To evaluate the quality of surgical guidelines on bariatric/metabolic surgery.Four independent reviewers used the AGREE II  tool to assess the methodological quality of the included guidelines and conducted a comparative analysis of the main recommendations for surgical methods of these guidelines.Nine surgical guidelines were included in this study. Five articles with AGREE II scores over 60% are worthy of clinical recommendation. The field of rigor of development was relatively low, with an average score of 50.82%. Among 15 key recommendations and the corresponding best evidence in the guidelines, only 4 key recommendations were grade A recommendations.The quality of metabolic and bariatric guidelines is uneven, and there is much room for improvement. Obesnd more) .Although some new drugs  and diet22.1In this study, the AGREE II tool was adopted to conduct methodological evaluation of clinical guidelines for metabolism and weight loss, and PRISMA  principles were followed .2.2In this study, metabolism and weight loss surgery-related guidelines were retrieved from PubMed, Ovid, Springer, Web of Science, CNKI, VIP database, Wanfang Database and other databases. This study examined relevant guidelines published from January 1, 2014, to January 1, 2021, that included supporting evidence for the main recommendations included in the guidelines and the impact of time span on evidence updates. This study also searched Google and Baidu Academics to obtain more guidelines. The language was limited to English and Chinese. Keywords included the Chinese and English keywords “bariatric surgery”, “metabolic surgery” and “guidelines”. Additionally, the reference lists of the included guidelines were manually searched.2.32.3.1(1) complete guideline text (2); the guidelines include information about metabolism and bariatric surgery (3); if the guidelines are updated, only the latest version will be included (4); guidelines published in English or Chinese.2.3.2(1) duplicate guidelines, translated versions of the guidelines, secondary or multiple publications, and brief abstracts (2); the translated versions of the guidelines may have lost the information of the original versions, which may have affected the accuracy of the evaluation of this study (3); if multiple guidelines were issued by the same organisation, older versions of the guidelines were excluded.According to the above inclusion and exclusion criteria, two reviewers (Xiao Wang and Yu-Lu Du) independently evaluated the obtained literature to determine whether to include or exclude the literature. Disagreements were resolved through negotiation until consensus or by consulting a third expert reviewer (Ya-Qi Zheng).2.42.4.1https://www.agreetrust.org/resource-centre/) to assess each bariatric/metabolic guideline that met the standards of this study. This tool consists of 6 domains and 23 items. . The reviewers were trained on the use of the AGREE II tool through a rigorous online training course on the AGREE website. Reviewers are guided and supervised by experts  who have published a number of articles through the use of AGREEII. The team includes experienced specialists in bariatric/metabolic surgery . The user manual defines each item and helps the user determine the guideline score for the item. Items are rated on a scale of 1 (completely inconsistent with the item) to 7 (completely consistent with the item). Domain scores are calculated by adding up the project scores for each domain for each reviewer, then normalizing them to the percentage of the highest score .For each area of the AGREE II tool, “points earned” is calculated as the sum of all points scored by the grader for all items contained in that area. The “proportional domain score” is calculated as a standardized score using the following formula: (score obtained − lowest possible score)/(maximum possible score − lowest possible score). The maximum score for each area is obtained by multiplying the number of items in that area by the number of raters, multiplying by 7 (which corresponds to “strong agreement”). The minimum score is obtained by multiplying the number of items in the field by the number of raters and multiplying by 1 (which corresponds to “strong disagreement”).2.5In this study, the relatively high AGREE II scoring guidelines were used to extract and analyse important recommendations related to metabolism and bariatric surgery, and a database search was conducted to further obtain the highest level of evidence supporting these recommendations. This study reclassified recommendations and evidence using the Oxford Centre for Evidence-based Medicine (OCEBM) grading system. Table S22.6We used a descriptive statistical analysis method to calculate the standardized scores for each guideline, which were expressed as a percentage, and we also listed the median scores and the range of each domain. We adopted a two-way ANOVA to calculate the intra-class correlation coefficients (ICCs) to examine the agreement among the scores from the four reviewers. Consistency among raters was determined by ICCs and 95% confidence intervals (CIs). ICC is equal to the individual variation divided by the total variation, with a value between 0 and 1 for the 23 items identified in AGREE II. If the ICC is between 0.01 and 0.20, the degree of agreement is considered to be slight; if the ICC is between 0.21 and 0.40, the consistency is considered fair. If the ICC is between 0.41 and 0.60, the consistency is moderate. If the ICC is between 0.61-0.80, the degree of agreement is considered to be high; if the ICC is between 0.81-1.00, it is considered perfect. P < 0.05 indicates statistical significance. Statistical analysis was performed using IBM SPSS Version 19.0 . Table S333.1A total of 264 records were obtained through database retrieval and other retrieval methods, which were evaluated by reading titles, abstracts and full texts. Finally, 9 guidelines for bariatric/metabolic surgery were included Figure 13.2The AGREE II standardized area scores for each metabolic and bariatric/metabolic surgery recommendation guideline and their overall recommendations are shown in In this study, four evaluators participated in the evaluation of the guidelines, and the ICC value range of the metabolic and bariatric surgery guidelines was > 0.8 using AGREE II, indicating a high degree of internal item score consistency among reviewers.3.3To further analyse the reasons for the heterogeneity of recommendations for metabolism and bariatric surgery among different guidelines, this study referred to guidelines  with rel4Compared to other disease-specific guidelines, the development of guidelines for metabolism and bariatric surgery can be a complex issue, as metabolism and bariatric surgery is a multidisciplinary, global issue. In this study, even within the same guidelines, the quality of metabolic and bariatric surgery guidelines was highly heterogeneous among different fields, and there were significant differences in the distribution of evidence level and recommendation strength between different categories of guidelines.Analysing the included guidelines, the study identified several areas where improvement was needed in the development of the guidelines. In the development of guidelines, patient perceptions, expectations and preferences for medical care have become increasingly important. Stakeholder participation can well reflect the views of prospective users and patients. The implementation of the guidelines also requires multidisciplinary medical expertise. However, the guidelines included in this study did not provide details about the involvement of patients and their representatives.Rigour of development is closely related to credibility in the implementation of the guidelines. This field assessment is used to locate and synthesize evidence and to develop and update recommendations . UnsysteAll nine guidelines included in the study scored > 60% for clarity and presentation. This shows that the recommendations in the guidelines are clear and easy to identify.The overall score for the applicability of the guidelines was low in the included guidelines. This indicates that the hindrance and promotion factors in the application of the guidelines have not been fully understood in the formulation of the guidelines . No recoIn the area of editorial independence of the guideline. The influence of sponsors’ views on the guideline and the conflicts of interest between members of the organisations involved in the development of the guideline are rarely mentioned , 12. TheThere are significant differences in recommendations in the included guidelines. Therefore, this study further analysed the consistency and controversy between current recommendations and corresponding evidence of metabolic and bariatric surgery guidelines with reference to key recommendations from the guidelines for metabolic and bariatric surgery with relatively high scores.4.14.1.1For this recommendation, only 2 guidelines , 17 are 4.1.2For this recommendation, four guidelines –17 are r4.1.32 to 35 kg/m2)  .4.24.2.1Three guidelines  agree on this recommendation. The other six guidelines , 16, 17 4.2.2Two guidelines , 15 agre4.2.3For this recommendation, two guidelines , 16 have4.2.4For this recommendation, two guidelines , 16 have4.2.5Two guidelines , 11 agre4.2.6The best evidence to date comes from a case-analysis study of 96 patients, which found that BPD/DS is a safe and effective option after initial SG failure, especially in patients with severe obesity before SG. SADI-S results in a more significant reduction in overall weight than RYGB after failure of SG , 29.4.2.7Two guidelines , 13 agre4.34.3.1Four guidelines –11, 15 h4.3.2Two guidelines , 15 reco4.44.4.1This recommendation is relatively consistent in most guidelines , 13–15, 4.4.2For this proposal, two guidelines , 15 are 4.4.3Three guidelines , 15, 17 In summary, suggestions for improving the quality of metabolic and bariatric surgery guidelines are as follows: (1) Developers should set different groups  clearly and fully consider the views and wishes of target groups when formulating clinical guidelines. (2) In the formulation, evidence standards should be clearly described, the link between recommendations and evidence should be shown clearly, and update steps should be provided. (3) Guideline developers should be familiar with guideline development standards, such as the AGREE II tool. (4) The guideline shall be externally reviewed by experts before publication. (5) Most of the key recommendations for metabolic and bariatric surgery are not supported by high-quality research evidence. It is recommended that international academic groups on metabolic and bariatric surgery organize and carry out multicentre high-quality research to provide high-quality evidence for the key recommendations on metabolic and bariatric surgery.This study has some advantages and limitations.The advantages of this study are as follows: (1) This study collated and analysed the key recommendations and relevant evidence in the recent guidelines for metabolic and bariatric surgery. This study identified issues of recommendations and evidence related to metabolic and bariatric surgery and suggests improvements that may help guideline makers and users identify gaps in practice and provide a reference for guideline users to select more reliable guidelines. (2) Most of the developers of the guidelines included in this study come from international organisations and from different backgrounds, including clinical experts and methodologists, who have rich experience in developing clinical guidelines, which improves the reliability of the results of this study.The limitations of this study are as follows: (1) In this study, only the guidelines written in English were evaluated, and the guidelines published in other languages may be missed in this study, resulting in inadequate representation of some less developed countries. (2) AGREE II is a methodological tool that does not evaluate the content and clinical significance of guidelines and focuses mainly on the formulation of guidelines. Thus, even if the guidelines are based on low-quality evidence, but the methodology is developed in compliance with AGREE II standards, the guidelines may still be scored highly by the AGREE II tool. (3) We decided to include all populations without setting age limits, but only one remaining article deals with the population of children and adolescents. This may be due to the lack of literatures and guidelines.5The quality of metabolic and bariatric surgical guidelines varies visibly. High-quality guidelines require multidisciplinary collaboration. Using the AGREE II tool, this study found significant room for improvement in the guidelines for metabolic and bariatric surgery, especially in terms of rigor, stakeholders, adaptability, and independence of guideline development. Effectively addressing these issues has vital implications for developing high-quality recommendations for metabolic and bariatric surgery guidelines.Z-HQ and XY were responsible for the information retrieval and the summary of characteristics of included guidelines; Y-LD and XW independently evaluated the obtained literature to determine whether to include or exclude the literature; Z-HQ, XY, L-YA, and TY were responsible for grading the included guidelines according to the AGREE II user manual; XY was responsible for writing, edit and revision of the body text; Z-HQ was responsible for the summary of key recommendations of included guidelines and corresponding best supportive evidences, and calculation of ICCs; Z-HQ, XY, and D-LS were drafted and revised the article; Z-HQ, XY, D-LS, and Y-YL were responsible for the theme, final editing, and preparation of the manuscript for submission; D-LS and Y-YL critically revised the manuscript. All authors contributed to the article and approved the submitted version.


Brief Admission was implemented relatively recently in child and adolescent psychiatric settings in Sweden. The purpose of this study was to phenomenologically explore the lived experience of parents whose teenagers, who recurrently self-harm and experience suicidal thoughts, use Brief Admissions.Brief Admission by self-referral is a preventive intervention here intended for individuals who recurrently self-harm and have a history of contact with emergency psychiatric services. Individuals with access to Brief Admission are empowered to self-admit to inpatient care for up to three days per stay and are encouraged to do so This is a qualitative study using phenomenological psychological analysis. We interviewed 17 parents who had experienced their teenagers using Brief Admissions. The interviews were recorded and transcribed verbatim and analyzed to arrive at the essential meaning structure of the phenomenon of Brief Admissions for the parent.We identified two essential meaning structures of the parent’s experience of their teenager’s use of Brief Admissions: being gifted relief and hope or being robbed of everything you believed in. The experience of Brief Admissions as a gift was structured by the following constituents: ‘a sense of safety and containment’, ‘liberation from a hostage situation’, ‘a return to wellbeing’, and ‘catalysts for relational shifts’. In contrast, the constituents of the experience of being robbed included ‘a tug of war for control’, ‘an unworthy wasteland’, ‘abandonment and collapse of authority’, and ‘no sense of purpose and plan’.Brief Admissions may come across as challenging, futile and painful in the life of the parent, yet they may also support a process of recovery and healthy development for the entire family. To realize the full potential of the intervention, mental health professionals providing Brief Admission must be mindful of the challenges the parent may face as their teenager starts self-admitting, tactfully and sensitively preparing the parent for a new parental role.The online version contains supplementary material available at 10.1186/s13034-023-00675-y. Self-harm and suicidal thoughts and behaviors are associated with great suffering, often extending to the surrounding family. Over the past 15 years, research on child and adolescent self-harm and suicidal thoughts and behaviors has increasingly attended to parental perspectives, not only in terms of the parental role in the child’s trajectory, but by considering parents’ experiences, perspectives and needs in their own right .BA is only offered to teenagers who have been in contact with psychiatric emergency services, meaning that most are struggling with both suicidal thoughts and self-harm and have previously been admitted with emergency admissions managed by a psychiatrist . Participants were interviewed individually by RL. Before initiating interviews, RL repeated information about the study, answered any questions, and obtained participants’ written or recorded verbal consent.Three interviews took place in in-person meetings in the participants’ homes. One interview started as a video meeting but, due to technical issues, was carried out over the phone instead, recorded over speakerphone. The others were video interviews, recorded in the Zoom video service provided by Lund University. One interview had to be interrupted after 22 min as the parent needed to respond to their teenager experiencing crisis. The other interviews lasted between 38 and 93 min, with a median duration of 55 min.body, time, space, and relations, though interviews also covered world/reality and sense of self , and practiced  reduction to narrow in on the psychological region of meaning in the parent’s lived experience. We then identified all sections related to the teenager’s use of BAs and divided these into their smallest meaning units in a new document. In a column beside these original verbatim expressions, we elucidated the psychologically relevant meanings of each of them, seeking to avoid unwarranted interpretive leaps or premature exclusions. RL then wrote cohesive, rich yet prudently concise texts explicating the (idiographic) psychological meaning structure of each parent’s lived experience, with no between-subject comparison. Refocusing on the existential constants and practicing free imaginative variation opened up to new intuitions of the whole. Finally, we moved from the vastly different situated structures to a general meaning structure of the phenomenon, again using imaginative variation and removing everything that did not appear essential. No direct participant quotes were included in this final text, as participants do not speak directly to the general level of meaning explicated by the researchers . As the teenager steps up, the parent steps down. This transition sometimes feels painful and difficult, yet the parent accepts it as healthy. Being supportive from a distance, the parent increasingly gets to be their own person in relation to their teenager.In the essential structure of experiencing BAs as being gifted relief and hope, the following constituents reveal themselves: ‘a sense of safety and containment’, ‘liberation from a hostage situation’, ‘a return to wellbeing’, and ‘catalysts for relational shifts’.uniquely safe, in contrast to the controlled environment during conventional admissions, which is accompanied by a sense of unpredictability, incomprehensibility, and imprisonment.Having a teenager who self-harms and experiences suicidal thoughts, the parent has been living in fear for their life. The lived world is one full of dangers: the city full of parks where the teenager may run off, of stores selling potentially harmful items, and of people who may have sinister intentions. To some extent, the parent still relates to the world this way during their teenager’s BAs, especially since the teenager is free to come and go. Even so, the parent relates to the BAs as safe for their teenager – The BAs also feel safer than the family home. The house is a potential death-trap where locked medicine cabinets may be pried open, cleaning aides may be consumed, and a whole host of everyday objects may have unpredictably sharp edges. The parent feels out of control of their own space, unable to mitigate perils, sometimes helplessly watching as their teenager self-harms. Difficult experiences from the past may also haunt the house, etched into the walls and floors like hidden mines, so that the lived space manifests as even more hazardous, where the parent gets no rest.contained in a positive sense: being held, getting to take a break and simply be. The parent feels contained as well, given a cue that they may now, finally, let go of their worries.From this place, the parent is relieved when the teenager self-admits. The parent knows their teenager will be kept safe during BAs, in a low-stimuli environment where professionals look out for them and tend to their basic needs. Whether there with the teenager or not, the parent feels their teenager is Prior to the teenager using BAs, the parent has their temporality constrained by the incessant need to be ready to respond to crisis. This makes for an everyday life jagged by interruptions; the parent suddenly needs to leave work, drop the employment interview, cancel family activities and any personal plans – essentially drop everything to speed to their teenager’s rescue. Life is moving from exception to exception with no sense of continuity or constancy. The rest of the world ceases to exist.The parent is spatially arrested as well. They stay at home to watch over the teenager, surveilling their every move as their warden. The price to pay for this is high; the parent cannot sleep properly, tend to their bodily needs, go outside or be with others. The house is stripped of its foundational homeliness and takes on an atmosphere of entrapment for both teenager and parent. This feeling lingers during the teenager’s conventional admissions as the parent is detained in the psychiatric unit, forced to breathe down their teenager’s neck against both of their wishes. Even if permitted to go home briefly, the parent remains in lockdown, tensely waiting to be summoned back. Sometimes, this hostage situation extends to their other children, unable to leave the house not knowing when their parent will be back.The parent may experience their sense of self held hostage, in the strain between parental responsibilities for their sick teenager and other responsibilities, such as work or tending to the needs of siblings. Younger siblings may witness frightening episodes during crisis, older siblings may tackle the teenager in crisis like security guards to protect them, and amidst this turmoil the parent’s heart breaks. Being a good parent, professional, person appears impossible. The parent experiences internal and external blame, guilt, and shame for not doing or being enough.When the teenager starts using BAs, however, everything changes. The parent regains spatiotemporal agency; they can take off their soldier’s helmet and step down from their exhausting, all-demanding stand-by duty. This liberation marks a return of autonomy and agency for the parent as well as the teenager. The parent is also free to have a dialogue with the teenager about their preferred degree of contact at the psychiatric unit, free to give the teenager room (to decide). The parent’s sense of self (as parent) is relieved from threat and, in accord, tensions within the family dissipate.The BAs represent a turning point for the parent: before them, life is suspended in space and time; with them, life begins anew. A burden is lifted and the lived body physically de-stresses, shoulders relaxing, lungs inhaling deeply and releasing a sigh. The parent associates their teenager’s BAs with bodily self-care practices, like having a massage.Little by little, the parent sees the teenager learning to care for their own emotions and needs, in a way they haven’t before. Even if they might still be struggling, the world and life itself begins to feel manageable for teenager and parent. Throughout crises at home, contact with psychiatry and conventional admissions, the whole family has collectively been sharing feelings of anxiety, frustration, despair, and hopelessness. When the teenager uses BAs, instead, the parent feels that the family shares experiences of relief, safety, calm and hopefulness. The siblings go on being children and the parent is more continually and predictably available to them now, getting to spend some treasured quality time with them. The BAs assimilate into and support a familiar family life, bringing back a sense of normalcy that the parent celebrates.The parent can also return to familiar activities and settings. Going back to work is a huge positive leap, not only in terms of escaping the stress of leave-of-absence and stabilizing the family’s economy, but in terms of gains intimately connected with a sense of a healthy life, like feeling gratitude and meaningfulness when tapping into the roles of the professional and colleague. These identities bring a sense of wholeness to their selfhood and allow them to reconnect with social relations, receive invaluable support from colleagues, take part in other people’s lives and feel like they belong.Both teenager and parent need to adjust to a new way of thinking. With psychiatry suddenly encouraging the teenager to initiate admissions, and enabling them to choose to admit alone, the parent’s lived experience with the world shifts to one where help is available, and they do not need to be the one to manage everything. These circumstances catalyze a shift in the parent’s lived relation with their teenager. As the teenager starts experimenting with how the BAs might be helpful, the parent gives them space and encouragement.all parents – and a normal and healthy part of parenting a teenager. Equally normal is the sometimes-painful experience of not being needed as much, not getting to perform the same concrete acts of care anymore. The parent retains their sense of self (as parent) though, adjusting to a new parental role.Stepping back from managing, moderating, and monitoring is challenging, though. Adjusting to a new world order where the teenager is not in imminent danger, the parent finds comfort in the realization that taking a step back is challenging to The sense of normalcy affords the parent with faith. They choose to trust their teenager, the professionals, and the BA method. They no longer need full insight into the happenings at the psychiatric unit and feel comfortable not being there. Their spatial absence manifests as freedom rather than hindrance, a natural part of a healthy process, and the parent willfully surrenders control and responsibility. The more the parent can let go, the more they get to experience their teenager growing and maturing, gaining self-understanding and self-regulation skills.The parent attunes to where the teenager needs them to be. They acknowledge the teenager’s capabilities, validate their need for space, mirror their disappointment in the face of setbacks, and encourage them. In place of the previously hierarchical parent-child relationship, a more symmetrical relationship is forming. The parent starts distinguishing the teenager’s needs from wants and preferences and can begin to consider their own as well, taking shape as person-beyond-parent even in relation to the teenager. The BAs provide parent and teenager with time and space to relate differently to each other.For the parent, in using BAs their teenager is being deprived of their fundamental needs. The parent engages in a tug of war for control where there is no true winning. The physical environment feels like a wasteland, a space submerged in despair and indignity, robbing the parent of hope. The psychiatric staff feel unreliable, inexplicably abandoning the teenager during BA. The parent does not see the purpose of the BAs, they seem like an echoing void where the teenager receives no help. Nothing adds up, nothing makes sense; there seems to be no thought behind anything. The parent is caught in the present, though aching for a future. They expected more from the BAs and psychiatry at large.In the essential structure of being robbed of everything you believed in, the following constituents reveal themselves: ‘a tug of war for control’, ‘an unworthy wasteland’, ‘abandonment and collapse of authority’, and ‘no sense of purpose and plan’.The teenager’s life has been hanging in the balance for a long time. Under such grave circumstances, the parent expects the psychiatry professionals to remain in control over the teenager at the unit. But the teenager is free to come and go during BA and the staff seem to have no clue about their whereabouts. The parent is given no reason to have faith in the BAs, and in their mind’s eye they are bombarded with dire scenarios of their teenager self-harming or running away. The parent’s lived sense of self is that of a rock, the one dependable thing out there, and they simply cannot take the risk of surrendering control to no-one.The parent engages in a tug of war versus both the teenager and the healthcare system. While the teenager is happy about their strengthened voice and autonomy, the parent does not trust their teenager to understand their own health and care needs or make wise decisions during BAs. Sometimes the parent is the one to get the teenager (self-)admitted. Sometimes the parent speaks for the teenager during intake meetings, or over the phone in the teenager’s absence. It may be that the teenager actively seeks the parent’s support, but the parent may also feel the need to go over their head in making plans about what is best for them. The parent instinctively cares for their teenager as if they were a younger child.not-there, so painfully on the outside physically that they must always remain inside mentally. They frequently call the unit and text their teenager, they worry incessantly, and may even try reaching the teenager’s friends for updates. ‘Winning’ the tug of war changes little of the teenager’s situation, but losing is excruciating.The tug of war with psychiatry means fighting both people and system. Paradoxically, the parent may authoritatively scold or command the psychiatry professionals, not trusting their judgement, yet insisting that the teenager is safer at the psychiatric unit than at home. But the parent must submit to certain conditions set by the psychiatric system, such as not staying at the unit and not listening in on conversations with professionals if the teenager doesn’t want them to. The parent feels distressed about this loss of insight into the teenager’s admission, not getting to experience first-hand that their teenager is safe. The parent’s lived space of detachment and absence rules them while they make every effort to overrule it. The parent is distinctly When accompanying the teenager to the psychiatric unit, the parent faces an environment conveying scarcity and urgency. Children’s suffering infuses the walls and hovers in the air, subtly yet profoundly weighing down on the parent, making them feel heavy, uneasy, suffocated. The other children admitted are also perceived as threats who may disturb their teenager’s delicate balancing act between health and illness, triggering self-harm or an eating disorder and competing for the attention of busy professionals in a setting plagued by high turnover and chaos. The parent instinctively wants to escape this environment yet may also feel a need to control it.this is the world you live in now; this is all there is for your child. The parent’s heart sinks.The room that is the teenager’s intended refuge is like a prison cell or broom closet – a tight, barren, inhospitable and unpleasant space devoid of hope. The teenager may be left with a bare mattress on the floor. The sense of unworthiness oozes from the lived space that is this wasteland. Though the parent may try to improvise curtains from blankets, the spatial inhospitality is difficult to challenge. The devoid setting, in its silence and givenness, has a demonstrative property to it, declaring why of the teenager’s being there-not-here is actualized. The implicit agreement to temporarily outsource the care of the teenager from parent to professional, is now violated. The parent experiences a relational breach of trust, betrayal, and is filled up with rage. How can the staff simply leave the teenager? How can they not care?Sometimes as the teenager self-admits alone, soon enough the parent starts receiving messages that their teenager feels alone. Maybe they have left the unit, sitting isolated in some diner. It tugs at the parent’s heartstrings to imagine their teenager lonely and abandoned like a street child, especially while feeling poorly. The parent’s instinctive response is to bring them home immediately, and so the The inaction and passivity of the professionals is interpreted either as incompetence and clumsiness, or as neglect and unforgivable recklessness. It feels deeply unethical, borderline criminal, to leave a suicidal teenager to their own devices. These experiences hollow out the authority of the professionals.real care. The parent is more oriented toward their absence than the presence of other professionals during BA. The contributions of the professionals present are eyed with skepticism, if at all considered. When the parent stays at the unit with the teenager, they sense that the staff consider BA patients less worthy of care, like second-class patients, deprived of their rights. Not feeling taken seriously makes the parent not take the BAs seriously. The professionals’ betrayal is experienced as deeply personal and unrecoverable.In fact, the nurses and nurse’s aides are not regarded as professionals at all. The parent is more inclined to trust psychiatrists, psychologists, and healthcare counsellors, feeling that they represent The parent feels frustrated as the BAs don’t seem to make any tangible difference in the family’s life. They seem pointless, futile, and impractical, or their short-term helpfulness appears to hinge on coincidence, such as which members of staff happen to be on duty at the time. Their teenager is in a no-man’s-land, a trench where no one will claim them, contained like an object.The parent grasps for something to believe in, feeling a pressing need to comprehend the overarching purpose with the BAs, get a sense of direction, a plan for their teenager. But the professionals handling the BAs offer no insight into the bigger picture. The parent’s lived time is in a standstill. They are arrested in the present situation, their future a thick fog, ethereal and impossible to see through.real care for a healthcare system on its knees. Realizing that the glimmer of the BAs was really l’or des fous, the parent feels disillusioned. Certain that their teenager would not survive losing hope, the parent keeps their soldier’s helmet on – they cannot and will not lose this fight.The parent is left feeling that they expected more from the BAs and psychiatry. They have been to war for ages to get their child the healthcare they need. This care should feel like an all-hands-on-deck situation, but the psychiatric system is deceitful and undependable. In the parent’s lived world, the BAs are bookkept along with other disappointments, as a budget alternative to The present study elucidates what the teenager’s Brief Admissions may be like for the parent, experienced as being gifted relief and hope or being robbed of everything you believed in. Given the purpose and delivery of the BA intervention as studied here, the parent’s experience of the BAs will inevitably be nested within their experience of having a teenager who self-harms and experiences suicidal thoughts. Indeed, we recognize several elements of our present findings from previous research on being a parent under such circumstances.A sense of safety and containment, is a well-documented experience for parents of children who experience suicidal thoughts and self-harm (Daly The parent being on the alert for dangers in the home environment and attempting to control them, as seen in the constituent arm Daly . This maarm Daly . NotablyFurther, our finding that the parent of a suicidal teenager lives in constant fear and preparedness to respond to crisis, is in line with previous research Daly . The preA return to wellbeing is how prominent aspects of the experience of the teenager’s self-harm, suicidal thoughts, and recovery are shared within the whole family system. Parent and siblings experience anxiety and despair, frustration and hopelessness together with the teenager through crises and psychiatric contacts. Not only does the parent witness the teenager’s relief, hopefulness, and recovery during BAs; they experience this first-hand as well, as they recover a sense of a normal life. From this, recovery is not only an individual process but a social one involving the entire family, as noted recently by Weissinger et al. (Also noteworthy, particularly in the constituent r et al. . Here wer et al. , p. 165.r et al.  account r et al. , a coller et al. .Catalysts for relational shifts, this is at once also a critique against the notion of recovery as returning to a baseline state ‘before’ ‘illness’ (Davidson uncovery: the teenager uncovers independence and personal growth not previously experienced, while teenager and parent uncover novel, healthy ways of relating to each other. Their ability to communicate around self-harm, with the parent asking about the teenager’s needs and preferences in relation to the BAs, is contrary to the interpersonal communicative breakdowns observed in Steggals et al. (Relating to the constituent Davidson , as beyos et al.  and Curts et al. . Certains et al. .Being robbed of everything you believed in speaks of entirely different ways of meaning-making in experiencing the BA phenomenon. The parent does not trust the BA method and is fighting psychiatry. We concord with Weissinger et al. (A tug of war for control are struggling with this, while parents experiencing Catalysts for relational shifts appear to have been able to uncover a new balance in their parenting, guided by trust. This is an exciting finding, although we must acknowledge that this individual-relational maturation process might have occurred for these parents and teenagers even if the teenager would not have self-admitted with BAs. Even so, the BAs appear to have potential in supporting healthy development.r et al.  that parr et al. , and finr et al. . In our A tug of war, we see how the struggle with exclusion and being on the outside of care becomes existentially acute for the parent. Previous phenomenological works may help us understand the magnitude of existential crisis, as parents of hospitalized children have a foundational need to presence themselves with their child, to be-with them and keep vigil by their side (Darbyshire Relating to the physical space at the psychiatric inpatient unit as a prison, and perceiving the other children admitted as potential threats to the parent’s teenager, are experiences observed in this study and previous research (Lindgren et al. devoid of care, stripped of financial resources and plagued by a short-sighted mechanistic view of patients as objects to handle and store, rather than human identities to relate to. There is a deep, seething sense of injustice here, which comes across as built into the very healthcare system. In contrast, in the other variant of experiencing the BAs as being gifted relief and hope, hopefulness may be associated with the sense that individuals who self-harm and experience suicidal thoughts are seen as persons with voice, abilities, agency and lives to lead. This is testament to how BA might be one potential ingredient for an antidote addressing structures of injustice within psychiatry (Scrutton A final noteworthy finding is that the parent may view the psychiatric system itself as ‘sick’. They may interpret the relative absence of interventions and professional interactions during BAs as further evidence of their prior experiences of psychiatric care as Scrutton , entrencScrutton . CertainScrutton . A promiScrutton .The above discussion points to the health-promoting potential of BAs for the parent and the whole family, as well as for the teenager who is the target of the intervention. We note the important role of mental health professionals in realizing this potential, in terms of their interaction with teenager and parent during BAs and importantly also in framing these admissions to the parent. It is imperative that professionals working with BA in CAP settings are attuned to the parent’s experience of the world in relation with their teenager. Such an attunement would enable the professional to, carefully and tactfully, support the parent’s sense of coherence; the parent needs to experience their teenager’s BAs as comprehensible, manageable, and meaningful (Antonovsky expectation of the parent to comply. Conveying this expectation without acknowledging the parent’s context – as if it is a given that the parent is suddenly ‘not to worry themselves’ any longer – would be insulting and insensitive, completely overlooking the existential cleft that is ripped open for the parent.In line with previous research (Simes et al. To help bridge that cleft, professionals may do well to emphasize that they are indeed oriented to the teenager’s safety and are in no way down-prioritizing them. We also recommend that professionals reiterate for the parent the rationale behind certain BA procedures, such as why the teenager’s medical prescriptions will not be adjusted and why numerous professional appointments will not be imposed on them, reorienting the parent to a preventive, recovery-oriented mentality. The professionals’ views on how BAs might fit into the teenager’s life ought to be explicated, as well as the new role of the parent and how they may best support their teenager’s development (Zhao et al. Parents may benefit from having such a conversation with mental health professionals in private and prior to the teenager’s first use of BAs, perhaps in connection with the BA contract negotiation. Professionals might also address these matters spontaneously as they come into contact with parents over the phone or in person during BAs; this would be especially important if professionals sense that a parent might be struggling with the BAs.There are several frameworks for evaluating the rigor and contribution of qualitative research, where Polkinghorne’s criteria of accuracy, richness, vividness, and elegance are suggested for evaluating phenomenological research (Polkinghorne, 1983, cited in Finlay use of BAs when we recognized that our original inclusion criterion was not well-defined for phenomenological research. We have practiced epoché and phenomenological psychological reduction continually. Overall, we have taken care to follow Englander and Morley’s (Additionally, we have sought to adhere to recommendations for methodological integrity, in terms of fidelity and utility, specifically for qualitative research within the psychological discipline (Levitt et al. Morley’s  recommenFurther, traditionally in qualitative research we ought to provide rich information about the research setting and context of our participants in order to clarify the potentials and limits of transferability of our findings (Levitt et al. Again, the extent to which we have succeeded in generating essential descriptions of the general meaning structures of the BA phenomenon is up for reader verification. One prominent limitation of our study, arguably the greatest threat to our claims, is our limited ability to fully ‘see’ the phenomenon we seek to study (Churchill Other issues that might have affected our ability to see the phenomenon pertain to the interview situation. Interviewing everyone who wished to participate may be regarded as a strength, yet it also meant we conducted vastly more interviews than would have been strictly methodologically necessary (Englander & Morley Even so, this study is uniquely informative of the parental lived experience of their teenager’s psychiatric admissions with BA, nested within the parental experience of their teenager’s self-harm and suicidal thoughts. Having performed a deep structural analysis of essential meaning, our research is grounded in human experience, which enhances the relevance of the recommendations we pose for improved clinical practice within CAP inpatient care.Being the parent of a teenager who recurrently self-harms and experiences suicidal thoughts may mean having one’s lifeworld reconstituted as a world full of perils, one where the parent must sacrifice life as they knew it in order to protect and fight for their teenager. The teenager’s BAs may become a turning point for the parent: a gift which helps the parent recover safety, familiarity, and agency in their everyday life, while uncovering new ways of being with their teenager. In this way, well-being may be enhanced for the whole family. However, the parent may also sense the promise of a turning point that does not arrive, leaving them feeling robbed of everything they believed in. A phenomenological psychological lens reveals the need to support parents who are struggling existentially, feeling unmanageably challenged in their parenthood during the teenager’s BAs. To do this, mental health professionals working with BA must mindfully, sensitively, and tactfully help reorient the parent to a sense of manageability, comprehensibility, and meaningfulness, preparing them for a new parental role. While BA educators may make effort to spread awareness among all professionals working with BA, representing continuity for families within a mental healthcare setting is a complex task, which may arguably be facilitated if professionals experience such continuity in their workplace. This may be achieved on different levels, from implementing routines and documentation helping professionals inquire about parents’ experiences in connection to BA contract negotiations, evaluations, and intake and discharge meetings, to dedicating supportive resources such as informative handouts or group psychoeducation sessions for parents whose children are provided access to BA, to more overarching workplace efforts to address work environment and employee turnover. Future research might explore the perspectives of healthcare professionals working with BA within CAP and how they relate to initiatives such as shared decision-making and person-centered care in the context of working with children and families affected by self-harm and suicidal thoughts and behaviors.Below is the link to the electronic supplementary material.Supplementary Material 1Supplementary Material 2


The act of searching and retrieving evidence falls under the second step of the EBP process—tracking down the best evidence. The purpose of this study is to understand the competencies of clinicians accessing electronic databases to search for evidence on pain management using a mixed methods approach. Thirty-seven healthcare professionals  who are actively involved in pain management were included. This study involved two parts  that ran in parallel. Participants were interviewed using a semi-structured interview guide ; data were transcribed verbatim. During the interview, participants were evaluated in comparison to a set of pre-determined practice competencies using a chart-stimulated recall (CSR) technique (quantitative data). CSR was scored on a 7-point Likert scale. Coding was completed by two raters; themes across each of the competencies were integrated by three raters. Seven themes evolved out of the qualitative responses to these competencies: formulating a research question, sources of evidence accessed, search strategy, refining the yield, barriers and facilitators, clinical decision making, and knowledge and awareness about appraising the quality of evidence. The qualitative results informed an understanding of the strengths and weaknesses in the competencies evaluated. In conclusion, using a mixed methods approach, we found that clinicians were performing well with their basic literature review skills, but when it came to advanced skills like using Boolean operators, critical appraisal and finding levels of evidence they seem to require more training. Evidence-based practice (EBP) is defined as integrating individual clinical expertise with the best available external clinical evidence from systematic research . EBP is Searching electronic databases is an essential skill for a clinician who wishes to base his/her clinical practice on research evidence to provide high-quality service to patients seeking care . This acMultiple steps are involved in the process of searching and retrieving evidence ,7. FirstThe next step is to identify the sources of evidence that could provide articles that can answer this question. There are many sources of literature that can be accessed to complete these searches ,14. PrevPrevious studies have documented the experience of clinicians using online electronic databases for literature review. Rosenbaum and colleagues have reported that many participants in the study that involved searching a commonly known electronic database displayed feelings of ineptitude, alienation, and frustration because of technical jargon and maneuvering difficulties . AnotherThere are few studies that have been conducted to understand the experience of clinicians, using online databases to find evidence related to pain management. A previous study that looked into the knowledge, attitudes, and behaviors of 675 physicians, nurses, occupational therapists, physical therapists, and psychologists who were involved in pain management and found that all of them had similar levels of knowledge and attitudes toward EBP; however, the physicians did better with the implementation of EBP . There aThe mixed method is a design which involves the integration of qualitative and quantitative data to better understand a concept that is being studied . Mixed mThe experience of clinicians, using online databases to find evidence related to pain management, is an area that has not been studied well. Getting to know their experiences can enable organizations and evidence repositories to plan better means of pushing out evidence to clinicians and modify current methods to provide a better experience of searching for evidence, thus improving evidence-based practice. We chose a mixed methods design because it can give us a greater understanding of the experience of clinicians as they use electronic databases to find evidence related to pain management. This would give us a greater insight into the matter just beyond numbers and validate the quantitative assessment with qualitative data . Hence, The purpose of the current study is to understand the experiences of clinicians accessing electronic databases to search for evidence on pain management using a mixed methods approach. Mixed methods—convergent parallel strategy. This study involved two parts  that ran parallel. The study followed the guidelines recommended by Leech . We usedA purposive sample was recruited for the study. Healthcare professionals who were part of a randomized control trial looking into the effectiveness of push versus pull  strategin = 37) were continued until saturation (the point at which no new data emerged). The interview guide is attached in Ethics approval for this study was obtained through Hamilton Integrated Research Ethics Board of McMaster University, Hamilton, Ontario, Canada (REB#10-586). We followed all guidelines described. The study was conducted from the MacHand Lab at McMaster University, Hamilton, Canada. Once participants were recruited, a research coordinator contacted them via mail and telephone and sorted a convenient time for a telephonic interview. The baseline interviews were completed for 37 participants over the phone. Structured interviews .Verbatim transcription of interviews and member checking with the other author and peer debriefing .Development and maintenance of audit trail throughout the research process, to ensure that the same questions were asked with every participant process .Analysis of transcribed data with the other authors and making separate codes and discrepancies found were checked as well followed by team discussions at all stages .All interviews were transcribed verbatim and then checked by the interviewer for accuracy. For the analysis, we used a general descriptive qualitative search methodology, as described by Sandelowski . NVivo 1Descriptive statistics including the mean and standard deviation for individual dimensions of the CSR scoring and overall score were calculated using SPSS version 22 .Participants were scored on nine practice dimensions as they were being interviewed. The mean total CSR score was 35.62 out of 63 (56.53%). This indicated that the participants had a low to moderate level of knowledge of the literature searches. When the individual dimensions were explored, it was found that the participants scored better on basic evidence search skills (mean scores > 4), but when it came to advanced skills such as appraising evidence or grading quality of evidence, etc., they had lower scores (mean scores < 4) See .Seven main themes were identified based on the analysis of the qualitative interviews. The use of the PICO format came up during the interviews. Two out of the thirty-seven participants used the PICO format as a guideline to formulate their research questions.“I guess what we learned in school was PICO, population, intervention, comparison or outcome so, for both of those, I think I did more population so low back pain.”(OT 643).This qualitative finding is backed by the moderate CSR score of 4/7 with a range of 2 to 7 for the dimension of “able to formulate a research question”.“I try to use the PICO format sometimes……” (PT 745).While exploring the low utilization of the PICO format to formulate research questions, participants said that not all searches are based on interventions, so they had to modify their search terms. This is what another participant mentioned in this regard; n = 13 (35.1%)] was the most commonly used followed byCINAHL [n = 9 (24.3%)], MEDLINE [n = 8 (21.6%)], Cochrane [n = 8 (21.6%)], Google Scholar [n = 6 (16.2%)], and PAIN+ [n = 6 (16.2%)]. The others that were used are PsychInfo [n = 5 (13.5%)], OVID [n = 3 (8.1%)], and EMBASE [n = 2 (5.4%)]. The following extracts describe this finding.During the interviews, the participants reported searching for and accessing evidence in various electronic databases. PubMed [“I would usually, where I would usually go sort of these two either go to PubMed or Google Scholar.”(OT 632).“I use the CINAHL database, OVID, Google Scholar, trying to find some journals that lend credibility.”(OT 639).Rehab participants tend to search databases specific to their profession, the American Physical Therapy Association (APTA), Rehab+, the Canadian Journal of Occupational Therapy, and the American Journal of Occupational Therapy, while RNs and psychologists were interested in Psych Info, the clinical information access portal, and the Journal of the international association for the Study of Pain.“For me, I always go to the APTA, … I might look in journals, I read abstracts to articles, maybe pain medication articles, the Journal of Pain and Orthopedic.”(PT 651).Clinicians use a variety of search engines but were able to tap into the most common sources of evidence. This qualitative finding is backed by the fact that the clinicians scored high (Mean 5.7/7 (Range 1–7)) on the CSR score for the dimension “Could identify the source of research evidence to answer this question”.Participants described a variety of search strategies that they used to search the electronic databases. When using search terms, participants in our study tend to use different forms of the same word to be more comprehensive in their search. “…if there were 2 ways of saying something, sometimes I would use ‘OR’, both back pain or chronic back pain or back pain in search engines.”(OT 643).Only a minority of participants reported the use of Boolean operators to connect search terms came up during the interviews. Three out of the thirty-seven participants used them for their searches. The three participants who used these Boolean operators were able to describe how they would use them in a typical search. They indicated that they use plus sign “+” to connect search terms.“Like what I try and do, for example, the first one, I would search diabetes + insulin + chronic pain and that’s how I do that one.”(OT 639).During the interview the reasons for using “AND” during the search which is for finding synonyms or for increasing the specificity of the search also came up. “I would probably put chronic pain AND whiplash AND female AND Interventions as well. I know it’s a really long search but I would probably add interventions afterwards.”(OT 649).The above qualitative findings of a relatively small number of participants using Boolean operators to enhance their search and general ability to use different forms of the same word is reflected in the moderate CSR score (Mean 4.2/7 (Range 1–7)) for the dimension of “Could identify how to find research evidence that would answer this question”.The participants in our study used different methods to narrow down or refine the search. Some use title scan, abstract scan, and full-text download. “Usually I would scan the titles… if the title looks like something that would actually be relevant, I would read the abstract. If the abstract looks good I would actually download the article… then actually reading the articles.”(OT 643).“Probably eliminate some by the titles and then I would look at when you read the article they have like an abstract.”(OT 643).Some limited the search by the date of publication, by looking for recent articles.“Usually I would scan… the year of publication just because if it’s super outdated, I probably wouldn’t look at it.”(OT 643).Another way was they looked into relevant articles section of the databases or/and the articles that cited the current paper.“……can do related articles or cited by articles so you can ballpark a whole new list of 30 articles that you get more recent ones.”(OT 643).Some just read the article that came at the top of the list.“Logistically I would look at the ones that came up first, I would open them, I guess I might be pulled by certain titles, I would.”(OT 643).A theme that came up during the interviews was barriers and facilitators for literature searches. Access, time, and resources were noted as major barriers, while institutional access was a major facilitator. The barriers and facilitators are summed up in All these barriers and facilitators lead to our next theme on the sources that clinicians use for clinical decision-making. These barriers not only lead to the next theme but also explain part of the reason why clinicians do what they do with the sources they seek to aid their clinical decision-making.For making clinical decisions, the participants in our study often looked up to their peers and were influenced by their knowledge of their peers within their field, and their professional expertise was valued.“…by talking to a physiotherapy colleague about that…So I didn’t recommend the back braces.”(OT 643).Some participants indicated that they give greater priority to clinical experience gained over the years dealing with various kinds of patients, in decision-making. “I was a registered nurse for 20 years and I’ve been a nurse practitioner since May, just knowing that they were contraindications. it’s basically from your experience…”(RN 750).“I have 25 years’ experience so here it comes; I give a set of exercises that have been effective for me and I use them. Have they been well researched, I doubt it…”(PT 653).“Well you know that’s probably just experience that I’ve learned over the years”(PT 673).Some participants relied on the entry-level training and stuck on to basic training and followed even after 20 years of experience.“ ……and it’s something that learned in school?”(RN 750).“… I learnt this in school when I did my undergrad.”(PT 653).Some participants also looked up actual evidence that would support their decisions.“Pretty much it’s evidence-based as far as the medications utilization in a particular patient group and it’s always tried to get informed by the evidence notes if it’s available.”(RN 677).One participant said that decisions are made both on experience and research and a little bit of both.“I’ve learned through colleagues, a little bit through research and upper management as well as too, and training as well as to how often they should be performing relaxation, how often they should be planning out their day and that kind of stuff, it’s been more on the job training I guess you could say.”(OT 649).The participants scored low on the three dimensions that explored their ability to extract results from the research article, interpret them, and apply them to their clinical question at hand. The dimensions are to articulate the general conclusion from relevant research (Mean 4.1/7 (Range 1–6)) the ability to articulate specifics of dosage or expected effects from relevant research (Mean 3.9/7 (Range 2–7)) and the ability to name contraindications or considerations derived from relevant research (Mean 3.6/7 (Range 1–7)).The low CSR scores for these dimensions are explained by the qualitative findings of most clinicians, looking on to peers, experience, and entry-level training to make clinical decisions rather than looking into the actual scientific evidence and interpreting them to answer clinical questions related to patient care.Most participants had limited knowledge of the types of research designs, levels of evidence, and how to apprise an article for their quality. Some participants were aware of the two types of research—quantitative and qualitative. “… there are various kinds of study designs, there’s quantitative … and then there’s qualitative.”(PT 673).Fewer participants were able to talk about the levels of evidence.“Yes, the National Guidelines for Acute Pain Management in Australia, there is a chapter on it, but I haven’t read it in many years, but it talks about level 1, level 2, level 3, level 4, and I think it goes up to 5; Level 5 is the more from experience by case studies, I think level 1 is randomized control trials, good research techniques.”(RN 733).When asked to define and describe a systematic review, only a few were able to do this.“…………it has been very high-quality research that’s been done on this and there has been good systematic reviews and meta-analyses and evidence-based guidelines.”(RN 754)The lack of advanced skills to understand the levels of evidence and the ability to appraise the quality of evidence in our participants was reflected in the low CSR score (Mean 2.4/7 (Range 1–7)) for the dimension of “Was able to identify and cite systematic reviews pertaining to this question” and (Mean 3.03/7 (Range 1–7)) for the dimension of “Was able to differentiate high-quality versus low-quality studies”. This study explored the retrospective recall of the experiences of clinicians using electronic databases to search for evidence related to pain. We used a mixed methods approach and found that the quantitative data backs up the qualitative data. The themes ranged from searching for evidence, refining the yield, barriers encountered during the search, and quality of studies searched. We found that clinicians performed well with their basic evidence search skills such as framing research questions, searching appropriate databases, using correct search strategies, etc. However, when it came to the appraisal of the literature and use of evidence in clinical decision making there were mixed responses.Formatting a well-built clinical question (foreground question) is the fundamental skill in an evidence-based search strategy, and these questions should be relevant to client problems and should be able to direct the search to get precise answers ,6,7. DesIn the current study we found that most of the clinicians used PubMed, Medline, Cinhal, and cochrane followed by Google Scholar. This was no surprise as this trend is evident in previous studies that have found PubMed and Google Scholar to be the most accessed electronic databases by health professionals ,30,31. Ip = 0.019). It is highly recommended that clinicians use electronic databases recommended for their discipline and at the same time use multiple electronic databases [Another trend that was observed was that clinicians in a particular profession tend to use electronic databases and online portals that are dedicated to their profession. For example, nurses and psychologists tend to use CINAHL and Psychinfo more than other databases as they contained more articles that were related to their field. This behavior is well documented in earlier studies. A recent study has reported that nurses commonly use MEDLINE, CINAHL, and Scopus to conduct literature searches . Clarke atabases .Boolean operators help to translate a clinical question to a specified format which the search engine can understand. This would help to filter off content that is irrelevant to the research question. However, in our study, only 2 out of the 37 participants used Boolean operators routinely in their searches. The reasons for this could be that many participants do not have the knowledge of these advanced literature search skills and these skills are not consistently taught at schools that train healthcare professionals. It may also be that clinicians may think that it is complicated and time-consuming to use these Boolean operators, which in reality would save their time by avoiding irrelevant articles. It has been previously reported that the skills required to acquire, appraise, and integrate knowledge into clinical practice are a major determinant of EBP ,37. Bettp < 0.005). This calls in for changes in policy that would enable increased access to electronic databases at workplaces. Additionally, another important barrier was lack of time which has become an endemic problem for research utilization. Previous research studies have identified this issue, and our qualitative finding adds credibility to the quantitative findings of those studies [The participants in our study also talked about various barriers and facilitators of online search for pain evidence. The most important barrier was access to the databases. Similar reports have emerged in the literature, and our findings confirm them ,38. Bost studies ,39. In our study, we found that the participants in our study scored less in the CSR (<4) for this area. Additionally, most of the participants in the current study were not able to identify the levels of evidence. As the clinical literature grows in a rapid pace, it becomes essential so that EBP becomes doable so as to improve patient care. It is important that clinicians would be able to differentiate between high quality and low quality evidence. Inability to identify the levels of evidence and classify articles of high and low methodological quality would impede the implementation of EBP in clinical practice resulting in patient care that is not current. The participants in the current study reported that they looked up to their peers to help with clinical decision-making. This has been previously reported and is more prevalent . The reaTo improve the implementation rates of EBP, it might be necessary to conduct refresher courses on literature searches for practicing clinicians and make it mandatory in students in professional schools for healthcare practice. A recent international, multi-disciplinary, cross-sectional study of pain knowledge and attitudes in nursing, midwifery, and allied health professions students found that there was little difference in pain knowledge and attitudes between all first- and final-year students other than physiotherapy . This inThe strengths of the current study are as follows: We used a mixed methods approach of integrating qualitative and quantitative methods. We used the quantitative data that was collected to back up the qualitative interview data. This enabled us to better explore the dimensions of evidence search that were studied. We used the chart simulated recall (CSR) technique to collect our quantitative data. This is valid and reliable for professionals such as physicians, nurses, and rehabilitation professionals to collect quantitative data in mixed methods studies and has added to the credibility of the data collected in this study. This study included participants from different geographical regions  thus giving a snapshot of how evidence-based practice is implemented in different parts of the globe. Interpretation and findings of the study have few limitations. The number of professional were not equal, so we did not try to compare the differences across professionals. Our study also had some limitations. We included a purposive sampling from an RCT in which not all professions were equally represented in this study. This may affect the generalizability of the study findings. Even though there were only two psychologists participating in the study, their transcripts were also analyzed and included since their behaviors are relatively less studied when compared with other professionals. Only nurses, physios, OTs, and psychologists were included in this study, which may affect the generalizability of these findings to other professions. In conclusion, using a mixed methods approach, we found that clinicians were performing well with their basic literature review skills, but when it came to advanced skills like using Boolean operators, critical appraisal, and finding levels of evidence they seem to require more training.