devoted to managing their back pain in everyday life and in consultations with health professionals. The study discusses how temporality can be a useful analytical entrance point to operationalise and explore the often-desired goal of empowerment in patient pathways., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: This study explored how health professionals experience in what way a digital self-monitoring solution influences their consulting practice targeting individuals with low back pain., Material and Methods: This was a qualitative study adopting a constructivist grounded theory approach. Nineteen health professionals participated in the pilot test of the digital self-monitoring solution BackTrace. Data were collected cross-sectionally and consisted of: (a) audio recordings from focus groups with health professionals, (b) field notes from participant observation of online meetings with health professionals, (c) field notes from participant observations of consultations between health professionals and individuals with low back pain and (d) audio recordings from workshops with health professionals., Results: Two main themes and one sub-theme were identified, describing how BackTrace enabled more focused consulting practices, supported patient-self management and improved the relationship between individuals with low back pain and health professionals. Barriers were identified describing how the implementation of digital health solutions required a change in workflow, resources and culture - as well as management support., Conclusions: Findings indicated a need for a change at the system level, including a changed view of digitisation in healthcare systems containing a more supporting approach.

Objectives: To describe the current content of low back pain (LBP) care in Danish general practice, the patients' self-management activities, and the clinicians' experienced barriers to providing best practice care., Methods: This cross-sectional observational study included adults with LBP seeking care in Danish general practice from August 2022 to June 2023. Patient-reported information included demographics, pain intensity, medical history, treatments, and self-management strategies. Clinicians provided data specific to each consultation, detailing the content of these consultations, and barriers to best practice in the specific cases., Results: The study involved 71 clinicians from 42 general practice clinics, with patient-reported data from 294 patients, and clinician-reported data from 283 (95%) consultations. The mean age for the included patients was 53 years, 56% were female, and 31% had been on sick leave for LBP during the previous 3 months. Moreover, 44% had seen two or more healthcare professionals in the previous month, 55% had previously undergone diagnostic imaging for LBP, 81% reported using any type of analgesics, and 14% reported using opioids. The majority (91%) reported engaging in self-management activities to alleviate pain. Consultations typically included a physical examination (84%), information about the cause of the pain (74%), and management advice (68%), as reported by clinicians or patients. In general, clinicians reported consultation elements more frequently than patients. Clinicians reported providing best practice care in 84% of cases, with time constraints (23%) and patient expectations (10%) being the most common barriers., Conclusions: This study provides detailed insights into the management of LBP in Danish general practice. It reveals a complex landscape of patient engagement, varying management strategies, and differing perceptions of care content between patients and clinicians. Patients were often engaged in self-management activities and clinicians reported few barriers to providing best practice care., (© 2024 The Author(s). Musculoskeletal Care published by John Wiley & Sons Ltd.)

Background: Low back pain is still the leading cause of disability and societal burden, with 619 million prevalent cases worldwide in 2020. Most countries produce clinical guidelines to support healthcare professionals in evidence-based care regarding low back pain. However, several studies have identified relatively poor uptake of guidelines. Tailored strategies to facilitate the implementation of guidelines have been argued to increase uptake. This study aimed to develop a contextually tailored implementation programme to enhance evidence-based low back pain care among Danish physiotherapists and chiropractors in primary care., Methods: A theory-driven implementation programme development study was conducted using the Behaviour Change Wheel, with high healthcare professional involvement. Data collection included four workshops with seven physiotherapists and six chiropractors from primary care clinics. The development process consisted of [1] establishing a theoretical frame, [2] involving participants, [3] understanding the behaviour, [4] designing the implementation programme, and [5] final implementation programme., Results: The target behaviours selected (guideline recommendations) for the implementation programme were (i) screening of psychosocial risk factors and (ii) offering patient education. The barriers and facilitators for the selected behaviours were described and linked to intervention functions and behavioural techniques. Finally, the implementation programme comprised five strategies: webinars, e-learning videos, communication exercises, peer learning, and group dialogue meetings. In addition, the programme consisted of implementation support: champions, a physical material folder, a weekly email reminder, a specially designed website and a visit from an implementation consultant. An essential element of the overall programme was that it was designed as a step-by-step implementation process consisting of 16 h of education and training distributed over 16 weeks., Conclusions: A programme for implementing low back pain guideline recommendations was developed based on behaviour change theory and four co-design workshops involving healthcare professionals to overcome the contextually identified barriers. A theory-driven approach involving healthcare professionals was useful in identifying relevant target behaviours and tailoring the programme to consider contextual barriers and facilitators for implementation. The effectiveness of the final implementation programme will be evaluated in the project's next phase., Trial Registration: Central Denmark Region, Registered November 11, 2021, act no. 1-16-02-93-19., (© 2024. The Author(s).)

Purpose: Low back pain (LBP) is the leading cause of disability worldwide. Providing evidence-based practice (EBP) for patients with LBP is more cost-effective compared with non-EBP. To help health care professionals provide EBP, several clinical practice guidelines have been published. However, a relatively poor uptake of the guidelines has been identified across various countries. To enhance future implementation of EBP, the aim of this study was to explore barriers to using LBP guidelines in clinical practice., Materials and Methods: A qualitative constructivist grounded theory design was employed in order to gain an in-depth understanding of the barriers. Semi-structured interviews (+/- observations) of nine physiotherapists and nine chiropractors from primary care in the Central Denmark Region were conducted., Results: Two key barriers were found to using guidelines in practice: (1) a scepticism due to doubts about validity and applicability of the guidelines, which emerged particularly among physiotherapists; and (2) a deep biomechanical professional identity, due to perceived role, interest, lack of skills, and patient preferences, which emerged particularly among chiropractors., Conclusions: For guidelines to be better implemented in practice, these key barriers must be addressed in a tailored strategy. Furthermore, this study showed a difference in barriers between the two professions.

Background:  Home-based rehabilitation exercise following Total Hip Arthroplasty (THA) shows similar outcomes compared to supervised outpatient rehabilitation exercise. Little is known about patients' experiences with home-based rehabilitation, and this study aimed to investigate how patients perceived home-based rehabilitation exercise and general physical activity after THA, focusing on facilitators and barriers. Methods: Semi-structured interviews of qualitative design were conducted with 22 patients who had undergone THA and who had performed home-based rehabilitation exercise. The study took place in a regional hospital in Denmark between January 2018 and May 2019. Data were analyzed using an interpretive thematic analysis approach, with theoretical underpinning from the concept 'conduct of everyday life'. The study is embedded within the Pragmatic Home-Based Exercise Therapy after Total Hip Arthroplasty-Silkeborg trial (PHETHAS-1). Results: The main theme, 'wishing to return to the well-known everyday life', and four subthemes were identified. Generally, participants found the home-based rehabilitation exercise boring but were motivated by the goal of returning to their well-known everyday life and performing their usual general physical activities, though some lacked contact to physiotherapist. Participants enrolled in the PHETHAS-1 study used the enrollment as part of their motivation for doing the exercises.  Both pain and the absence of pain were identified as barriers for doing home-based rehabilitation exercise. Pain could cause insecurity about possible medical complications, while the absence of pain could lead to the rehabilitation exercise being perceived as pointless. Conclusions: The overall goal of returning to the well-known everyday life served as a facilitator for undertaking home-based rehabilitation exercise after THA along with the flexibility regarding time and place for performing exercises. Boring exercises as well as both pain and no pain were identified as barriers to the performance of home-based rehabilitation exercise. Participants were motivated towards performing general physical activities which were part of their everyday life., Competing Interests: No competing interests were disclosed., (Copyright: © 2023 Poulsen AG et al.)

Aims: To explore how consultation exercises were described in a convenience sample of recent scoping reviews., Design: Critical literature review., Data Sources: We searched PsycINFO, Embase, CINAHL and PubMed in July 2020. Our inclusion criterion was a peer-reviewed journal article reporting a scoping review in Danish, English, Norwegian or Swedish., Review Methods: We identified a convenience sample of articles (n = 66) reporting a consultation exercise as part of a scoping review. The descriptions of the consultation were charted, summarized and critically discussed., Results: The current analysis showed no widely accepted consensus on how to approach and report a consultation exercise in the sample of scoping reviews. The reports of stakeholder consultation processes were often brief and general, and often there were no reports of the effects of the stakeholder consultation processes. Further, there was no discussion of the principal theoretical problems mixing stakeholder voices and review findings., Conclusion: The finding that conventional research ethics and research methods often were suspended could indicate that the stakeholder consultants were in a precarious position because of power imbalances between researchers and stakeholder consultants. We suggest that a consultation exercise should only be included when it genuinely invites participation and reports on the effect of alternative voices., Impact: Scoping reviews are common across a range of disciplines, but they often lack definitional and methodological clarity. In their influential approach to scoping studies, Arksey and O'Malley introduced an optional 'consultation exercise', which has been heralded as a valuable tool that can be used to strengthen the process and outcome of a scoping study and to support the dissemination of the study's findings and its implications. However, there is no clear outline on about how to operationalize consultations of stakeholders in scoping studies/reviews. This article includes recommendations for consultation exercises, including encouraging an aspirational move from 'consultation' to 'participation'., (© 2022 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.)

Background: Low back pain is a leading cause of disability and sick days worldwide. This type of pain has a fluctuating and recurrent nature, and affects all aspects of a person's life, with profound psychosocial consequences., Objectives: This study aims to explore the everyday life of individuals with low back pain over time and across various contexts., Design: A longitudinal Grounded Theory study with the concept, conduct of everyday life, as the theoretical framework., Settings: The study was conducted in Denmark, and participants were sampled from a regional spine centre in a hospital context., Participants: Twenty-seven individuals with low back pain referred to a hospital for assessment and treatment for herniated discs were sampled. Participants were divided equally between women and men 37-71 years old., Method: Participants were followed through interviews and participant observation for 6-18 months. They were interviewed at least twice, at the beginning and end of the study period. The interviews took place in participants' homes. Data consisted of transcribed interviews and field notes., Results: Two themes, " When 'support' systems become disrupters" and " Adapting to a new life", describe important elements of the participants' conduct of everyday life through a period of low back pain and the time after. The first theme explains how healthcare and sickness benefit systems play an existential role in the individual's life during a period of low back pain. These systems made extensive, often conflicting, demands on participants, which challenged their everyday lives. The systems and their diverse needs could take precedence over other concerns, challenging participants' social self-understanding. In the second theme, we identified three typical patterns of how participants adapt to living with a potential exacerbation of low back pain over time: 1) Resignation, 2) Balancing and 3) Ignoring., Conclusions: From the participants' perspectives, healthcare and sickness benefits systems are supportive, but they often disrupt everyday life due to extensive and conflicting demands. Individuals with low back pain must continually adapt to everyday life. Therefore, professionals should support a balanced pattern of adapting to life with recurrent and fluctuating low back pain., Competing Interests: None., (© 2021 The Author(s). Published by Elsevier Ltd.)

Background: Extended scope physiotherapists (ESP) are increasingly supplementing orthopaedic surgeons (OS) in diagnosing patients with musculoskeletal disorders. Studies have reported satisfactory diagnostic and treatment agreement between ESPs and OSs, but methodological study quality is generally low, and only few studies have evaluated inter-professional collaboration. Our aims were: 1) to evaluate agreement on diagnosis and treatment plan between ESPs and OSs examining patients with shoulder disorders, 2) to explore and evaluate their inter-professional collaboration., Methods: 1) In an orthopaedic outpatient shoulder clinic, 69 patients were examined independently twice on the same day by an ESP and an OS in random order. Primary and secondary diagnoses (nine categories) and treatment plan (five categories, combinations allowed) were registered by each professional and compared. Percentage of agreement and kappa-values were calculated. 2) Two semi-structured focus-group interviews were performed with ESPs and OSs, respectively. Interviews were based on the theoretical concept of Relational Coordination, encompassing seven dimensions of communication and relationship among professionals. A thematic analysis was conducted., Results: 1) Agreement on primary diagnosis was 62% (95% CI: [50; 73]). ESPs and OSs agreed on the combination of diagnoses in 79% (95% CI: [70; 89]) of the cases. Partial diagnostic agreement (one professional's primary diagnosis was also registered as either primary or secondary diagnosis by the other) was 96% (95% CI: [91; 100]). Across treatment categories, agreement varied between 68% (95% CI: [57; 79]) and 100%. In 43% (95% CI: [31; 54]) of the cases, ESP and OS had full concordance between treatment categories chosen, while they agreed on at least one recommendation in 96% (95% CI: [91; 100]). 2) Positive statements of all dimensions of relational coordination were found. Three themes especially important in the inter-professional collaboration emerged: Close communication, equal and respectful relationship and professional skills., Conclusions: In the majority of cases, the ESP and OS registered the same or partly the same diagnosis and treatment plan. Indications of a high relational coordination implying a good inter-professional collaboration were found. Our results support that ESPs and OSs can share the task of examining selected patients with shoulder disorders in an orthopaedic clinic., Trial Registration: ClinicalTrials.gov Identifier: NCT03343951 . Registered 10 November 2017.

Objective: The aim of the study was threefold: Firstly, to investigate the adherence to clinical practice guidelines for low back pain (LBP) among Danish physiotherapists with regard to three key domains: (a) activity, (b) work and (c) psychosocial risk factors. Secondly, to investigate whether adherence differed between physiotherapists working in private clinics (private physiotherapists) and physiotherapists working at public healthcare centres (public physiotherapists). Thirdly, to describe the physiotherapists' treatment modalities for patients with LBP., Methods: A cross-sectional online survey was conducted with 817 physiotherapists working in the Central Denmark Region. Adherence to the guideline domains was assessed using two vignettes. The difference in adherence between the groups was assessed using the Chi-squared test. Treatment modalities were reported using descriptive statistics., Results: A total of 234 physiotherapists responded, hereof 163 private physiotherapists and 71 public physiotherapists (response rate 29%). The proportions of physiotherapists managing the patients strictly in line with the guideline domains were 32% (activity), 16% (work) and 82% (psychosocial risk factors) for Vignette 1 and 6% (activity), 53% (work) and 60% (psychosocial risk factors) for Vignette 2. Public physiotherapists were more likely to manage patients strictly in line with guidelines for assessing the psychosocial risk factors compared to private physiotherapist (Vignette 1: 92% vs. 77% p = .030; Vignette 2:70% vs. 55% p = .035). Regarding the other two domains, there was no significant difference between the two groups in terms of adherence (p > .05). Concerning treatment modalities, the majority of physiotherapists instructed the patients in adopting an exercise program or informed the patients about the benign nature and prognosis of LBP., Conclusion: Overall, the participating Danish physiotherapists strictly adhered to only one out of three key domains. This underlines the importance of bringing focus on implementing the current guidelines' recommendations in clinical practice., (© 2020 The Authors. Physiotherapy Research International published by John Wiley & Sons Ltd.)

Open dialogue is a resource-oriented approach to mental health, which aims to help those involved in a crisis situation support each other and engage in dialogue. While language use in open dialogue is generally characterized as being open-ended, nondirective, and nonevaluating on the professionals' side, little is known about the specific conversational features. The aim of this study was to analyze the interactional functions of a stance-eliciting question of the form: "Y, what do you think about what X just said?" We used conversation analysis (CA) to examine this in eight video-recorded Danish open dialogue network meetings. In CA, stance involves expressions of attitude, affect, or judgments about people or events. We describe the interactional functions of these stance-eliciting questions and discuss how clinicians used them as a tool for accomplishing neutrality. The findings can be used to gain a more nuanced understanding of open dialogue psychotherapeutic practices., (© 2020 American Association for Marriage and Family Therapy.)

This article reports a case study of the illness career and identity work of patients who have had medically unexplained symptoms for many years with a particular emphasis on their interactions with a specialized and standardized health care system. Patients with medically unexplained symptoms often experience being met with mistrust and feel their identity threatened as a consequence of being illegitimately ill. There is a strong tendency in health care towards assessment thorough standardized so-called assessment packages. The study used a case study approach. Ethnographic fieldwork was carried out and several types of data were sampled through theoretical sampling, resulting in data from and about a sample of 13 patients, from which two patients were selected as cases. The study showed that a standardized health care system characterized by a tendency towards narrow diagnostic assessment with limited time can lead to a diagnostic limbo and that patients and health care professionals keep on searching for legitimate explanations for the patients' still unexplained symptoms. Consequently the patients were left in a constant identity negotiation.

Introduction: Rehabilitation exercises are offered to patients after total hip arthroplasty (THA); however, the effectiveness and optimal type and dose of exercise remains unknown. The primary objective of this trial is to indicate the preliminary efficacy of home-based rehabilitation using elastic band exercise on performance-based function after THA, based on the relationship between the performed exercise dose and the change in performance-based function (gait speed) from 3 (start of intervention) to 10 weeks (end of intervention) after surgery. The secondary objective is to investigate if a dose-response relationship exists between the performed exercise dose and changes in: hip-related disability, lower-extremity functional performance, and hip muscle strength Methods: In this prospective cohort study, patients scheduled for THA will be consecutively included until 88 have completed the intervention period from 3 to 10 weeks postoperatively. Participants perform the standard rehabilitation program with elastic band exercises. Exercise dose (exposure) will be objectively quantified using a sensor attached to the elastic band. The primary outcome is gait speed measured by the 40-m fast-paced walk test. Secondary outcomes include: patient reported hip disability (Hip disability and Osteoarthritis Outcome Score (HOOS)), hip muscle strength (hand-held dynamometry) and lower extremity function (30-s chair stand test). Discussion: This trial will add knowledge concerning the relationship between performed exercise dose and post-operative outcomes after THA. The protocol paper describes the study design and methods in detail, including the statistical analysis plan. Trial registration: Pre-registered on March 27, 2017 at ClinicalTrails.gov (ID: NCT03109821)., Competing Interests: No competing interests were disclosed.

Introduction: Rehabilitation exercises are offered to patients after total hip arthroplasty (THA); however, the effectiveness and optimal type and dose of exercise remains unknown. The primary objective of this trial is to indicate the preliminary efficacy of home-based rehabilitation using elastic band exercise on performance-based function after THA, based on the relationship between the performed exercise dose and the change in performance-based function (gait speed) from 3 (start of intervention) to 10 weeks (end of intervention) after surgery. The secondary objective is to investigate if a dose-response relationship exists between the performed exercise dose and changes in: hip-related disability, lower-extremity functional performance, and hip muscle strength Methods: In this prospective cohort study, patients scheduled for THA will be consecutively included until 88 have completed the intervention period from 3 to 10 weeks postoperatively. Participants perform the standard rehabilitation program with elastic band exercises. Exercise dose (exposure) will be objectively quantified using a sensor attached to the elastic band. The primary outcome is gait speed measured by the 40-m fast-paced walk test. Secondary outcomes include: patient reported hip disability (Hip disability and Osteoarthritis Outcome Score (HOOS)), hip muscle strength (hand-held dynamometry) and lower extremity function (30-s chair stand test). Discussion: This trial will add knowledge concerning the relationship between performed exercise dose and post-operative outcomes after THA. The protocol paper describes the study design and methods in detail, including the statistical analysis plan. Trial registration: Pre-registered on March 27, 2017 at ClinicalTrails.gov (ID: NCT03109821)., Competing Interests: No competing interests were disclosed., (Copyright: © 2019 Mikkelsen LR et al.)

Open Dialogue is a resource-oriented mental health approach, which mobilises a crisis-struck person's psychosocial network resources. This scoping review 1) identifies the range and nature of literature on the adoption of Open Dialogue in Scandinavia in places other than the original sites in Finland, and 2) summarises this literature. We included 33 publications. Most studies in this scoping review were published as "grey" literature and most grappled with how to implement Open Dialogue faithfully. In the Scandinavian research context, Open Dialogue was mainly described as a promising and favourable approach to mental health care.

Background: Due to an increased focus on productivity and cost-effectiveness, many countries across the world have implemented a variety of tools for standardizing diagnostics and treatment. In Denmark, healthcare delivery packages are increasingly used for assessment of patients. A package is a tool for creating coordination, continuity and efficient pathways; each step is pre-booked, and the package has a well-defined content within a predefined category of diseases. The aim of this study was to investigate how assessment processes took place within the context of healthcare delivery packages., Methods: The study used a constructivist Grounded Theory approach. Ethnographic fieldwork was carried out in three specialized units: a mental health unit and two multiple sclerosis clinics in Southern Denmark, which all used assessment packages. Several types of data were sampled through theoretical sampling. Participant observation was conducted for a total of 126h. Formal and informal interviews were conducted with 12 healthcare professionals and 13 patients. Furthermore, audio recordings were made of 9 final consultations between physicians and patients; 193min of recorded consultations all in all. Lastly, the medical records of 13 patients and written information about packages were collected. The comparative, abductive analysis focused on the process of assessment and the work made by all the actors involved. In this paper, we emphasized the work of healthcare professionals., Results: We constructed five interrelated categories: 1. "Standardized assessing", 2. "Flexibility", which has two sub-categories, 2.1. "Diagnostic options" and 2.2. "Time and organization", and, finally, 3. "Resisting the frames". The process of assessment required all participants to perform the predefined work in the specified way at the specified time. Multidisciplinary teamwork was essential for the success of the process. The local organization of the packages influenced the assessment process, most notably the pre-defined scope of relevant diseases targeted by the package. The inflexible frames of the assessment package could cause resistance among clinicians. Moreover, expert knowledge was an important factor for the efficiency of the process. Some types of organizational work processes resulted in many patients being assessed, but without being diagnosed with at package-relevant disease., Conclusion: Limiting the grounds for using specialist knowledge in structured health care delivery may affect specialists' sense of professional autonomy and can result in professionals employing strategies to resist the frames of the packages. Finally, when organizing healthcare delivery packages, it seems important to consider how to make the optimal use of specialist knowledge., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

This study explored how eight pregnant women diagnosed with depression managed the decision whether or not to take antidepressants during pregnancy. In total, 11 interviews were conducted and analysed by means of constructivist grounded theory. The major category constructed was Balancing risk, with two minor categories: Assessing depression and antidepressants and Evaluating the impact of significant others. The participants tried to make the safest decision, taking all aspects of their life into consideration. They described successful decision-making in the context of managing social norms that surround pregnancy, in a way that was acceptable to themselves, their significant others and healthcare professionals.

This article reports a conversation analysis of assessment package consultations. Healthcare delivery packages belong to a highly structured mode of healthcare delivery, in which specific courses of healthcare interventions related to assessment and treatment are predefined, both as to timing and content. Assessment packages are widely used in an increasing number of medical specialities; however, there is a lack of knowledge about how packaged assessment influences the interaction between doctor and patient. In this study, we investigate the final consultation in assessment packages, which is when the final clarification of the patient's symptoms takes place. The primary data of the study were eight audio recordings of consultations, and the secondary data were ethnographic field descriptions. In most consultations, packaged assessment was a resource as it provided fast and efficient clarification. In most cases, clarification was treated as good news since it either confirmed the absence of a serious disease or resulted in a diagnosis leading to relevant treatment offers. However, in some cases, clarification was not perceived as good news. This was the case in consultations with patients whose goal was to leave the consultation with clarification in the form of a definite diagnosis, but who were not offered such clarification. These patients negotiated the outcome of the consultation by applying implicit and explicit pressure, which induced the doctors to disregard the boundaries of the package and offer the patient more tests. The study highlights some of the problems related to introducing narrow, specialized package assessment., (© The Author(s) 2014.)