The aim of this study was to explore healthcare professionals, managers, and other key employees’ experiences of oilcloth sessions as a strategy when implementing new emergency departments in Denmark, based on their participations in these sessions. The study addresses the importance of securing alignment in implementation strategies. Too often, this does not get enough attention in the literature and in practice. In this study, alignment among components was achieved in an educational implementation strategy called oilcloth sessions.The study is based on participants’ observations of 13 oilcloth sessions and follow-up via 53 semi-structured interviews with the board of directors, managers, and key employees from the present emergency department and different specialty departments. Data were analysed deductively using Biggs and Tang’s model of didactic alignment.The analysis showed the complexity of challenges when using oilcloth sessions as a strategy when implementing a new emergency department described in terms of three phases and nine main themes (a–i): the preparation phase: (a) preparing individually and collectively, (b) objectives, (c) involving participants, (d) selecting cases; the execution phase: (e) using materials, (f) facilitating the sessions, (g) temporal structures; evaluation: (h) following up on the sessions, (i) adapting to the context.This study shows that it is important to ensure alignment among elements in implementation strategies. Thus, oilcloth sessions with high alignment are useful if the challenges experienced are to be overcome and the strategy will be experienced as a useful way to support the implementation of a new emergency department from the participants’ point of view. Bigg and Tang's didactic model is useful as an analytical framework to ensure alignment in implementation strategies in general. Emergency services in Denmark have changed over the past decade as a result of policy reforms by the Danish Health Authority . These rThe new EDs in Denmark represent an organizational innovation because considerable changes both in the organization’s practices and routines and in the workplace organization and professional relations are required. Innovation involving the implementation of new methods in an organization’s business practices, workplace and/or external relations  is imporThe challenges of organizational innovation in healthcare are substantial  due to tThe current study concerns a new organizational model of an ED that is being constructed in a university hospital in the Capital Region in Denmark. The new ED is expected to be built and operational by spring 2023. It involves setting up a single point of hospital entry for all emergency care patients . The newThe board of directors of the hospital in question has decided on several implementation strategies to facilitate the implementation of the new ED. One strategy involves so-called “oilcloth sessions” (in Danish “voksdug”), a strategy that has been used in a few studies of organizational innovations in Denmark in relation to the reorganization of hospitals  and physOilcloth sessions are a type of learning laboratory . Such laOilcloth sessions as an implementation strategy to facilitate the implementation of an organizational change such as a new ED have not been studied. Further, organizational and structural changes in EDs are a global issue . Thus, kThis study is based on a qualitative design, which is particularly suitable to explore deeper understandings of attitudes, experiences, motives, behaviours, and any discrepancies between these . Data inThe study was conducted in Denmark, where the public healthcare system is funded by taxpayers and provides free treatment for primary medical care, hospitals, and homecare services for all citizens. The hospital in the study has around 700 beds, 5000 employees, around 100,000 admissions a year and a catchment area of 517,000 citizens. The board of directors constitutes the top management of the hospital and is supported by 18 clinical departments with separate management teams in charge of clinical, financial, and organizational decisions within the department.2 in the hospital. All participants and the facilitator stood around a table to view the blueprint. Each oilcloth session lasted between 1.5 and 2 hours. During the sessions, the researcher, other members of the board of directors, and managers from non-clinical departments were seated on chairs along the walls and were allowed to participate as well. The oilcloth session study forms part of a larger implementation research programme (the FAM implementation programme) initiated in March 2019 and is expected to continue until 2023, when the new ED opens.The purpose of the oilcloth sessions was to train staff, key employees and managers in new patient pathways and introduce the new physical building design. A key employee is defined as an employee appointed by managers to play a central role in the implementation of a new ED in relation to their department. Oilcloth sessions are a social scientific methodology whereby healthcare managers, representatives of the board of directors, and key employees work together on a blueprint of the layout on A0 paper of the new ED combined with either LEGO figures or other types of plastic figures, generating knowledge, workplace learning and experiences in relation to the implementation of the new ED. The programme theory based on the stipulated plans for the sessions is shown in Table Oilcloth sessions were facilitated by two members of the board of directors. One facilitated the two first sessions and another facilitated the remaining 11 sessions. The facilitators were chosen due to their management positions and were therefore expected to have good negotiation, facilitation, and communication skills. In this study, facilitators are understood theoretically as individuals who facilitate the form of participants’ conversations and interactions (a process) rather than the content by making requests and guiding questions that the participants can agree upon , 33.The following participants took part in each oilcloth session and interviews: members of the board of directors; managers from the present ED; managers, health professionals, and key employees  from one or two other specialty departments. The managers were invited to participate by the board of directors and had the responsibility to invite key employees and health professionals from their department. Sometimes, the board of directors also invited managers from non-clinical departments. On average, 15 to 20 participants employed in the departments mentioned in Table N=64, including two members of the board of directors). Eleven individuals either did not answer or decline to participate due to heavy workload. Fifty-three semi-structured interviews were conducted due to considerable clinical heterogeneity  and covered eight themes contained in a semi-structured interview guide. The interview guide was developed by NTS and JWK and was pilot tested with a senior consultant employed at the management secretariat of the hospital. The interviews were conducted by JWK, and NTS wrote notes and asked follow-up questions. The pilot test led to minor revisions of the interview guide. All 53 interviews were recorded and transcribed verbatim by a research assistant. In total, 790 pages were transcribed. Of the 790 pages, one theme (experiences with oilcloth sessions as a method for implementing a new ED) covered 315 pages which were selected as data relevant for analysis in this study.The transcribed data material was read and re-read by JWK to get a sense of the whole dataset. Then, an inductive thematic analysis of the transcribed interview data was conducted . InterviIn this study several conceptual frameworks are used both in the analysis and in the discussion. In the analysis, Biggs and Tang’s  didacticAccording to Biggs and Tang , construThe interview data were analysed and presented in three phases in the form of preparation, conducting, and execution as well as several didactic elements (in parentheses). The emerging themes were as follows: (a) preparing individually and collectively (teaching method); (b) objectives (objectives); (c) involving participants (the participants’ prerequisites); (d) selecting clinical cases (content); (e) using materials (teaching method); (f) facilitating the sessions (teaching method); (g) temporal structures (teaching method); (h) following up on the sessions (teaching method); (i) adapting to the context . Furthermore, the themes were compared with findings from the ethnographic field study to verify or contrast the findings. This was done by reading the field notes based on specific keywords or meaning content contained in the themes Table .Table 4TThe analysis showed that experiences of the health professionals, managers and other key employees with oilcloth sessions as an implementation strategy were based on an interplay of different actors, temporal structures, and a sensitivity to the context that can be described in terms of the three temporal sequences and nine main themes (a–i): preparation phase: (a) preparing individually and collectively, (b) objectives, (c) involving suitable participants, (d) selecting clinical cases; execution phase: (e) using materials, (f) facilitating the sessions, (g) temporal structures; evaluation: (h) following up on the sessions, (i) adapting to the context. The themes included 31 sub-themes illustrating the complexity of experience using oilcloth as an implementation strategy when implementing an organizational structure as complex as an ED Table . The resI think it's cool that [the chief physician] asked and invited me. I think he sent a PowerPoint presentation about how it [the oilcloth session] would be conducted and what the objectives were, so I could prepare myself […] .According to Biggs, quality learning takes time in preparation. Participants in this study highlighted preparation as a key element. Preparation took place on an individual level; some participants experienced it as appreciation to be selected by their managers to participate in the oilcloth sessions:Being asked to participate and receiving written material was appreciated, and it enabled the participants to prepare for the oilcloth sessions . Some participants mentioned that they did not receive the material from their managers before participating in the session.I think the oilcloth sessions require that the managers are aligned. It was not my experience at the beginning of the oilcloth sessions. We participated in some oilcloth sessions where we actually discussed things that we should have agreed on [beforehand] at management level (a representative from other departments).Preparation also affected a collective level, including participants’ compliance with agreements established before the oilcloth sessions . Agreements could be about the overall objectives or direction of the future ED. However, several of the participants did not experience that the managers were aligned before the sessions. Alignment can be understood as a collective way of thinking, understanding, and interpreting the rules and direction of the new ED. One participant expressed this:After conducting the first two sessions, this topic was discussed by some of the managers. They agreed that they should appear as role models for their employees and not create unnecessary worries among the employees by not appearing aligned. Against this background, the board of directors introduced pre-meetings with managers from the ED and/or specialty departments. These pre-meetings became a learning space for the managers, with the purpose of creating “collective meaning and thinking”  that couAnd then, of course, there will be time wasted on debating some clinical things, which may be fundamentally unimportant in relation to the organizational context .The objective of the oilcloth sessions seemed to be unclear to many of the participants, causing some confusion among them. The field study showed that several different objectives and outcomes were presented in the sessions. A stated objective was: “We are going to focus on the organizational and not the clinical work” . In this context, the “organizational” was expressed as new ways of working together for all health professionals in the new ED, including new ways of organizing the work of the specialist physicians. Another stated objective was: “We should work with the current patient pathways and focus on what bumps we can improve clinically”  and yet another objective that was stated was: “We must work with future optimized patient pathways” . According to Biggs and Tang, objectives exist to provide a focused mindset for the participants. When the objectives were stated in a continuum between the professional and organizational and in relation to the current or future patient pathways, the consequence was an unfocused mindset among the participants:In our [surgical] specialty, we receive patients according to slightly different procedures than you do [referring to the managers from the existing ED]. Both physicians and nurses are physically located in the same room, so we jointly discuss the patient. It is characteristic of us, and I think we should continue with this organization in the new ED .Review of existing patient pathways at the oilcloth session triggered a positive “aha experience” for several of the participants because it clarified how other specialties handled the patient pathways. This internal identification process must be recognized by outsiders for an objectified collective identity to emerge. As one participant explained:Such a narrative of the surgical practice was a source of motivation among the surgical participants to convince the participants and managers from the ED that tasks should be performed in line with the surgical identity and practice when working with existing patient pathways. After this statement in the session, the dialogue focused on physical spaces and the possibilities and limitations the participants considered for a future collaboration between nurses and physicians. In this way, the participants came to know each other, themselves, and the world while jointly enacting collective practices mediated by cultural tools (language as a symbolic system), building on efforts of each other and on achievements of previous generations (the “we”), and cumulatively expanding on and amplifying these practices through the oilcloth sessions.We spent so much time discussing whether it was the organizational or the professional clinical that was at the centre. It was a waste of time .Several of the participating managers disagreed that the objectives were to work with future clinical patient pathways or the organizational structure, which gave rise to frustrations among some of the key employees. These different foci of the objectives were conveyed in discussions that either became very detailed regarding the clinical practice: “Should we take blood samples for both electrolyte counts and C-reactive proteins”  or regarding the organizational “In the new ED, it will be the flow master who ensures the flow on both floors” . The different foci caused a lot of discussions in the first sessions:I think it is impressive how many people you can gather… for so little. […] What did we learn from it? I would like to see a sign hanging on the door stating how much money we have spent. Some, maybe the managers, probably learn something but we clinicians, we did not learn anything .The consequence of the perceived lack of clarity of the objectives of the oilcloth sessions was that the participants perceived them as fictitious and left the sessions with the experience of creating a them/us situation that they perceived as group boundaries, giving the feeling of exclusion and that no result was generated from the sessions; instead, they were regarded as a waste of time and resources:I think the challenge at the beginning of the oilcloth sessions was ‘what were the objectives exactly?’ […]. I do not think there was anyone who knew, either among the board of directors or from either of the participating groups. Therefore, I think we quickly grabbed a case we knew and worked with that. Today, I am convinced that we must develop new patient pathways, and that this will contribute with an increased focus for the participants (a representative from the emergency department).Even so, time became a key factor in consolidating a common objective with the oilcloth sessions. Over time, the sessions became more and more standardized and objectives “solidified” and became clearer and more distinct to the participants, which was perceived positively. One participant said:The clarification of the objectives created focus for the participants over time, which was evaluated as positive and that the oilcloth sessions were a useful strategy in relation to the implementation of a new ED.As the objectives of the oilcloth session were unclear to us, the appropriate or right participants were not invited .When designing implementation processes through oilcloth sessions, the question of who should participate is extremely relevant . The parSeveral physicians expect to be invited to the oilcloth sessions because they are the ones who take care of the patients .If the objective was to work with the organizational aspect of implementing the new ED, some managers considered clinical development nurses and physicians responsible for education as the right target group to be involved. If the objectives were to work with the clinical aspects in the form of present or future patient pathways, clinicians were assessed as the right target group. One manager expressed:The lack of clinicians was perceived as a didactic error in the oilcloth sessions. As one participant explained: “Clinicians who handle the clinical work should have been represented to give realism to the oilcloth sessions” (a representative from the emergency department). The lack of realism was mentioned by several of the participants. “Constructive inputs require that you have been in an ED before and know how it works” .It was clear that the trainee physicians voiced their concerns from their position close to the clinic, which are different from the concerns of, for example, the top managers.At a later time point in the oilcloth sessions, trainee physicians were invited to counteract this issue, which was evaluated positively by many of the participants. One representative from the medical specialty stated:The patient pathways start with the patient being picked up by the ambulance, therefore they should have participated in the oilcloth sessions (a representative member of the emergency department).In addition, the question was raised whether there were other target groups that should have been involved, such as porters or the pre-hospital emergency services. As one participant expressed:However, a member of the board of directors stated the importance of being in control in the internal organization before inviting external partners, a statement that was related to the objectives of the sessions.Some participants  assessed that, in the future, they would only have sparse contact with the new ED and therefore they felt out of place at the oilcloth sessions. During the interviews, it became clear that several of the management had selected key employees to participate because they were perceived as good role models in their departments and therefore were expected to speak positively about the future ED. Other arguments were that they were good advocates for the new ED, had extensive professional knowledge or had a good strategic mindset. This was deemed necessary by managers to avoid unnecessary concerns and barriers in relation to the reorganization and implementation of the new ED.Clinical cases referring to existing patient pathways was mentioned by the participants as central for learning. A case was a patient pathway retrieved from a medical record. The uses of these cases gave the participants insight into how the patient was handled by other professions or elsewhere in the organization and became a way of avoiding fragmentation between specialties and a way for the participants to learn across social and cultural practices.As we say, it is very easy to receive the patients if we have physicians available […] But what do we do when we [the physicians] are not available, or when there are three very ill patients at once? I think it would be good to go a little further with these types of cases. As realistic cases as possible.Before the oilcloth session took place, the details of two cases were distributed to the participants. The practicalities of selecting and distributing the cases from the managers to the selected participants was experienced as working well. The selection of the cases was central to the participants. The cases should not be too simple; they should be examples of worst cases because the participants experienced these as resource demanding both physically and mentally in their daily practice. A representative from the surgery specialty stated:We felt that it was very medically orientated, and we felt a little excluded; the cases were very simplified and hierarchical.The cases included were often considered too medical by participants from professions other than physicians, because the cases focused on treatment only. Consequently, some of these participants perceived oilcloth sessions as constructed and controlled by the physicians with a medical background. One of the participants explained: “… and the details are copied from the medical record and that was very much the case” . The fact that the details were copied from the medical record and not from the nursing record led to other professions felt excluded and the cases were perceived as too simplistic by only focusing on the medical professions. A representative from the medical specialty stated:Considering these medical cases as cultural tools and signs, they suggest that the oilcloth sessions were experienced as a method that supported hierarchies whereby physicians and treatment became the dominant focus in contrast to nursing care or therapeutic treatment .And even though it seemed a little … here we are playing with small figures it was … I think it was very rewarding (a representative from other departments).Two central artefacts were highlighted by several of the participants; the small plastic figures (named “LEGO men” by the participants) and the whiteboard introduced during the oilcloth sessions. Although on the one hand several of the participants found them a bit comical, the figures were found useful:The figures were compared with LEGO men because several of the participants had previous experience working with improvement processes in the form of LEAN , where LIt is instructive for me to hear and see why the other medical specialties think it is a trainee physician they believe should receive the patient [shown by moving the figure on the oilcloth]. It tells me something about their collective thinking and organization within the specialty .The figures were designed differently depending on which physicians the figures were to symbolize (the full figure was an experienced physician and trainee physicians were symbolized by a narrow figure). These different depictions triggered many comments, laughter and created a positive climate among the participants. A participant stated:In this way, the use of the figures became a sign of collective ways of thinking and acting, depending on which figure the participants jointly agreed should be used.Something I think is good about the oilcloth sessions is that when we encounter a challenge, we park it [on the whiteboard] and then we work with it later, instead of discussing loudly in the room (a representative from the emergency department).Another mediating tool that was evaluated positively was a whiteboard that was introduced along the way. As mentioned earlier, several of the participants did not consider it appropriate for managers to have a discussion (sometimes in a sharp tone) in front of their selected key employees, because this could create fear and concern among employees, which could ultimately complicate the implementation of the new ED. By writing down and placing disagreements and ambiguities on the board, the board functioned as a mediating tool by collating different understandings of different points of view but also as a sign of differences in cultural practices within different specialties and professional identities. A participant stated:Then one of the representatives from the board of directors sat and wrote post-it notes. Why? I have no idea. Any other participant or consultant could have done so .Facilitation was an integral part of the oilcloth sessions and it involved many of the participants. The oilcloth sessions were facilitated by a deputy managing director and the representation of managers and the CEO participating in the room. The presence of members of the board of directors was evaluated differently. Some participants wondered about the role that, for example, one of the representatives from the board of directors took on:It is an important signal and of value to everyone in the room that the members of the board of directors prioritize participating in the oilcloth sessions. The new ED is thereby made an important and prioritized change in the organization.Others found it positive that the members of the board of directors were represented, because it signalled the importance of conducting and participating in oilcloth sessions. One representative from the surgery specialty expressed:I always considered what I said because the managers were in the room and I did not want to appear ignorant .But the participation and facilitation of the oilcloth sessions by the board of directors was also questioned with reference to hierarchies and power: “If you want to hear the truth from the managers, you need impartial facilitators” . Through the interviews with the managers and key employees, it became clear that members of the board of directors were assigned a dominant position, which was assessed as hampering communication and the process of the oilcloth sessions, especially among participants who considered themselves less significant and with less influence than, for example, many of the managers. A participant mentioned:Although the managers had invited relevant key employees and health professionals from their department, expectations of hierarchies were brought into the oilcloth sessions and became a guiding and mediating force for some of the participants and affected how they participated and communicated during the sessions.It is a good opportunity to learn about the organization and find out what is going on in the medical specialties and with the specialists in relation to the forthcoming reorganization.Another consideration concerned differences in the professional identity of those who facilitated the oilcloth sessions. As mentioned earlier, many of the participants expressed that the oilcloth sessions focused too much on the medical profession. This was reinforced by the observation that the deputy managing director who facilitated the sessions was a physician and placed himself at the table close to the other physicians and top managers. Conversely, it was a strategic choice from the board of directors because this deputy managing director was newly appointed. A member of the board of directors expressed:You can feel that several of the participants had participated many times. Newcomers could not keep up at all when introduced .Participants who joined some of the last oilcloth sessions for the first time expressed that facilitation was lacking. They felt that the introduction to the sessions went too quickly, was too superficial and not empathic. As one participant said:Several new participants pointed out that they lost track along the way due to a lack of management and facilitation, thereby highlighting the importance of the facilitator’s role, competencies, and experiences. Many participants said that a visit to the new physical buildings before attending the oilcloth sessions had given them a different insight into the new ED and an opportunity to better keep up in the sessions.Many of the participants had opinions about time and timing. Patterns of time can be viewed either as an objective entity (the metaphoric clock), which is mechanical, linear, and quantitative , or as aIn theory, it is probably very smart, but I think we are a little too early. Because we do not have proper agreements in place about what the staff should do where and how .Sufficient time for the sessions was discussed in the form of the duration of the oilcloth sessions. Each session took 1.5 to 2 hours and most specialties participated in the sessions one or two times. Only the managers and the key employees from the existing ED participated in all 13 oilcloth sessions, because they were to be the top managers in the new ED. Most participants rated the duration and the period between the sessions as appropriate. This contrasted with others who found the timing for the oilcloth sessions inappropriate due to delayed deadlines for moving into the new ED. One participant said:For some participants, the timing of the oilcloth sessions created tension between the need for better temporal coordination and the organizational circumstances. Several of the issues discussed in the oilcloth sessions were already stated in written documents and agreed by the board of directors and the managers from the ED but were not being followed strictly by the managers of the specialty departments and therefore were subject to ongoing debate.But it is because they do not think that the new ED is important yet and others are generally opposed to the reorganization that is happening. It became clear at the sessions (a representative from the other department).Timing of the oilcloth sessions was often mentioned by the participants. The timing was deemed inappropriate because within some specialties and professions, there was opposition to the establishment of the new ED. This resistance was expressed during the oilcloth sessions. A participant mentioned:Why now? [with reference to conducting the oilcloth sessions]. There is plenty a time until we are going to move and there are other tasks that we have to take care of that are more important. It becomes a stress factor .Other participants experienced that the oilcloth sessions mentally burdened them in their daily practice as one participant said:For us it is not just about participating an oilcloth session. It is a sign of the major reorganization we are about to undertake, the closure of a section and the merging of our staff .Several of the participants expressed that the oilcloth sessions were a burden, but this experience probably related to the contextual situation they found themselves in . One participant expressed:Yes, it is mentally time-consuming, but it also gives me the opportunity to think further, plan what the next step should be, depending on what we experienced at the last oilcloth sessions .Others approached the oilcloth sessions with a more positive attitude and saw them as an opportunity to work with the reorganization and implementation of the new ED based on the knowledge and experience achieved during the sessions regarding future collaboration with other specialties. One participant explained:Thus, temporalities such as timing and time both as an objective entity and as a subjective conceptualization played a central role in the participants’ experiences of securing alignment in the oilcloth sessions.I think it is a gesture from the management to invite us, to involve us. I think this is a strong signal to send to us in the other medical specialties (a representative from the other department).According to Biggs and Tang, the connection between in-class and out-of-class is important to ensure optimal learning. After the oilcloth sessions ended, most of the participants stated that they lacked a follow-up plan. Some managers had been given tasks to continue with on the future reorganization, but most of the participants had no idea what was going to happen after the sessions. They did not know if they should participate in more sessions, if there was an overall announcement or feedback from the oilcloth sessions or if there was something they had to follow up on. One representative from the other another department expressed: “I also do not know what the plan is after the oilcloth sessions” Several participants initially acknowledged the invitation from the board of directors to participate in the oilcloth sessions and perceived it as an opportunity for involvement. A key employee said:I am not sure what this circus was. Did they [the board of directors] really want our ideas and feedback or was it just a superficial action, now that we do not hear anything more about what is going to happen; so they [the board of directors] could say that we were involved? The question is whether there is control of the implementation of the new ED? ” .The lack of a plan for the next steps in relation to the implementation plan created doubts about the board’s actual intention and willingness to involve the specialties:Yes, it can be characterized as a somewhat random activity we have participated in. I do not know what significance it has for the future implementation of the new ED (a representative from the other department).The lack of feedback and a follow-up plan created distrust about the agenda and whether there was control over the implementation of the new ED. The oilcloth sessions were perceived as a detached and sporadic strategy that ultimately created uncertainty about the future implementation of the new ED:Oilcloth sessions can be experienced not only as a game but also as a strategy for implementing the future, including collaboration and organization with other medical specialties (a representative from the emergency department).The participants’ general evaluation of the oilcloth sessions was linked to the historical and situational context to which the individual specialties and participants relate. Contextual issues in the form of historical practice emerged when asking for a general evaluation of the oilcloth sessions as a strategy for implementation of a new ED. As one representative from the surgery specialty explained: “Oilcloth sessions were taken seriously due to ownership of the specialized patients, who are on loan in the new ED.” This statement was an example of a historically manifest specialized “silo thinking” that the political objectives of the establishment of new EDs were meant to overcome. Other participants experienced the oilcloth sessions as a means to an end, namely to ensure that specialty patients were offered the most efficient and quality-assured specialist-related patient pathways when they were admitted to the new ED and before they were either discharged or transferred to the specialty departments. A key employee stated:. This statement needs to be viewed in light of the fact that the participant came from a specialty department that was to have only a few beds in the new ED. Several of the participants from this department shared their experience:There was not much room for being heard. It seemed like an agenda had been set before we got to the oilcloth sessions, an agenda that left no room for discussion .Other participants evaluated the oilcloth sessions in relation to the situational context as: “The oilcloth sessions were assessed as a waste of money and a waste of public funds in proportion to the results of the sessions” One of the specialty departments had to close their ED and merge with the new ED. In connection with this, the use of oilcloth sessions was compared with Lars von Trier's movie film “Dogville”. The comparison could be interpreted as arriving at oilcloth sessions [the new ED] and being granted asylum [their own emergency department had to closed down] in return for work [in the future the specialists must be on call in the new ED]. The participants’ experiences of the usefulness of the oilcloth sessions were thus shaped by the “fate” they thought their department would have in the new ED. It became clear in an interview with one deputy manager who stated:” we thought we knew of all the challenges”, that these historical and contextual thoughts must be learned by the managers and the facilitator to make it possible to act on the participants’ experiences in relation to oilcloth sessions as an implementation strategy.The aim of this study was to explore challenges with oilcloth sessions as an implementation strategy based on the experiences of healthcare professionals, managers, and other key employees who participated in the sessions. Through the perspectives of Biggs and Tang’s didactic model , nine thApplying Biggs and Tang model , the manAn important challenge in the preparation phase was the objectives, which were stated in a continuum between the professional and organizational and in relation to the current or future patient pathways. The consequence was frustration and an experience of wasted time and effort as well as an unfocused mindset among the participants. Ordóñez and colleagues  argued tIn this study, the participants’ frustrations were related to conflicting objectives caused by participants being prone to concentrate on only one objective, e.g. the clinical or the organizational. Objectives that are easier to achieve are often given more attention , and thiAnother important consequence of the conflicting objectives related to the selection of cases and participants. When the focus was on existing patient pathways that was experienced positively by clinicians, e.g. trainee physicians. Thereby alignment was achieved between the objectives, target group and the cases. In these examples, the participants learned across social and cultural practices . The conConversely, cases with a focus on future patient pathways, and thereby the organizational issues, created many contradictions and tensions for some of the participants and managers. One reason was that some of the organizational issues relating to the new ED were still being negotiated with the board of directors, e.g. the number of specialists who were to be present in the new ED. This meant that the participants constantly negotiated their mutual working relationship, which often proved to be ambiguous and frustrating and meaningless to the participants. Due to the organizational ambiguities and based on the way the hospital was formally organized, dialogues arose between the ED and the specialty departments. Nugus  referredThe difficulties became evident through positions of power that were expressed explicitly through a narrative of “us and them”, which predominantly related to an interdepartmental hierarchy of specialized departments dealing with particular body organs, versus emergency medicine, which is a generalized specialty . A positThe study showed that the participants experienced the learning objective of the oilcloth sessions as performance goals that led to competition between the specialties and between different professions. Scholars have previously pointed out that learning objectives should be used in complex situations rather than performance goals, because they support collaboration and learning . The boaIn the execution phase, the use of LEGO figures functioned as mediating tools and signs that supported changes in the external environment by making future tasks visible and distributed among relevant managers and in the communication between the managers . These tImplementation facilitation (IF), an important and often discussed implementation strategy , 59, hasThe choice of two of the board of directors as facilitators was a strategic management decision, and the oilcloth session was thus viewed as a good opportunity for them to learn about the organization. The literature recommends that a facilitator is selected based on the person’s facilitation skills , 62, 64.The position of the deputy managing director created other barriers for some of the participants because they believed his presence could hinder honesty and communication due to unequal power relations. Being a physician or a nurse had significance for the facilitation due to different professional identities and thereby different foci. On the one hand, this became a barrier to motivation for participation for some participants with a different professional background. For other participants, the presence of a physician as facilitator created credibility and became a sign of the importance of these oilcloth sessions as a method to support the implementation of a new ED. As facilitation of implementation processes is complex, it is easy for facilitators to become overwhelmed, and it is not only recommended but a prerequisite that facilitators have the right skills or seek training, mentoring or consultation before entering implementation processes. Scholars have been concerned about defining good facilitation skills , 63, 64,The connection between in-class and out-of-class is a facilitator for ensuring alignment . Lack ofConsideration of alignment is also highlighted as important in implementation research and especially within healthcare organizations that are characterized by multiple objectives and power relations that challenge the implementation . Alignme. Both historical and situational contextual issues were raised by the participants, and these were shaped by the fate they believed their department would have in the new ED. This notion of future fate forms part of cultural models [Finally, the participants’ evaluation of the oilcloth sessions was linked to contextual issues that extended beyond the common definitions of context in the IS literature understood as the environment in which a concrete change is to take place –72. Bothl models . As an eEducational strategies are widely used to initiate and implement change in healthcare . In thisAnother strength of the study is the use of two learning theories: Biggs and Tang  and CHATFinally, a strength of the study is the combination of participant observations and interviews. This has made it possible not only to talk to the participants about their experiences with participating in oilcloth sessions but also to learn directly from the participants by attending the sessions. This engagement has the advantage of yielding highly detailed and in-depth data, and it has enabled relationships to be built with participants and access to insider perspectives , 80. BeiOne limitation that could be discussed is the position of the researchers. The insights that researchers can get from the participants’ learning processes at the oilcloth sessions depend on their position and access to the field . Formal Another limitation of the study was that we did not succeed in clarifying to all participants that the project was not initiated by the board of directors. This oversight may have affected the data collection; some participants became reluctant with their statements. Only a select group of departments participated. For instance, the department of physiotherapy and occupational therapy was not invited, a function that will be central in a new ED. Their presence might have provided additional perspectives to assess the full potential of future patient pathways and oilcloth sessions as an implementation strategy. Another limitation is that our study is the first to examine oilcloth sessions as an implementation strategy and the first to use Biggs and Tang's theoretical model for alignment. This makes it impossible to compare our results with other similar studies, which may decrease the reliability of the results. Despite this, our results highlight the relevance of securing alignment between elements in implementation strategies, an aspect that seems somewhat overlooked in the literature, which usually focuses on the effectiveness of strategies , 74.We believe that the transferability of the study findings is quite high. This is due to use of ‘thick description’  that proThis study show that it is important to ensure alignment between elements in implementation strategies, i.e. conducting oilcloth sessions with high alignment, if the challenges that are experienced are to be overcome and the strategy experienced as useful in supporting the implementation of a new ED from the participants’ point of view.If oilcloth sessions are to be used as an implementation strategy, it is recommended that the planning of these sessions focuses on alignment between clear objectives, suitable participants, and cases. If managers are to participate, it would be relevant to schedule pre-meetings to ensure alignment among the managers and to gain insight into contextual factors, including the situation they experience themselves to be in. We would also recommend considerations of whether a physical visit to new buildings or locations can be a help to participants who have not previously participated in oilcloth sessions. Communication of a clear plan about the purpose of oilcloth sessions as an implementation strategy before and after the sessions is essential for experiences of alignment. We believe the facilitator role should be discussed and selected based on facilitator skills. The greater the complexity, hierarchies and power involved in the implementation process, the more significant it is to select a trained facilitator. Bigg and Tang's didactic model is useful as an analytical framework when alignment is to be ensured in implementation strategies in general.


The liquid phase exfoliation (LPE) of graphite has allowed to produce graphene materials on a large scale and at a reasonable cost. By this method, stable dispersions, inks and liquid suspensions containing atomic-thick graphene flakes with tailored concentrations can be produced, opening up applications in a wide range of cutting-edge technologies such as functional coatings, printed and flexible electronics, and composites. However, currently established LPE techniques raise several health and environmental risks, since unsafe and toxic solvents  are often regarded as the most effective liquid media for the process. Therefore, it appears necessary to unlock eco-friendly and sustainable methods for the production of graphene at an industrial scale. This review focuses on the latest developments in terms of green solvents for LPE production of graphene. We highlight the use of a new green solvent, Cyrene, and its performance when compared to conventional solvents. Within  MPa0.5) . Non-pol MPa0.5) . In gene MPa0.5) . Hernand MPa0.5) . The inion times . Successon times . Althougon times , severalon times  and the on times .e.g., safety equipment, fume-hoods, exhausts, etc.), with a direct impact on the production cost. In order to scale-up the process and approach an industrial production, the identification of environmentally safe solvents that do not raise health risks is thus imperative. These solvents should be efficient for the exfoliation process, while having a moderate cost. A low boiling point is also a desired feature. Such characteristics would at once minimize the ecological impact and lower the production complexity and cost of the production of graphene. Capello et al. proposed a framework for a comprehensive assessment of how “green” a solvent is (−1)  . However is (−1) .e.g., sodium dodecylbenzenesulfonate (® (−1). Surfactant-assisted exfoliation in aqueous media is one of the most suitable alternatives to achieve high-quality graphene at high concentrations (−1) (−1) , and/oronate (® ) useful trations . Green eons (−1) . In an aons (−1) . Coleman−1) (−1) . Dispers−1) (−1) . Neverth−1) (−1) , such as−1) (−1)  and wate−1) (−1) . HoweverD, δP and δH . These three parameters can be set as coordinates for a point in a three dimensional graph known as the Hansen space. The Hansen solubility space in P. Nonetheless, they have high boiling points and led to dispersions with low concentration.Therefore, there is a need for new green solvents which fulfill the aforementioned requirements. Salavagione et al. identified efficient solvents by computational methods. The authors applied criteria including polarity, surface tension, viscosity, toxicity and “greenness” to evaluate and shortlist a solvent set of more than 10,000 . Three bH and δP components). As a proof of that, a very low yield (2.4%) was reported  and 10 times lower defect density with respect to NMP , demonstrating the greatest affinity to graphite (as shown in As shown in 6H8O3) is a bio-based solvent derived  in two steps from cellulose via levoglucosenone (biomass)  and EC50  values of >2000 mg kg−1 and >100 mg L−1, respectively. Overall, Cyrene is biodegradable and not mutagenic. Although it has a rather high boiling point (227°C), its low flash point  makes it safe to handle.Cyrene  , a procebiomass) . It neit−1, with a very high yield (∼48%). These values are larger than those obtained by most conventional organic solvents, also requiring more complex LPE procedures . The authors produced highly concentrated dispersions (up to 3.70 g L−1) of few-layer graphene flakes (three to five layers) with mean lateral size of ∼200 nm  as a stabilizing agent to achieve even a higher concentrated ink (70 mg ml−1)   of multi−1) using inks produced with significantly different sonication times (8 h for Cyrene vs. 48 h for NMP). The electrical conductivity of dried and compressed graphene laminates from Cyrene ink (8 h sonication) was 7.13 × 104 S m−1. These results pave the way to low-cost, screen-printable graphene-based wearables for Internet of Things applications, such as healthcare and wellbeing monitoring (−1). They embedded such electrodes in a working prototype of a multi-touch screen with a high signal-to-noise ratio (14 dB). These results illustrate a potential pathway toward the integration of LPE-graphene in commercial flexible electronics . In particular, the device showed a high sensitivity towards ethanol  as exfoliation media. Among the possible options, Cyrene appears as the most promising green solvent for LPE techniques. The performance of Cyrene for the exfoliation of graphite was analyzed, also focusing on research literature reporting graphene-based devices prepared using this solvent. This mini-review sheds light on a sustainable solution processing methods for graphene, but the findings could be translated to other layered 2D materials, such as hBN, transition metal dichalcogenides and MXenes.


We evaluated utilization of emtricitabine/tenofovir disoproxil fumarate or tenofovir alafenamide  among PN after the approval of F/TAF for PrEP in the US.EMR and dispensing data from Trio Health HIV Research Network were used for this retrospective observational study. The study included HIV-negative PN ≥ 18 years with first dispense of daily oral PrEP (≥30-day supply) between 10/19-5/21 followed for ≥6 mo; individuals with hepatitis B or post-exposure prophylaxis were excluded. Prescription adherence, measured as proportion of days covered  and time to regimen discontinuation (no drug >3 mo) or switch  were compared between regimens. Characteristics associated with PDC and time to first regimen stop (switch/discontinuation) were evaluated using generalized linear regression and Cox proportional hazard models, respectively.Of 1330 PrEP starts, 86% (1144) were dispensed F/TAF vs 14% F/TDF (186). Baseline characteristics differed by regimen [Table 1]. While PDC was similar for both regimens, F/TAF had higher number of dispenses and mean days supplied vs F/TDF; mean days of follow-up were similar [Table 1]. F/TAF users had longer TRD ; median TRD was 3.9 mo for F/TDF and not reached for F/TAF [Figure 1]. A higher proportion of PN on F/TDF discontinued (46% vs 24% F/TAF) and switched (26% vs 2% F/TAF) their regimen (both p< .001).After accounting for gender, race, payer, age, high-risk behavior, F/TDF had a higher risk of discontinuation or switch (HR=4.9 CI 3.9-6.2); Black race was also associated with higher risk of discontinuation or switch [Table 2]. Results were similar when considering only discontinuation (censoring at time of switch or loss to follow up). Older age was identified as the primary driver of PDC controlling for other factors [Table 2].In this study PN adults dispensed F/TAF had greater number of dispenses, mean days supplied, and were less likely to discontinue or switch from F/TAF compared to F/TDF. Older age was the primary driver of increased PDC when considering other factors, including demographics, insurance and regimen.Rick A. Elion, MD, Gilead Sciences: Advisor/Consultant|Trio Health: Employee|ViiV: Advisor/Consultant Joshua Gruber, PhD, Gilead Sciences: Employee Janna Radtchenko, MBA, Trio Health: Employee Megan Dunbar, PhD, Gilead Sciences: Employee Kenneth H. Mayer, MD, Gilead: Advisor/Consultant|Merck: Advisor/Consultant|ViiV: Advisor/Consultant Gregory Huhn, MD, MPHTM, Eli Lilly: Advisor/Consultant|Eli Lilly: Grant/Research Support|Gilead: Advisor/Consultant|Gilead: Grant/Research Support|Jannsen: Advisor/Consultant|Jannsen: Grant/Research Support|Merck: Advisor/Consultant|Viiv: Advisor/Consultant|Viiv: Grant/Research Support Karam Mounzer, MD, Epividian: Advisor/Consultant|Gilead Sciences: Advisor/Consultant|Gilead Sciences: Grant/Research Support|Janssen: Advisor/Consultant|Janssen: Grant/Research Support|Merck: Advisor/Consultant|Merck: Grant/Research Support|Trio Health: Advisor/Consultant|ViiV: Advisor/Consultant|ViiV: Grant/Research Support Anthony Mills, MD, Gilead Sciences: Advisor/Consultant|Gilead Sciences: Grant/Research Support|Merck: Advisor/Consultant|Merck: Grant/Research Support|ViiV: Advisor/Consultant|ViiV: Grant/Research Support.


Graphene is an allotrope of carbon consisting of a single layer of atoms arranged in a two-dimensional (2D) honeycomb lattice. Graphene’s unique properties of thinness and conductivity have led to global research into its applications as a semiconductor. With the ability to conduct electricity well at room temperature, graphene semiconductors could easily be implemented into the existing semiconductor technologies and, in some cases, successfully compete with the traditional ones, such as silicon. Research has already shown that graphene chips are much faster than existing ones made from silicon. The world’s smallest transistor was manufactured using graphene. Flexible, wearable electronics may take advantage of graphene’s mechanical properties, as well as its conductivity, to create bendable touch screens for phones and tablets, for example.On the other hand, the physics of graphene and graphene-based systems has inspired the application (and development) of many advanced theoretical methods, including those outside the scope of traditional condensed matter physics. Graphene thus turned into the favorite benchmark of theorists. Fundamental studies go hand in hand with the applied ones and, in some cases, the former even opened doors to possible applications.Graphene has already led to substantial progress in the development of the current electronic systems due to its unique electronic and thermal properties, including its high conductivity, quantum Hall effect, Dirac fermions, high Seebeck coefficient and thermoelectric effects. It paves the way for advanced biomedical engineering, reliable human therapy, and environmental protection. This suggests substantial improvements in current electronic technologies and applications in healthcare systems.This Special Issue of Nanomaterials covers recent studies, both theoretical and experimental, that advance our understanding of graphene and may be relevant to graphene electronics. With the growing number of flexible electronics applications, environmentally friendly ways of mass-producing graphene electronics are required. Kralj and coworkers  present Field-effect transistors have attracted significant attention in chemical sensing and clinical diagnosis, due to their high sensitivity and label-free operation. Huang and coworkers  present The study of electronic transport in the lowest Landau level of disordered graphene sheets placed in a homogeneous perpendicular magnetic field, a long-standing and cumbersome problem which defied a conclusive solution for several years, is presented in the paper by Sinner and Tkachov .The paper by Berman et al.  containsThe electrical properties of polycrystalline graphene grown by chemical vapor deposition are determined by grain-related parameters, such as average grain size, single-crystalline grain sheet resistance, and grain boundary resistivity. Park et al.  have obsElectric devices have evolved to become smaller, more multifunctional, and increasingly integrated. When the total volume of a device is reduced, insufficient heat dissipation may result in device failure. A microfluidic channel with a graphene solution may replace solid conductors for simultaneously supplying energy and dissipating heat in a light emitting diode (LED). Chung et al.  designedSilkin and coworkers  present The tunneling of electrons and holes in quantum structures plays a crucial role in studying the transport properties of materials and the related devices. A new two-dimensional Dirac material, 8-Pmmn borophene, hosts tilted Dirac cone and chiral, and anisotropic massless Dirac fermions. Kong et al. [The process of formation of carbon nanoscrolls with non-uniform curvatures is worthy of a detailed investigation. Lin et al.  present In the paper by Krasovskii , angle-rIn the paper by Do  and cowoIn summary, this Special Issue presents several examples of the latest advancements on graphene science. We hope the readers will enjoy these articles and find them useful for their research.


The health-promoting school (HPS) approach was developed by the World Health Organization to create health promotion changes in the whole school system. Implementing the approach can be challenging for schools because schools are dynamic organizations with each a unique context. Many countries worldwide have a health promotion system in place in which healthy school (HS) advisors support schools in the process of implementing the HPS approach. Even though these HS advisors can take on various roles to provide support in an adaptive and context-oriented manner, these roles have not yet been described. The current study aims to identify and describe the key roles of the HS advisor when supporting schools during the dynamic process of implementing the HPS approach.The study was part of a project in which a capacity-building module was developed for and with HS advisors in the Netherlands. In the current study, a co-creation process enabled by participatory research was used in which researchers, HS advisors, national representatives, and coordinators of the Dutch HS program participated. Co-creation processes took place between October 2020 and November 2021 and consisted of four phases: (1) a narrative review of the literature, (2) interviews, (3) focus groups, and (4) a final check.Five roles were identified. The role of “navigator” as a more central one and four other roles: “linking pin,” “expert in the field,” “critical friend,” and “ambassador of the HPS approach.” The  description of the five roles was recognizable for the HS advisors that participated in the study, and they indicated that it provided a comprehensive overview of the work of an HS advisor in the Netherlands.The roles can provide guidance to all Dutch HS advisors and the regional public health organizations that employ them on what is needed to provide sufficient and context-oriented support to schools. These roles can inspire and guide people from other countries to adapt the roles to their own national context. Such an advisor has previously been described by Boot et al. as a professional that can be seen as an important change agent who convinces the school of the benefits of working on HP and who guides the process of change , 10. ManWhat are the key roles of HS advisors when supporting schools in the implementation process of the HPS approach? This study will focus on the Dutch context because a translated version of the HPS approach already runs for several years and also includes the support of an HS advisor.Several studies have described various tasks of HS advisors in their support to schools, such as being a contact person who maintains links between a school and local HP partners or an advisor with knowledge on health promotion interventions , 12. As The implementation of the HPS approach in the Netherlands finds its origin in a project called SchoolBeat (“SchoolSlag”) . Since SA participatory research approach was used in the current study by focusing on a process of sequential reflection and action, carried out together with HS advisors . The stuTwo principal researchers (NB and BvD) facilitated the co-creation process. Participants who contributed to this study were HS advisors employed at different regional Public Health Services in the Netherlands, two national coordinators of the HS advisors, and a project team. This project team consisted of two national representatives of the HS program, as well as the two principal researchers and three other researchers in the field of school health promotion. All participants provided feedback on the base of their experience, knowledge, and expertise. The co-creation processes relevant to the current study took place from October 2020 to November 2021 and consisted of four main phases : (1) a nA narrative review of the scientific literature was performed to explore what was already known worldwide about the supporting role of an HS advisor in schools during the implementation process of the HPS approach. A literature search was conducted by NB from October 2020 to November 2020 with a focus on identifying tasks that HS advisors performed or are stimulated to perform. Both principal researchers (NB and BvD) had extensive knowledge regarding the existing literature on the implementation of the HPS approach. Based on this expertise, the first selection of articles was made in which the focus was on the implementation process of the HPS approach. Then, the snowballing method was used in which the reference list of the articles was checked to identify other possible relevant articles. Finally, all articles were screened to identify the ones that describe  tasks of HS advisors. When this was the case, the article was included. All tasks were extracted from the articles. The extracted list of tasks was grouped by NB, as overlap existed among them. Overarching these tasks, several key roles were identified. These key roles were described based on the tasks found in the articles. The identified roles and its description were first discussed with the other principal researcher (BvD). Following this, they were discussed with the two national coordinators of the HS advisors. Finally, the roles were discussed in the project team.Individual semi-structured interviews with Dutch HS advisors were conducted to gain insight into their experiences and perceptions regarding the support they provide to schools during the implementation process of the HS program. In addition, identified roles of an HS advisor and their descriptions were introduced to check and improve these roles. The interviews were held online from February 2021 to March 2021 by one of the two principal researchers. The participants of the interviews were recruited by using the existing network of the two researchers and in consultation with the involved representatives of the HS program. Two inclusion criteria were used: (1) no more than two HS advisors from the same regional public health services to ensure that the participants were as representative as possible for all the HS advisors in the Netherlands and (2) sufficient practical experience with supporting schools in the HS program. Therefore, HS advisors who had less than a year of experience were excluded. The number of included participants was based on data saturation. All participants were recruited via email with information about the aim of the study and the procedure and duration of the interview. All participants signed an informed consent form before the interview.How do you do your work in general? What are the most important tasks? What do you need to be able to support a school in this phase? To what extent do you adapt what you do to the specific situation of a school? The second part of the interview focused on the results of the narrative review. We asked whether the results of the narrative review, i.e., the identified roles and their descriptions, were recognizable, if they provided a complete overview of their work and their various roles in relation to the school, and if the HS advisor had any suggestions for improvements or adjustments. All interviews were audio-recorded, and a summary was written after each interview and sent to the participant for member checking. Based on these recordings and summaries, the two principal researchers applied a thematic analysis technique, beginning with open coding to identify the tasks and competencies mentioned by HS advisors. Then axial and selective coding was applied to group these findings into the roles identified in the narrative review. This was done to provide better insight into these roles and/or readjust them, and to develop additional roles if HS advisors had mentioned tasks that did not fit in these roles. The overall findings and insights were fed back and discussed with the project team.The interviews were based on an interview guide consisting of two parts. The first part focused on their HS advisory work in general to gain a deeper understanding of their daily tasks and roles. This was done in order to let the HS advisor speak freely about their roles and tasks without framing from the roles identified in the narrative review phase. Questions were divided into three implementation phases of the Dutch HS program, such as (1) (adoption and) preparation in which an HS advisor is getting acquainted with a school, (2) execution in which a school is actively working on HS activities supported by an HS advisor, and (3) continuation in which an HS advisor is working with a school for several years. For each phase, the following questions were asked: The insights from phase 2 were used to further improve the identified roles and their descriptions. The roles were then discussed in several focus groups with HS advisors to see whether the improvements were helpful and to investigate whether adjustments were needed. All focus groups followed a semi-structured setup with several topics to discuss based on the development of the training module for HS advisors. Group discussions among participating HS advisors were encouraged. Participants were recruited in April and May 2021 via the snowballing method. First, the HS advisors who participated in the interviews were asked to join the focus groups. Then, these HS advisors were asked whether they had colleagues or knew other HS advisors who would like to join. Participants could sign up if they were interested and decide per focus group session whether they would join that specific session. Financial compensation was offered for every hour they participated. Two online focus groups were held, the first in June 2021 and the second in September 2021. In order to keep the group size manageable for online sessions, in a way that everyone had the opportunity to fully contribute, both sessions were divided into two sub-sessions . Even though the content of these focus groups was mainly related to the development of the module, the roles were also part of the discussions during these sessions. In the June sessions (1a and 1b), the roles and their descriptions were presented and discussed in the group. The participants were hereby asked, similar to the interviews, whether the roles were recognizable, whether they provide a complete overview of their work and their various roles in relation to the school, and whether they had suggestions for improvements or adjustments. In the September sessions (2a and 2b), the participants were asked to apply for the roles by discussing a real-life situation in the daily work of an HS advisor (the case discussed was: no support among the school team members for the implementation of the HPS approach). Each sub-session was recorded, transcribed, and summarized. The summary was sent to the participants of that specific sub-session for member checking. Based on the transcriptions and summaries, the two principal researchers conducted a thematic analysis to identify perceptions of HS advisors of their role and tasks in general, as well as the roles developed in previous phases. The two researchers discussed findings and insights in order to explore whether the roles were complete and/or needed readjustments. These overall findings were combined into two overarching summaries: one summary for the June sessions (1a and 1b) and the other summary for the September sessions (2a and 2b). These summaries were fed back and discussed with the project team.The insights from phase 3 were used to make any last improvements and finalize the identified roles and their descriptions. Also, the roles were visualized in a model to show how they relate to each other. In November 2021, the roles, their descriptions, and the model created were sent by email to all active participants of the focus groups, i.e., at least participated in one focus group. The aim of this round of feedback was to identify whether the HS advisors had any suggestions for last improvements or adjustments regarding the roles and/or their descriptions and to investigate whether they have any feedback on the model. The final roles and descriptions were then presented and discussed with the project team.Fifty-five publications were identified and screened based on the primary researcher's experience in the field of implementation of the HPS approach. Of those 55 publications, 14 studies discussed the tasks of an HS advisor during the implementation process of the HPS approach in a school. The HS advisor links the school to external partners and helps to enhance the participation of all stakeholders in the school. The HS advisor helps to create a co-creation process in which all partners collaborate, and a balance is found between the expertise of external partners and the involvement of the stakeholders in the school.The HS advisor has the expertise and up-to-date knowledge about specific health topics, such as physical activity, smoking, and wellbeing, and the HPS approach, in general. The HS advisor uses this knowledge, together with his/her own experiences, to support the schools with the implementation and continuation of the HPS approach.The HS advisor is involved, observes the specific context and dynamics in the school, and has a close collaboration with the HS coordinator. This helps the HS advisor to gain insight into the wishes, needs, expectations, and opportunities of the school, and he/she can deal with this in a flexible manner.The HS advisor is a “detached outsider” of the school. He/she guides the school in the implementation, continuation, and evaluation of the HPS approach. The HS advisor not only supports, motivates, and advises the school but also remains critical during the whole process.The HS advisor creates enthusiasm for the HPS approach in the school and at external organizations by making them aware of the importance and the need to work with such an integral approach.The five roles resulting from phase 1 were discussed with 12 HS advisors from eight public health service regionsFindings showed that all participants recognized the five identified roles in their own work as HS advisor and the work of HS advisors in general. According to the HS advisors, the various roles describe a complete overview of their work, and no roles were missing. However, it was also mentioned that applying all these roles can be challenging, because it depends on the situation as to which role(s), ore part of a role, are applicable.All roles are recognizable to me. They provide a complete overview of my work as HS advisor. I also do not miss a specific role. However, the extent to which I apply a role can differ quite a lot per school and situation.” .“Several nuances were also given for each specific role as follows.Most participants mentioned that this role is the most recognizable one. It describes very specifically how you can support the schools when applying for this role. Since the HS advisor often actively works with local partners in a municipality, he/she can really have added value by linking the school to external partners, such as sports clubs or welfare organizations. These partners can, for example, help the school to promote a healthy lifestyle and wellbeing on a specific topic. Moreover, the findings showed that when discussing this linking pin role, the participants mainly focused on the external partners and hardly on the participation of the stakeholders in the school. Enhancing this participation was seen as mainly a task for the HS coordinator who operates within the school.Yes, I recognize this role, but in my opinion the HS coordinator is the real linking pin inside the school.” .“The participants perceived this role as important but challenging. They indicated to have knowledge and expertise about the HS program in general and when needed, they know how to find in-depth information about a specific health topic. However, since new insights or newly developed interventions constantly lead to developments in different topics, they find it challenging to keep their knowledge up to date. Several participants indicated that they have divided this task of having up-to-date knowledge among colleagues who also work as an HS advisor and that they consult each other when they need more in-depth information on a specific topic. In contrast, some participants mentioned that this was not possible as they did not have enough colleagues in their region who also work as an HS advisor. In general, many indicated that the support in this from the national HS program could be optimized.I have the expertise and knowledge, but I do not think it is realistic to be an expert in everything. I know where to find the information when needed. Though, in my opinion a general and up-to-date overview per theme is missing. I have to be very proactive to find all information.” .“The perceptions regarding this role varied considerably among the participants. Some perceived it as the most crucial role, and others perceived it as the least recognizable one.This is very much recognizable. I think it is the main role of an HS advisor.” .“I do not recognize this role as much as the other roles. Schools know very well what they want, we do not have to take them by the hand. The school is in the lead, and when there are any questions, they can let me know.” .“Despite varying perceptions, HS advisors agreed that collaboration with the HS coordinator, who is specifically mentioned within this role, is very important as he/she knows the school best. This HS coordinator can, therefore, help the HS advisor to gain more in-depth insight into the school context and its dynamics; the HS advisor can then support this HS coordinator in finding ways how to adapt HP actions and activities to that specific situation.The word “critical” in this role triggered some participants. The more experienced HS advisors mentioned that being critical of the process and the decision for specific actions and/or activities is important to create effective and sustainable change. According to them, being critical can be seen as the added value of the HS advisor to the process, and he/she is a quality gatekeeper of the integral approach and the implementation of HP actions and activities. However, the HS advisors with less working experience perceived the word “critical” more often as negative and mentioned that they were very careful to apply this part of the role. In their perception, being critical could damage the good relationship with the school, which could lead to losing the school's support and enthusiasm.The role is recognizable but being critical can be very challenging. You must find a balance in how critical you can be. You do not want to lose them. So, there is not always the luxury of being critical.” .“This role, including the part of being critical, should be more prominent in the work of HS advisor compared to what we do now. As an HS advisor you have specific expertise, and you can trust on this and stand for it. When you perceive resistance in the school, it is important to figure out the reason for this resistance.” .“The findings showed that the participants, when discussing this ambassador's role, mainly talked about the adoption phase in the implementation process or when a school decides to start working with the HS program. They also indicated that in this adoption phase, it can be challenging to take this role due to how the Dutch HS program works. A school often has already received funding and decided on a topic, before they come into contact with an HS advisor. The ambassador's role is less needed, according to the participants. Also, it was indicated that when a school does not have the motivation to work on health promotion, they do not want to put their limited time into taking the ambassador's role to convince the school to continue with the HPS approach. They rather use that time to support other, more motivated, schools. Finally, the participants mentioned that in this ambassador role, it is important not to forget the potential external partners, as they can be very valuable in supporting a school in promoting healthy lifestyle and wellbeing.This role is obvious and a natural part of the HS advisor. However, it is not always easy to apply this role due to a lack of time.” .“A school is often quite busy with many other issues; they just do not want to focus on health promotion then as well. I want to give them this space, I do not want to ruin the relationship, by pushing them all the time.” .“n = 7) had also participated in the individual interviews. The 13 participants  were located in 11 different regions in the Netherlands (see note 2), with some participants also having worked in other regions than their current location  and nine participants joined in the September session (four HS advisors in sub-session 2a and five in sub-session 2b). Each sub-session lasted for 2 h. Minor improvements to the description of the roles were suggested in the June session, such as that the linking pin role could be a bit more described in relation to the HS coordinator of the school. The September session, in which the roles had to be applied in a case, resulted in an important insight into the role of the involved adapter. It was observed that the participants were struggling with it. More specifically, they indicated that the title of this role was confusing to them. At the same time, however, they emphasized that they felt this role was relevant in every situation they encountered as an HS advisor. They mentioned that an HS advisor is always searching or navigating for the best fit with the specific school context, based on the close contact they maintain with the school through an HS coordinator (who in the Dutch context is a school employee). According to them, this role should, therefore, be stated on a more central level than the other ones.I wonder whether you should call it involved adapter, aren't you just an adapter and being involved is part of that? I do really believe that this role is at the base of the work of an HS advisor; it then depends on the support that is needed which other roles you will take.” .“Renaming this role “navigator” was proposed as a suitable alternative because, in the Dutch context, an HS advisor is essentially someone who guides, coaches, supports, and empowers the school to become a healthy school, or in other words, helps the school navigate their unique context via the good relationship they build with a central contact person in the school.n = 13), and they were asked for final suggestions. Seven participants were available to respond. None of the respondents had any final adjustments, additions, or other comments and agreed to the final description and model of the five roles of the HS advisor in Dutch schools. Likewise, no improvements were suggested in the project team when discussing the final roles.After phase 3, the roles were finalized by the two principal researchers, and a model was created to visualize how they relate to each other. Both the description and the model were presented to all active focus group participants .“A good representation of the discussions we had, my compliments for that.” .“Cool new name [read: for the involved adapter role], definitely an improvement to change from involved adapter to navigator. This name fits much better.” .“The final description of the five roles is presented in Box 1Central role:Navigator: The HS advisor has close contact with the HS coordinator. Due to this contact, the HS advisor has insight in the specific context and dynamics in the school and has insight in the wishes, needs, expectations, and opportunities of the school. He/She can deal with this in a flexible manner.Other roles:Linking pin: The HS advisor links the school to external partners, such as the municipality, and helps the HS coordinator to enhance the participation of the stakeholders in the school. The HS advisor helps to create a co-creation process in which all partners collaborate and a balance is found between the external expertise and opportunities and the involvement of the stakeholders in the school.Expert in the field: The HS advisor has expertise and up-to-date knowledge about the HPS approach and the local opportunities. When needed, he/she is able to gain in-depth knowledge about a specific topic from colleagues or theme-related institutes. The HS advisor uses this knowledge, together with his/her own experiences, to support the schools with the implementation of the HPS approach.Critical friend: The HS advisor is a ‘detached outsider' of the school. He/She guides the school in the implementation of the HPS approach. The HS advisor supports, motivates, and advises the school and is a gatekeeper of the quality: He/She follows the whole process critically and helps the school adjust the course of the process when needed.Ambassador of the HPS approach: The HS advisor creates enthusiasm for the HPS approach in the school and among external partners by making them aware of the importance and the need to work with such an integral approach. This is done in the beginning of the process to create enthusiasm to start with the HPS approach, but also during the process to keep the enthusiasm alive.The current study identified and described the key roles of an HS advisor during the implementation process of the HPS approach in schools in the Netherlands. The study was based on a co-creation process involving Dutch HS advisors, as well as researchers and national representatives and coordinators of the HS program. The co-creation process consisted of four main phases: (1) a narrative review, (2) individual interviews with HS advisors, (3) focus groups with HS advisors, and (4) a final check of the roles. This process has led to the identification and description of five key roles of the HS advisor: a navigator role as a more central one, and four other roles, namely, linking pin, expert in the field, critical friend, and ambassador of the HPS approach. Despite the fact that many studies mention the importance of support from HS advisors to schools during the implementation process of the HPS approach, only limited research has been performed on specific roles of such advisors –21. TherEven though the five roles seem to provide a clear overview of the work of the HS advisor that is generalizable for the Dutch context, it does not mean that it is applicable in other countries. This was also not the aim of the study and was even perceived as impossible since each national context is different, and every country has its own system with specific contextual factors regarding the implementation (support) of the HPS approach in schools , 22. TheLooking specifically at the perceptions of the HS advisors on the five roles during the interviews (phase 2) and focus groups (phase 3), it can be observed that some HS advisors perceived more difficulties with the roles than others. This is not surprising, as the roles describe how an HS advisor can optimally support schools. It can be very challenging though to figure out how to fulfill these five roles in different contexts. HS advisors indicated, for example that the navigator role (previously named involved adaptor) was a bit vague and the least recognizable role for them, while others described this role as the most crucial one. According to them, navigation should be part of every situation to be able to work in a context-oriented manner. Also regarding the critical friend role, some issues were discussed. Some HS advisors perceived that being critical when supporting schools is challenging in real life. Others had no difficulty with it and thought that being critical was the added value of an HS advisor. They identified themselves as quality gatekeeper who has specific expertise to add to the process. As this study is part of an overarching research project to develop training for HS advisors, we aim to include the roles in this training. In this way, HS advisors can discuss the five roles based on real-life working situations and practice translating the roles into specific support they provide to each school. Even though the practical application of different roles was not the main focus of this study, an interesting finding regarding the ambassador's role was observed throughout the phases of the current study. The ambassador's role was specifically added by the national coordinators as something they expected HS advisors to do. Although HS advisors involved in this study agreed with this, they also noted that in practice taking on this role was sometimes difficult to achieve or not needed anymore. In their perception, the role matters most in the adoption phase of the implementation process, when schools choose to start working with the HS program and prioritize a specific health topic. HS advisors experienced that they were often contacted by the school after the decision was made to, indeed, work with the HS program and on which health topic they wanted to focus. According to HS advisors, this results in mainly supporting schools that are already motivated and often only need a little push to implement HP in the school. However, the ambassador's role is still important in these schools to keep all stakeholders in the school motivated and engaged throughout the whole implementation process to create a sustainable impact. In addition to this, the ambassador's role is also important to proactively convince the other, maybe less motivated, schools to start working with the HS program. Considering these two aspects, it can be recommended to pay specific attention to the broad application of the ambassador's role when discussing or applying for the roles.Several strengths and limitations should be considered when discussing the results of the current study. An important strength of the study was that both researchers and professionals in the field were involved in co-creation processes enabled by participatory research. This led to findings that were shaped by the insights from science and experiences from practice. In addition, the methods were based on a combination of research and practice. The narrative review provided the existing knowledge and insights from the scientific literature, which served as input for the interviews and co-creation sessions with the HS advisors. Their experiences and perceptions from “the field” led to the further identification and description of the five roles and made sure that these fit real-life practice. The study also had several limitations. Since the narrative review was not conducted systematically, some relevant studies may have been missed. However, almost no studies focused on the tasks of an HS advisor in particular. Instead most studies focused on factors important for the implementation of the HPS approach in which the task of an HS advisor was often only mentioned in one or two sentences in the discussion section of an article. Therefore, it is unlikely that a systematic review would have led to more relevant articles. Another limitation was the limited number of HS advisors included in the interviews. Since only 12 HS advisors were interviewed, with all having their own context, it is hard to say whether data saturation was reached. However, comparable responses were given to the roles, suggesting that data saturation was reached. This, together with the fact that different roles would be discussed again in the focus groups, led to the decision to continue with the process after interviewing these 12 HS advisors. Finally, even though many efforts were taken, not all regions in the Netherlands were represented in the interviews and focus groups. This could have led to the findings that are not completely representative of all HS advisors in the Netherlands. However, the participating HS advisors came from regions all over the Netherlands, and no more than two HS advisors from the same region were involved. Since full consensus was reached in phase 4 of the study among not only the participating HS advisors but also the national representatives and coordinators of the Dutch HS program, generalizability of the findings does not seem to be an issue.The current study has led to the identification and description of five roles of HS advisors in their support of schools during the implementation process of the HPS approach. The five roles are: (1) navigator, (2) linking pin, (3) expert in the field, (4) critical friend, and (5) ambassador of the HPS approach. The navigator role is hereby centrally stated because navigating is needed in every situation to be able to work in a context-oriented manner. The application of the other four roles is depended on the specific situation, and these can be seen as a playground in which context-oriented support takes place. Overall, the five roles can provide guidance to all HS advisors on what is needed to provide sufficient and context-oriented support to schools. Moreover, the roles may inspire and guide professionals from other countries from science and practice who are involved in implementing the HPS approach to adapt the five roles to their own national context, and thereby optimize the implementation support of the HPS approach provided to schools in their country.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Review Committe Health, Medicine and Life Sciences (FHML-REC) of Maastricht University. The patients/participants provided their written informed consent to participate in this study.NB and BvD acted as principal researchers. NB drafted the manuscript. BvD provided continuous input. All other authors provided advice on the study, the analysis, and the results, as well as provided feedback on the manuscript. All authors were involved in the design of the study and read and approved the final manuscript.