Nevertheless, the results indicate that with only two isotopic ratios, discrimination could not be achieved, and further analysis is required. There is a plethora of food products with geographical indications registered in the European Union without any study about their discrimination from other similar products. This is also the case for Greek currants. This paper aims to analyze if stable isotope analysis of C, N, and S could discriminate the Greek currants “Vositzza”, registered as a product of Protected Designation of Origin, from two other currants registered as products of Protected Geographical Indication coming from neighboring areas. The first results show that the stable isotope ratio of sulfur is not detectable due to the very low sulfur content in the samples, and the analysis should be based on the stable isotope ratios of carbon and nitrogen to discriminate these products. The mean value of δ Food products with geographical indications increasingly attract consumers’ interest, along with their willingness to pay more for such products and their distinctive characteristics. At the same time, the higher prices of these products motivate mislabeling or even adulteration, as an easy way for more profits, at least in the short run ,2. Food In other words, it is the assurance that a food product is genuine, has not been tampered with, and is safe for consumption. In 1992, the EU enacted the Protected Designation of Origin (PDO) and Protected Geographical Indication (PGI) schemes (Regulation 2081/92/EEC), followed by Regulation 510/2006/EEC and amended by Regulation 1151/2012/EU, which are European laws against mislabeling . Certainly, verifying food authenticity is an important process for a number of reasons, including the safety of consumers, consumer confidence, fair trade, and regulatory compliance. Firstly, adulterated or mislabeled foods can be a serious health risk to consumers. Verifying the authenticity of food products could help mitigate risks about safety by ensuring that the food products are safe for consumption and free from harmful contaminants. This is particularly important for those with food allergies or other dietary restrictions. Secondly, food authenticity verification provides consumers with confidence that the food they are buying is what it claims to be. This helps build trust between consumers and the food industry and is especially important at a time when food fraud is becoming more prevalent. Thirdly, verifying food authenticity helps ensure that food producers receive fair compensation for their products. It also helps ensure that consumers are not deceived or misled about the origin or quality of the food they are purchasing. This promotes fair trade practices and helps to support the livelihoods of farmers and food producers. Lastly, many countries have regulations in place that require food producers to meet certain quality and labeling standards. Verifying food authenticity helps ensure that producers are in compliance with these regulations, which can have legal and financial implications for businesses. Geographical origin is an essential part of food authenticity since there is a direct link between food characteristics, such as flavor, aroma, texture, and nutritional content, and the unique environmental and cultural factors of the production area. Geographical origin verification is particularly important for certain food products that are associated with specific regions or traditions, such as the PDO and the PGI products established in Europe. Verifying the authenticity of a PDO or a PGI product is important for promoting consumer safety and confidence, meeting regulatory standards, preserving cultural heritage, and supporting the local economy. Verifying the geographical origin of a food product involves analyzing various chemical, physical, and biological characteristics of the food.Various analytical techniques, including chromatographic techniques, such as gas chromatography–mass spectrometry (GC-MS)  or high-The aim of this study was the differentiation of the geographical origin of “Vostizza” currants from the region of Egialia by means of stable isotope analysis and the use of EA-IRMS. As there are no studies about the stable isotope composition of “Vostizza” currants, these are the first published data. Worldwide, a very popular and beneficial vine product for human health is dried grapes, which are very rich in nutrients. The chemical composition of dried grapes is complex and includes a variety of bioactive compounds that contribute to their nutritional and health benefits. These compounds make dried grapes a nutritious addition to a healthy diet. Some examples of the key components of dried grapes’ chemical composition include antioxidants and a high percentage of anthocyanins, flavonoids, vitamin C, potassium, and fiber ,25,26,27Dried grapes in Greece are usually known as raisins (dried white grapes) and currants (dried red grapes), mainly coming from different types of the Corinthian variety . More spIn Greece, and especially in the wider area of Peloponnese, there are two types of Corinthian currants that hold a protected geographical indication scheme: Corinthian currants cultivated in the Egialia area and registered with the name “Vostizza” (PDO reg No. 442597/93) since 1993, and Corinthian currants cultivated in the Prefecture of Ilia registered as a PGI product under the name “Stafida Ilias” (PGI reg No. C233/2010) since 2010. There is also a PDO product based on the Corinthian variety that is cultivated on the island of Zakynthos, belonging to the Ionian Island Prefecture . This prHowever, according to the Greek Ministry of Agriculture, “Vostizza” currants are the ones with the largest production volume, and their cultivated area reaches almost five thousand hectares, which is almost twice the cultivation area of “Stafida Ilias” currants and three times the area of “Stafida Zakynthoy” currants. Furthermore, “Vostizza” currants are one of the very first Greek products registered under the Protected Designation of Origin policy scheme. According to Vasilopoulou and Trichopoulou  “the worVerifying the authenticity of “Vostizza” currants could provide consumers with confidence that they are buying a genuine product and all its known and desired characteristics. This could help establish trust between consumers and the food industry that trade “Vostizza” currants, which hold a PDO. Increased trust consequently leads to increased sales for verified and authentic products. This has a direct impact on the prices of the products, especially for “Vostizza” currants, which constitute an important export for both Greece’s national agricultural economy and local economy, as well as for producers/farmers of the product, helping to support the livelihoods of farmers and other businesses involved in the production and sale of this product. At the same time, since “Vostizza” currant is a traditional Greek product that has been cultivated for centuries by small family-owned farms using traditional methods, it enhances the product’s unique characteristics, such as flavor and aroma. “Vostizza” currants are harvested by hand and then sun-dried, which further concentrates their flavor and sweetness. Thus, verifying their authenticity could help preserve this traditional way of cultivation, which is a cultural heritage, and ensure that this product remains true to its origins as it is described in the European Union’s PDO registration files. Additionally, this is a point of crucial importance since verifying the authenticity of “Vostizza” currants means that the product meets regulatory standards by ensuring that the product confronts specific quality and labeling requirements. 1H-NMR non-targeted fingerprinting method for the differentiation of “Vostizza” currants from currants of other geographical origins , while Dimitrakopoulou et al. [Many studies have been carried out in order to determine the geographical origin of table grapes and wines using stable isotope analysis ,32,33,34u et al.  discrimiIn total, 100 currants samples were examined: eighty samples were from Egialia in Peloponnese in southern Greece , and theδ15N and δ13C. To determine δ15N, the homogenized sample was extracted in a mixture of acetone/distilled water (10% v/v) to remove sugars and lipids, as described in the ENV 13070 method, followed by centrifugation and picking up of the solid part, which was oven-dried at 50 °C for 2 h. The extraction was applied for the enrichment of nitrogen in the received solid. Afterward, it was further homogenized with a mortar. In order to determine δ13C, the homogenized sample was also oven-dried at 50 °C for 2 h and crushed with a mortar. After processing, each part was put in Eppendorf tubes and placed in a freezer until the IRMS analysis.Fifty grams of each currant sample were freeze-dried at −50 °C for 24 h, followed by homogenization in a mill . Then, the samples were divided into two sections for the determination of δ (‰) and calculated according to the following equation:13C, 15N, and 34S), Rsample is the isotope ratio of the measured element in its physical form  in the sample, and Rstandard is the isotope ratio of the reference material.The isotopic analyses of carbon, nitrogen, and sulfur were performed by an Elementar Isoprime 100 Isotope-Ratio Mass Spectrometry (IRMS) instrument  coupled to an Elemental Analyzer . The samples, ≈1–2 mg, were weighed into tin capsules for measurement and were loaded on the auto-sampler of the IRMS analyzer. The results of the isotope ratio analyses were expressed as delta values Before sample analysis, instrument calibration was performed with the means of the reference materials with a known composition (standard substances). The standard substances were selected based on the isotope  that was required for the analysis. In addition, physicochemical properties are an important factor for the selection of the reference materials, i.e., their isotope ratio should be near the one of the samples that was examined. 13CV-PDB = −27.77‰) and B259  were the reference materials used for δ13C analysis. IAEA-N1  and B259  were the reference materials used for δ15N analysis. IAEA-S1  and B259  were the reference materials used for δ34S analysis. During sample analysis, a quality-control-check sample with B2155,  was analyzed to test the results of our samples. The batch routine began with the analysis of a reference material, followed by a number of the samples, and ended with another reference material. In this study, IAEA-600  and δ13CV-PDB (‰) for the examined areas are presented in δ34SV-CDT (‰)); however, the content of sulfur was 0.00–0.04% w/w, which was not enough for a reliable calculation of δ values. The results obtained by the analysis are depicted in Eighty samples from the cultivation zone of the PDO product “Vostizza”, along with twenty more samples coming from other areas outside the PDO zone of “Vostizza”, were analyzed. For each sample, two repetitions were performed. The mean values of δ13CV-PDB (‰), almost three out of four samples can be classified correctly with this approach.The next stage in this analysis was to find out if it was possible to determine, based on our data, a decision rule to discriminate the samples coming from the PDO zone of “Vostizza”, that is, the Egialia area, against other areas cultivating currants in southern Greece. For this reason, a classification analysis was performed. Classification analysis is a common method used to classify samples based on their chemical composition. It is particularly useful when dealing with complex datasets, where it is difficult to manually classify each sample. Classification analysis typically involves developing a statistical model that uses the measured features or variables  to predict the class membership of each sample. The model is typically developed using a training dataset, where the class membership of each sample is already known, and then validated using an independent test dataset. In this study, the classification analysis was based on the “party” R package by using 70% of the data as the training set, and the remaining 30% was used as the testing set for analysis. The following table  presentsThe next step in the analysis was to increase the accuracy of the classification approach. Since our samples were classified into two groups, those coming from the “Vostizza” PDO zone and those coming outside the PDO zone, a binomial logistic regression was applied. Binomial logistic regression is a statistical method used to model the relationship between a binary dependent variable and one or more independent variables known as the predictor variables or covariates. The dependent variable can take only two values  representing two possible outcomes, such as success/failure, true/false, or yes/no, and in this case, if a sample came from the PDO zone or not. The goal of a binomial logistic regression is to estimate the probability of the dependent variable taking a specific value , given the values of the independent variables. Since the probability of an event must lie between zero and one, it is impractical to model probabilities with linear regression techniques because a linear regression model allows the dependent variable to take values greater than one or less than zero. This is achieved by fitting a logistic function to the data, which transforms the linear combination of the independent variables into a probability value that ranges from zero to one . δ ratios for stable isotopes. These ratios were formulated by different parameters, including soil characteristics, climate conditions, and cultivation techniques, which created a unique set of characteristics that altogether formulated these stable isotope rations [It was assumed that samples coming from different areas had different  rations . Neverth15NAIR (‰) and δ13CV-PDB (‰), and the dependent variable, which is coming from the PDO zone or not. In addition, the estimated coefficients can be used to make predictions on new data of δ15NAIR (‰) and δ13CV-PDB (‰) combinations.Finally, the regression coefficients were estimated through an iterative maximum likelihood method. 13C, as it has been proven that different coffee species varied in δ13C [13C values of Schisandra fruits increased with latitude, which was possibly due to the comprehensive action of multiple factors, such as climate and species. Nevertheless, carbon isotope ratio is not sufficient to discriminate between different origins when the regions are narrow and neighboring, such as those presented in this study.The above results indicate that by using the binomial logistic regression approach, 85% of the samples outside the PDO zone and 80% of the samples coming from the PDO zone can be correctly classified. Thus, more than four out of five samples can be correctly classified. The difference of the Corinthian currants species tested might also contribute to their variation in terms of of δ in δ13C . In a si in δ13C  showed tThus, the results of this analysis indicate that further stable isotope ratios should be included in the analysis in order to increase the overall accuracy level. A follow-up study will combine trace elements with stable isotope ratios to analyze a larger set of samples with more geographically diverse samples and adulterated samples.15N and δ13C, an attempt was made in order to find the best alternative chemometric approach to verify the authenticity of the Greek “Vostizza” currants. It was not possible to detect δ34S due to the low sulfur content. This fact made the second stage of the discrimination procedure even more difficult since the analysis had to be based on only two variables, namely δ15NAIR (‰) and δ13CV-PDB (‰). For the statistical analysis, one-way ANOVA and classification analysis were performed, which are the most common approaches to discriminate geographical origin. Stable isotope analysis has been used in many products to authenticate their geographical origins. This is a preliminary approach since there are no previous studies focusing on stable isotope analysis of “Vostizza” PDO currants. This study aimed to investigate if the geographical origin of the most known Greek currant—“Vostizza”—could be differentiated from other currants registered as PGI products from neighboring areas in the same prefecture, namely Peloponnese. Currants are historically important for the economy of both Peloponnese and Greece; thus, determining the origins of these products is essential to establish their authenticity and detect any possible commercial fraud. Beyond the stable isotope ratio analysis and the determination of δHowever, due to the small number of samples and the use of δ values of only two elements, as well as the fact that the examined products came from neighboring areas, the results and, consequently, their explanatory strength were not sufficient. However, applying a different approach, namely binominal logistic regression, managed to improve the explanatory strength and correctly classify 85% of the samples outside the PDO zone and 80% of the samples coming from the PDO zone. Even though these results have been improved, they are still not satisfying to effectively discriminate samples coming from such close neighboring areas. The results of the stable isotope analysis suggest that geographical discrimination is not feasible based only on, firstly, carbon isotopes and, secondly, nitrogen isotopes. To achieve sufficient discrimination between different origins, especially when regions are too narrow and neighboring, such as those presented in this study, further research is needed in order to include more samples from the areas producing these products and to analyze more stable isotopes (such as hydrogen and oxygen).


The Voluntary, Community and Social Enterprise (VCSE) sector offers services and leadership within the health and care system in England and has a specialist role in working with underserved, deprived communities. This evaluation aims to identify best practices in self-management support for those living with type 2 diabetes mellitus (T2DM) and to develop a theory of change (TofC) through understanding the impact of VCSE organisations on diabetes management. An appreciative inquiry (AI) was carried out and co-delivered using qualitative interviews and an embedded analysis with VCSE partners. A voluntary service coordinated seven VCSE organisations who assisted with recruiting their service users and undertook interviews to identify the impact of existing activities and programmes. People living with T2DM were interviewed about services. Themes were as follows: (a) individual and group activities; (b) trusted services and relationships across the community; (c) long-term engagement; (d) sociocultural context of diet and nutritional choices; (e) experience of adaptation; and (f) culturally appropriate advice and independent VCSE organisations. The structured educational approach (DESMOND) for T2DM was accessed variably, despite these services being recommended by NICE guidelines as a standard intervention. The VCSE offered continuity and culturally appropriate services to more marginalised groups. This evaluation highlights the importance of targeted engagement with underserved communities, particularly where primary care services are more limited. The TofC is a unique insight into the impact of VCSE services, offering bespoke support to manage T2DM, suggesting areas for improvements in capacity and offering the capability to sustain the VCSE sector as an essential element of the T2DM care pathway in England. In England, the Voluntary, Community and Social Enterprise (VCSE) sector comprises organisations that are independent of the government and are constitutionally self-governing. They exist to represent and advocate for the local community or groups with specific needs and aim to promote social, economic, environmental or cultural benefits . The divVCSE organisations play a key role in facilitating dialogue between a system and its residents, ensuring that services are co-produced with residents at the heart of service provision . HoweverManagement of T2DM can be complex and requires, among other components, continuous self-management, multidisciplinary team input and community support . The prePsychologically, a diagnosis of T2DM can also lead to a ‘biographical disruption’ , a term Previous studies in the UK identified a greater risk of diabetes in ethnic minority groups, particularly South Asians ,24,25. SThis research aimed to critically engage with and understand the role of VCSE organisations and their impact on the self-management of people with T2DM from underserved communities and to produce a theory of change (TofC) . A TofC Local VCSE partners were invited to take part in the study via the sponsor. Seven VCSE partners participated in the project, representing organisations from across the city. The VCSE partners provided a variety of services, including a drop-in cafe for people of African–Caribbean heritage, weight management programmes in groups and/or online, exercise referral programmes, diabetes education in the Urdu language, outreach activities for the Roma–Slovak community, men’s health groups and wellbeing clinics at local community centres. A co-ordinating voluntary services organisation commissioned the evaluation from an academic team. Their complex programme of work was ongoing and sought to identify the impact of VCSEs offering a health-oriented service to people with T2DM. The sponsor sought to co-produce a TofC from the existing work of VCSE organisations that participate in the delivery of T2DM services as part of the statutory care pathway. To be included, the VCSE had to offer a service in a specific underserved community and have pre-existing embedded connections and relationships with ethnic groups or socially or financially deprived areas. The evaluation team used the appreciative inquiry (AI) model as an evaluation framework because the process examines, identifies and further develops the best of what is happening . This enThe theoretical approach to the study was based on organisational development and systems thinking used in health and care services in the UK . This reThe AI approach provides a framework for data collection based on the 4D cycle, i.e., discovery (what is the best of what it is), dream (envision the impact), design (co-production) and destiny . The participation of the seven VCSE services was particularly welcomed, in part to engage and build capacity for evaluation practices; in AI terms building “images of possibility into reality and belief into practice” . In a coThe research team comprised a dietitian (LN), an occupational therapist and systems researcher (SFD), a community and practice nurse (AY), a director of voluntary services organisation (HS) and a senior research fellow in global public health (SB).A semi-structured interview guide was co-produced and designed in collaboration with the VCSE partners to ensure appropriate questions and prompts were used to gather the required information. It was developed to lead participants from their initial diagnosis to the present day, with specific questions regarding what having diabetes meant to them, how they manage their diabetes, where they access support and appropriate advice, what they liked and what could be improved regarding their experiences with primary care, secondary care and the VCSE sector regarding their diabetes. They also were asked what they felt would be important when designing a diabetes service for their community. The full interview guide is provided in the VCSE organisations recruited participants (either face-to-face or via telephone or e-mail) if they had received support and advice from the VCSE and had a diagnosis of T2DM. Participants were recruited and interviewed between December 2021 and February 2022 when COVID-19 rules were variable in the UK. Participants were given a detailed participant information sheet before the study commencement, with information about the voluntary nature of the input, assurance of data anonymisation and maintenance of confidentiality. Consent was confirmed before participation in the evaluation. Participants were free to withdraw from the study at any point during the process without impacting their routine care.Demographic questionnaires and qualitative semi-structured individual interviews were used to collect data for this study. VCSE partners and staff members conducted the interviews. The project team members (LN and SB) provided training to the interviewers before they interviewed the participants. All interviewers completed a pilot questionnaire, and the project team provided feedback on their interviewing process and skills. The interviewers then completed their questionnaires and qualitative interviews with two to seven participants recruited by the VCSE organisations. The influence of the interviewers on the research processes and data could not be assessed as they needed to maintain field diaries or document their observations to achieve this.The questionnaires were designed to collate basic demographic information such as age, gender, postcode, time since diagnosis and education status.The interviews were conducted online, face-to-face or via telephone using a predetermined co-developed topic guide; each lasted between 20 and 40 min. After obtaining informed consent, the interviews were audio-recorded or hand-written verbatim, with some interviews translated from Urdu to English. The research team  received anonymised voice files which were transcribed by Otter.ai transcription software . The resThe data were analysed by the research team using the qualitative framework analysis approach ,43,44. TThree researchers  analysed the data manually by following the five steps in framework analysis: (a) data familiarisation: the researchers read the transcripts several times to develop an understanding and interpretation of the participant’s perceptions of their diabetes journey; (b) framework identification: each researcher suggested a theme heading for the framework analysis and these were discussed and amended until a consensus was reached; (c) indexing: condensed data from the transcripts; (d) ‘charting’; and (e) mapping and interpretation ,44. FollThe initial TofC was developed from the framework analysis, with the themes forming the basis of further discussion between the research team, the participating VCSE organisations and the coordinating VCSE agency. The charted data and thematic descriptors were shared and used to highlight the collated impact of VCSE interventions ; the disParticipant organisations working within local communities were invited to sessions to scope the research area, agree on the key research topics and devise, pilot and agree on the interview topic guide. The local VCSE organisations’ interviewers recruited community members to understand their lived experience of T2DM in the local setting. In total, 33 interviews were collated from seven organisations and 30 were included in the analysis (2 interviews were excluded as the interviewees had type 1 diabetes and 1 interview was a duplicate). The sociodemographic characteristics of the participants are described in Participants were diagnosed between 12 months and over 30 years ago, with most participants being diagnosed within the last 5 years. Nearly half of the participants lived in the top 20% most deprived centiles, according to the English Indices of Multiple Deprivation (2019) from postcode data.Six themes were identified overall: individual and group support for self-management; trusted services and relationships across the community; long-term engagement with services; sociocultural context of diet and nutritional choices; multifaceted adaptation to the long-term condition; and shared community support network.The study participants reported several ways they were given initial information, which they thought was generic but a good start. Most said that they commonly received early advice and guidance, but the overall messaging was associated with nutrition and lifestyle. For example, a White British male participant (65+ years old) said, “they told me to watch my diet, watch what I eat-plenty greens, fewer carbs, and to exercise, and that will keep my blood sugars down”.However, many of the interviewees mentioned that they preferred tailored or specific information that could meet their individual needs.In the initial information, the participants were offered medication such as Metformin and referred to DESMOND. DESMOND was attended and received variably by the participants. Due to ongoing comorbidities, there were many barriers to attending DESMOND, such as timings, location and inaccessibility. As a participant expressed his concern that: “I was invited to some talks, but I didn’t go. I was overweight and struggled to walk, and nobody could take me in their car” .However, some that did attend found it useful and reiterated their existing knowledge. For example, a Black Caribbean female (age 65+ years) mentioned that: “I was signposted to DESMOND. The programme affirmed things I know. It was useful”Therefore, when attending the programme, she found it to be a good source of information for diabetes self-management. Nevertheless, some participants felt the information was ad hoc and only sometimes available when needed. Similarly, many respondents felt overwhelmed by the information they were provided with at diagnosis and could not initiate any positive behaviour change. When the shock of the diagnosis had settled, and they could act on the information, they felt that additional support was lacking. A participant expressed his concern as:“…very disjointed, and it’s difficult to find out about that. I tended only to find out about things by chance, in some instances through desperation” .It was evident from the interview data that there was shared knowledge in families and across communities. In the absence of other information, this was also used to supplement understanding from health professionals. A Pakistani female (65+ years) said: “My GP told me to lose weight and stop eating rice and chapati and other things. My sister also had diabetes a few years before, and she also told me some tips”.However, following initial advice from the GP or the DESMOND programme, many participants stated that there was confusion and uncertainty associated with the long-term effects of living with diabetes and what strategies to take forward in daily living. The advice was limited and from mixed quality sources. As a participant shared:“At present, I don’t get any [information]. I am just living with the original information I was given about diet and taking one tablet until today. It concerns me because I don’t know whether my blood sugar is gone” .For those who could use the internet for information about the management of their diabetes, the quality of the information was varied, and some of the behaviour changes they took from it were inconsistent with usual dietary advice. A White British male (aged 65+ years) found it useful and emphasised that, “I think it has to be the internet, to be honest. Yeah. I found a lot on the internet about various foods and how they affect your blood sugars”.Many participants reported finding answers and support from neighbours, friends, the local community, and voluntary organisations. This support was tailored to the community and individuals’ needs and delivered when the participants were ready to accept the information to improve their diabetes knowledge or control. A Black Caribbean female (age 65+ years) participant said that:“And it also happened that she [neighbour] had diabetes. And she says to me, “oh, there’s a group going on at [name of VCSE]”… And I felt renewed, elated because it was a group that, that there were other people with the same diagnosis, the same struggle”.Most participants stated that they received formal and informal information from various sources such as healthcare professionals, DESMOND, peers, relatives, family members and the internet. Most of the participants valued the information they received from their family, community or peers as they believed it was based on the lived experience of people, and they found it relevant to their lived experience. There was a strong recognition by the participants of “good” services that they trusted and those they felt had let them down. Many of the services also seemed to have been impacted by the COVID pandemic, so the patients felt they were receiving a substandard service. A participant said:“Diabetic nurse.... Well, it’s just generally sent me for bloods, look at my feet. Quick chat. Jobs a good ‘un!” (Unknown).In contrast, a White British male (age 65+ years) felt that: “at the moment, due to the pandemic, no one [is supporting with diabetes management]; that’s what I feel let down by because I think if you’ve got something like diabetes, I should be getting support”.Characteristics of the health professionals and services which participants appreciated were regular contact, building a good rapport, being personalised/culturally appropriate and referring or signposting them to services in the local community which were delivered primarily by the VCSE organisations. For example, an Asian British female (56–65 years) stated that: “the information I was given was appropriate for me. I visited the nurse at the doctor’s surgery every 3 months for my bloods, she was very good, and I developed a good relationship with her. She told me about exercise classes in the area and also told me about health walks”. Some participants also discussed how their personal circumstances prevented them from attending some of the services or how they avoided appointments because they knew that they had poorly controlled diabetes. As a mixed heritage male (26–35 years) said: “my mental health is really bad due to not managing diabetes. It has affected my life. I try to avoid my GP appointments because I know I struggle to manage my diabetes”. Many respondents also spoke about the VCSE organisations they had received support from and how it improved their knowledge of diabetes control. As a participant said, “I get most of my information now from community hub, I go for the keep fit sessions, and they do some health information cafes where they talk about healthy things to eat and portion sizes. They also tell you what food to avoid if you have diabetes. It has been a good refresher for me”. .The level of participants’ trust in service providers and healthcare professionals varied. Still, most patients trusted those services and healthcare professionals who listened to them and addressed their individual needs. The diabetes journey reported by many of the participants was similar. They had gone to the GP with symptoms of thirst, tiredness, poor wound healing, etc., and were diagnosed with diabetes. For many, this was expected, and participants reported having parents and siblings with diabetes. Participants linked their diabetes journey to their family history and said, “I had a couple of things that I spoke to a doctor about: dehydration, night sweat, that kind of thing. And they did a blood test. So, it was a blood test that revealed. Like yeah, because yeah, my mom’s diabetic. And then I’ve always known it was coming. Yeah, it was just a case of, obviously, two brothers. And I was never sure if it was going to be me or them too. But it seems to have come down the female line” .However, for some participants, this was a complete shock due to their perceived idea of who gets diabetes, and this caused a large biographical disruption. For instance, for an Asian British female (56–65 years), it was a shock when she learnt that she had diabetes. She shared that: “the doctor sent me for blood tests, and they came back showing I had diabetes. I was so shocked and upset. I didn’t even know young people got diabetes”. Most participants expressed that the diabetes diagnoses often led to strong emotional responses where people were stressed and upset. It took a long time for them to process their new diagnosis and accept what this might mean to them. As it was for a Pakistan female (65+), “I was very, very upset when I found out I had diabetes. I was scared that I would not be able to eat all the food that I loved and worried about what I would eat”.After the initial support and advice that was offered, participants reported a period of struggling, anxiety and uncertainty. The reported impact of the diagnosis on their mental health was incredibly significant. It often prevented them from processing or using the diabetes management information they were provided with at this time to make any meaningful lifestyle change. An Asian British female (56–65 years) shared her experience, “The first few years were very tough. I stopped eating out and I stopped visiting parties and friends because I was worried that they would offer me food and I wouldn’t be able to eat anything. I was also scared that people would be watching me and watching what I eat. This made me isolated and depressed, and I developed social anxiety. It has taken me years to get over this, and now I feel I am confident and in control”.The participants also reported ongoing concerns about the long-term implications and co-morbidities associated with their diabetes diagnosis. For example, “I didn’t really take on board or understand how serious diabetes is. I thought if I take my tablets, watch my diet, and look after my feet, I’d be ok…. but talking to people, they tell me about problems with their kidneys and blood flow to their legs, lots of problems. I hope I don’t get any of this” .The participants had mixed feelings and responses when they were diagnosed with diabetes. Where participants had a family history of diabetes, they knew that they would have diabetes too; however, some of them were shocked when they were diagnosed with it and had a need for long-term support. The interview data revealed that some participants were self-motivated or had household support that seemed to be a significant beneficial factor in their response to the diagnosis by driving more appropriate food choices and aiding weight loss, whilst others relied on food banks and struggled to make appropriate food choices due to the limited availability of foods. As an Asian British Female (56–64) said, “My husband was very helpful and supportive...he helped me reduce some weight…I realised that when I cut down on sugary stuff and started eating less rice and chapati, my weight dropped by itself. I also started walking a lot, and me and my husband would go for walks after the evening meal.”Moreover, the participants spoke about dietary changes they had been advised about or initiated. It was apparent that carbohydrate-rich foods are ones that people regard as bad for them, and the participants have engaged with the idea of eating more fruit and vegetables. However, the messaging they had retained from the advice appeared generic and only sometimes helped the individuals make a specific dietary change suitable for them. As a White British male (56–64 years) said, “Anyway, apparently, you’re not supposed to have carbohydrates and sugars, which is, like, most of what I eat, potatoes, bread”.In addition, advice from healthcare professionals was combined with advice from other sources such as the internet, family and friends. For instance, a White British male (65+ years) stated that:“I eat a lot of onions and green onions and leeks and that kind of thing…very particular triggers and learning how to regulate how much fruit I eat, shouldn’t eat too much fruit, certain fruits you should avoid, and so on. Yeah, I learned a lot from the internet”.It was evident from the interviews that most participants were conscious of their diet and followed the nutritional advice they received. Moreover, they mentioned a variety of sources of information concerning diet, including healthcare professionals, family, friends and neighbours, but were only able to enact behaviour change within their social, economic and cultural resource constraints. Most participants were users of VCSE services and appreciated the focus on local knowledge and shared information in a familiar setting. The support was focused on practical daily activities and was derived from discussing and planning with others with similar concerns. For example, a Black British Caribbean female (65+ years) said: “The information I got was from …. a really good group. You know, it’s, it helps me really, to manage.. day -to-day menu, day-to--to-day exercising, everything. I mean, every…everyone that was there was going through the same thing. I mean, the shared experience, we all shared our experience, you know, because everybody was different there. And they understood what everybody else had going on. So, it helped”.A common consideration was that participants had multiple morbidities and often multiple stresses arising from household challenges, including social stress and deprivation. These competing priorities made lifestyle behaviour change difficult for participants, resulting in a deprioritisation of diabetes self-management. For some, the initial stages following diagnosis were easier to manage, involving weight loss and a degree of support via the DESMOND programme. Still, the progress of the disease was difficult to manage, and there were varying responses—some more positive than others—but predominantly associated with medication changes or blood checks. A participant said:“I immediately started walking and eating more fruits and vegetables and lost a lot of weight. I controlled it via diet for at least 2 years. After 2 years, I was put on medication. I am still learning about things even at this stage. I have stopped eating all sugary stuff; I have a lot of self-control” .Home remedies were recognised as alternatives to allopathic medicine and a part of active self-management, and some participants favoured mixing these with their medications and lifestyle choices. For example, a Pakistani female (65+ years) shared examples of using home remedies: “I also tried some bitter drinks that people in Pakistan drink when they have diabetes, that helps me keep my sugar level under control, and I also eat bitter gourds, that is a very bitter vegetable. I also put cinnamon in my tea as I have heard that it helps lower when levels are high. I am very careful I don’t let my levels go high”.In an extreme case, the self-management of diabetes was complicated by other habits and problems or a sense that there were limited options concerning being well and managing their lifestyle. One man reported having a perforated eardrum. “So, there’s nowt [nothing] he’s going to do for me, says you…you’ve got diabetes, and you smoke. So anyway, so basically, I’m just left here with a perforated eardrum,” said a White British Male (56–64 years).As a part of active self-management, there was a range of comments about the continuity of activities, what participants liked to do, and what they stopped doing—particularly associated with exercise. In many cases, people wanted to move but were out of practice, had their routine altered due to COVID, found it difficult to find time or were too embarrassed to use municipal facilities.Following the appreciative inquiry model, the participants were asked how they envision existing services’ improvements and impacts. The participants from black and ethnic minority backgrounds dreamt of being recognised as having a cultural heritage and a health support need. For example, older adults from Pakistan wanted information in Urdu, which they saw as the only culturally appropriate way to overcome language barriers. On the other hand, there was recognition that some groups needed to include collective knowledge about health. As an Asian British male (46–55 years) put it, “There is a need for a lot of improvement culturally because then if we introduce…traditionally if there is one person gets the information, he spread it out to the [the rest of the community]… a big job to for the people’s awareness in mainly an Asian community”.Both participants from ethnic minority and white backgrounds suggested they would like simple but meaningful practical formats for health advice, including regular exercise and cooking support, that were associated with a healthy lifestyle but delivered in ways specific to the community. For instance, a Black British Caribbean woman (65+ years) wanted to incorporate exercise, with different topics and ideas about how she would take the group outside to get fresh air. The social and collective stimulus was repeated with the suggestion that groups learn, support and share informal information in a way that promotes long-term communication associated with changing personal behaviours. A participant emphasised that“we need to meet up regularly and consistently. Peer support and good communication” .The social nature of these interventions was associated with inclusion and, for some, was not exclusively about their diabetes but was a ‘place-to-be’, where a sense of belonging was experienced. For example, a White British man (46–55 years) reflected that: “A safe place, a comfortable place…. I’d like to make a place where anybody can come. You don’t have to talk about it if you just want to come to sit. Have a cup of coffee—a bit like the men’s group”.Many wanted to see more proactive services associated with primary care. These were associated with the need for physical checks and professional advice from a service based on technical knowledge. There was a suggestion that the technical knowledge must be complemented with a different communication style and a more nuanced, local and community understanding. Overall, there was consensus among the participants concerning using and sharing collective wisdom and experiences to have culturally appropriate and accessible spaces that can stimulate participants to embark on active management of T2DM. This evaluation used AI and qualitative framework analysis synthesised into a TofC ,48) to p to p48])The TofC proposes that trusted local VCSE services are embedded into the diabetes care pathway alongside their primary and secondary care partners. The VCSE’s appear to offer nuanced information that can be delivered at a time and in a way that meets the needs of underserved communities and thus may be a more effective model of working. Short-term outcomes involve the use of current services by marginal communities, whilst longer-term service development and delivery may be undertaken by individuals from such communities, representing a deeper understanding of the needs of the population. It is noted that the multicultural service models and staffing are aligned to the community, and the sense of belonging afforded to communities by VCSE organisations is significant to the perceived impact, with VCSEs acting as coordinators across the community to achieve sustainable services which work for underserved communities within a complex health system.The themes contributing to the TofC suggest that a combination of statutory and VCSE services is available, but that many participants in this evaluation preferred to use ‘local’ advice and more community ‘embedded’ knowledge. An important finding was that the needs of individuals changed whilst living with diabetes. Initially, people with T2DM seek reassurance at an early stage post-diagnosis; however, latterly, they need to ‘check in’ and appreciate ‘technical’ support to monitor and manage the disease process. Primary care is recognised as the professional service and emphasises patient-centred, comprehensive care where communities are underserved, as is often the case with marginal and diverse ethnic groups . HoweverThe findings of the study are reflective of previous research; the Care Quality Commission (CQC) report ‘My diabetes, my care’ 2016) recommended the development of local plans to put people at the centre of their own care, with appropriate levels of support for self-management and ensuring emotional and cultural considerations are met . Similar016 recomVCSE services receive marginal and short-term funding to deliver pockets of activity . Their rThe strengths of this study lie in the collaborative working and co-design of the research tool and protocol between different organisations, which has built on existing relationships with VCSE providers and enabled access to seldom heard and more marginalised patient groups. The findings and the TofC were also shared with all VCSE groups and stakeholders within the region to obtain feedback and ensure that the process was transparent and representative of the data collection. If a strong collaborative process is established in the initial stages of a TofC evaluation, it can help assure that stakeholders will work with the evaluator to explore creative measurement strategies . HoweverThe study methodology had some limitations, as the participants were interviewed by staff members from a VCSE service that they had accessed, which may have constrained what they said about the organisation. There may have been selection bias towards those individuals who experienced a VCSE service more positively, and these individuals were likely to be more engaged with their own self-management of diabetes as they were accessing healthcare and VCSE organisations. However, the researchers believe this elicited high-quality data due to the prior relationship with the ‘trusted’ organisation and the interviews were not generally carried out by the participants’ usual contact at the VCSE organisation. Using non-academic researchers for data collection led to some inconsistencies in data collection. Still, the benefits outweigh the limitations, and the interview data collected are equally critical for all diabetes care providers. Other limitations may relate to the specific context and configuration of VCSE services that may not be replicated in other countries. Whilst the findings are recognised to be context specific, and have no clinical implications, they do have implications for changes in health and care utilization. Additional research to understand the perceptions of those who have not engaged with VCSE services would also be beneficial to determine factors which lead to engagement with such services. The initial TofC seeks to map the impact of services, and the study demonstrates again the preferences for tailored person-centred interventions delivered in a local context. There is value in assessing whether this TofC is replicable in other contexts, including different cultures and other long-term health conditions, and in assessing the impact of the VCSE sector on reducing the NHS burden.Participants with T2DM presented challenges associated with their diagnosis and early management and appreciated the consistent and embedded community support of the VCSE providers. Participants reported an inconsistent range of support post-T2DM diagnosis and very limited engagement with the main educational programme offered as a standard . The evaluation identified the benefits of hyper-local group activities, often employing peer-to-peer processes to share information about living with T2DM and providing support at a time which suited them. Advice, guidance and long-term support were only sometimes available but deemed important. The strength of the impact of VCSE organisations was associated with the engagement and continuous relationships with individuals, knowledge of the community and culturally appropriate provision ; there was still a demand for more responsive and cohesive support for lifestyle and behaviour changes. The services appear to strengthen the specific lifestyle behaviour change based on ‘what mattered’ to individuals—recognising and overcoming some barriers to accessing statutory care. The findings highlight a systemic and organisational issue which can be resolved by a cross-sector integrated health and care system which embeds the VCSE organisations into the diabetes care pathway. The TofC indicates that with consistent, sustainable funding and recognition, VCSE organisations can contribute valuable services targeted to more marginal and underserved communities. Other competencies through health coaching training or similar may be helpful and require collaboration across the sector to enable a specific response to diabetes management.


Violence exercised by children against their parents has increased significantly, affecting society both directly and indirectly. This type of violence is one of the least investigated and least exposed by the media. The aim of this work is to examine how the media have portrayed this problem, by means of a qualitative methodology and a multidimensional analysis of journalistic and literary texts. News related to violence committed by children against parents published from 2010 to 2020 were sourced from the following Spanish newspapers: El País, ABC, El Día, El Mundo, La Vanguardia, El Periódico, La Provincia, Canarias 7, 20 Minutos, and Diario de Avisos. The text corpus was subsequently analyzed with the open access software IRaMuTeQ. The results show a total of 204232 words (number of occurrences), of which 4561 appear only once (number of hapaxes). The words “violence,” “father,” and “son” are those that appear most frequently in the analysis of the texts and present a strong co-occurrence among them. It should be noted that child-to-parent violence is described as a problem confined to the family environment. The importance of prevention strategies against violence within the family context is shown in this paper. Family violence is a very important problem in society. It has various facets and can be carried out in various ways. Among them, the best-known types are child violence and gender violence, in particular violence against women . Although there have been some research teams studying the subject  can be defined as abusive behavior perpetrated against a parent by a legally recognized child who usually lives in the family home Holt, .Moreover, it is necessary to add the final definition of FPV proposed by the SEVIFIP Group of Experts, cited by Pereira et al. , p. 220:These definitions display different characteristics, such as the intention to cause harm, the presence of a legally recognized child, or a cohabitating parent in the same house. Unfortunately, in the last decade, the use of different conceptual and operational definitions to study YPA has affected the ability to identify risk factors for this type of abuse .The topic of “violence” is diverse and can be analyzed in various ways, but the aggression of young people toward their parents or caregivers has become a cause of social alarm in the last decade.To this end, the bibliographic review by Calvete and Perreira  is interAs for age, there are variations depending on “the methodology employed, the sample inclusion parameters and the criteria used to determine the age of the children” .Certainly in this latter respect, the bibliographic review by Calvete and Perreira  highlighFPV is usually a problem that does not spread outside the family environment, which is believed to be due to shame, rejection by society, or even fear of the reaction that the children may have. As a result, in order to protect the family environment, the victims prefer to keep quiet and to not transmit domestic occurrences outside the home  who, as a consequence of the aggressions, suffer stress and tension, as well as feelings of frustration, helplessness, and fear  and “La Provincia,” “El Día,” “Canarias7,” and “Diario de Avisos” (islands); and to discover if there were differences between newspapers in the treatment of FPV and to discern the relationship between the terms “father” and “violence” based on the studied variables together with the texts. Furthermore, we were interested in understanding the “clusters,” lexical classes, or categories that were formed when studying the full text corpus.In order to explain the results, we almost always appeal to what happened in the past, which, although a good predictor, may not coincide with our results. The introduction given to previous research  can then be studied through the analysis of the organization and distribution of co-occurring main words in the simple sentences of a text. This methodology focuses on the statistical distribution of successions of words that make up the sentences of a text; this does not consider the syntax of the discourse, but only the “co-occurrence” or simultaneous presence of several main words  in the same sentence, eliminating relational words from the analysis—namely, conjunctions, prepositions, and articles Reinert, . A clearThe preparation and tabulation of the text was conditioned by the presence or absence of the concept of FPV; therefore, only those texts in which the concept explicitly appeared were selected. To prepare the text, we used the procedure of selecting main words, verbs, and nouns, and the analysis software lemmatized the words to ensure there was no overlap; however, we applied the root for the final count.The selection of the terms for analysis was carried out jointly by the authors, together with the research team with whom we worked during the textual statistical analysis. The terms were chosen by a majority of the members; if a word created uncertainty or had a double meaning, it was eliminated from the text. The perspective guiding the choice was a clear relationship with the phenomenon of domestic violence. Although the program detected words that were irrelevant to this type of violence, as the authors of the texts were responsible for selecting the texts, they were kept as referents of the newspapers where they were published regardless of their ideological tendency.The database under analysis included news related to FPV that were published between 2010 and 2020 by the Spanish written press. In total, there were 119 news items obtained from 9 Spanish newspapers: El País, ABC, El Día, Diario de Avisos, La Vanguardia, El Mundo, Canarias7, La Provincia, and 20 Minutos.analyse statistique des données textuelles) was used, which is a lexicometric approach that originated in French-speaking countries and is still strongly rooted in continental Europe. It is mainly based on the comparison of lexical profiles and thus on the distribution of word occurrences without going through the direct reading of the text .A statistical analysis of textual data  program was used, which allows the analysis of texts and questionnaires  for analysis by the IRaMuTeQ program. For this, the archives of each newspaper were accessed and, by use of word search filters  that were limited to the years of publication and the keywords associated with the subject in question, the articles were selected one by one after verifying that they were relevant to the object of study. The FPV manual was incorporated complete with the same coding as the newspapers. Subsequently, so that the categorical variable would be the year of publication, the texts were grouped by year using an 8-bit Unicode Transformation Format (UTF8) to serve as the input for the IRaMuTeQ program as a text corpus, i.e., the chosen set of news items formed the corpus of the text on which the analyses were performed.The program carries out a stemming process, by which it reduces words to their roots, classifying them syntactically. This process facilitates the analysis and interpretation of the results, since it allows to choose what type of words to include in each analysis. Therefore, in our procedure, several lexicometric analyses were carried out in which both nouns and verbs were included: word frequencies, word cloud, analysis of specificities, descending hierarchical classification (Reinert Method), and analysis of similarities.The results obtained are divided into four sections, which correspond to the lexicometric analyses carried out: frequency and word cloud, specificity analysis, descending hierarchical classification, and similarity analysis. In the first section, we explore the characteristics of the text and the most frequent words. In the second section, we examine the relationship between the most frequent words and the year variable. The third describes the classifications of words found in the corpus, their interdependence, and their importance according to the year. In the last section, a global graphic representation of the words is provided, showing their frequency and co-occurrence.A frequency analysis was undertaken to provide an overview of the analyzed data: number of texts, number of total words, and grammar categories, etc. Some of these data are reflected in Some of the words that appeared most frequently were “violence” , “son” , “father” , “family” (749 times), “case” (657 times), “problem” (503 times), “mother” (480 times), “parent” (437 times), “adolescent” (347 times), and “child” (318 times), among others. These words can be seen in the “word cloud” depicted in The factorial analysis of correspondence allowed the semantic contextualization of the object of study, as well as the visualization of the distances between the textual corpus. As shown in The results obtained, both in the descending hierarchical classification and those described in the factor analysis of lexical correspondence, could be considered the most interesting of the study. The descending hierarchical classification, as shown in In order to analyze the co-occurrence between terms, we used the similarity analysis technique. This analysis makes use of a graph that represents the connection between words in the analyzed textual corpus, which makes it possible to identify the existing co-occurrences between them. It also helps to identify the structure of a textual corpus and distinguishes common parts and specificities. As shown in The results obtained in this study show that the press in general, and the Spanish press more specifically, reflect in their texts the contemporary reality. In the case that concerns us, FPV is captured in a different way in 2010 than in 2020. The main objective of this study was to analyze the vocabulary used in the different newspapers that refer to FPV and the relationship and concordance between the words that comprise it. In the analysis carried out, the lexicon takes on a special relevance, since it expresses contents or concepts by which the meaning of words is studied, as well as the different relationships that are established between the terms. In this work, FPV appears to be associated with terms such as father, mother, child, interpersonal relationships, authority, government, and measures, among others.The examined newspapers differ in their ways of approaching this phenomenon, since they do so from different spheres, such as the family, judicial, institutional, and academic spheres. Likewise, in the division of the “clusters,” similarities were observed between them, since terms such as “violence,” “son,” and “father” are among the terms most frequently most used by all journalists.The frequency analysis provided a quick overview of the most frequently used words over the last decade. The most frequently repeated word is “violence,” after which follow others such as “father,” “son,” or “family”, which are the most frequently occurring after “violence” but nonetheless remain far behind in the number of times they are repeated. When looking at these results, one might note that while the word “father” appears as the second most used word, the word “mother” is the sixteenth.With the analysis of specificities, we observed the variations in frequencies according to the year. The most striking change in this analysis was the great presence of the concept of “violence” in a dominant way throughout much of the decade. However, in 2020 the trend changed, and the most used word became “father.” In the factorial analysis of correspondences, the two factors were presented, and the distance between the corpora was observed. It is clearly seen how the four clusters remain independent: on the one hand the institutional section, on the other the one related to people and their processes, and thirdly the one related to the facts, violence, complaint, and abuse.The descending hierarchical classification shows these “clusters” or lexical classes: the first class focused on the institutional–judicial sphere, with terms such as “program,” “government,” “center,” or “justice”. The second class focused on everything related to personal feelings, with terms such as “frustration,” “fear”, “shame”, “syndrome,” or “bad” centered on the “child” or the “father”. The third class was related to family conflict, with terms such as “relationship,” 'parent,” “child,” “behavior,” “difficulty,” “attachment,” or “separation”. Finally, the fourth class focused on the act of “violence,” with elements such as “aggression,” “mistreatment,” “abuse,” “aggressor,” “denunciation,” or “threat.”This classification reflects the characteristics of the phenomenon, which has only recently been investigated in the literature.With regard to the first cluster, and in particular the judicial effects of the phenomenon, the mass media tend to confuse the judicial and institutional consequences of the phenomenon of child-to-parent aggression with those of adolescent-to-parent aggression. However, as in early childhood aggression, less harm is caused, and the consequences are not as serious. The parental role in this developmental stage is different from that of young people, as are the legal consequences for children and parents. Furthermore, aggression by young children hardly results in physical injury, although it may cause emotional distress to parents and continues into adolescence and adulthood, the latter in the sense of violence against an intimate partner Ibabe, .In relation to personal feelings—the second cluster—internal factors such as shame and external factors such as social judgment on parenting skills lead the victim to deny or minimize the phenomenon , in doing so dismantling the causality between mental health and FPV , because many young people still live with their parents after becoming legal adults, although it is not necessary for parents and children to reside together for abuse to happen.Since risk factors and patterns of abuse may evolve with age, it is important to study different development phases, starting with children under 14 years of age—whose cases are seldom processed by the mass media—up to young adulthood.In conclusion, in samples of Spanish teenagers, young people, and adults, it is common to find more psychological violence perpetrated by girls than boys, with no gender difference detected in physical violence. However, other studies have found higher rates of parental violence in young boys, leading to the hypothesis that CPV patterns change with the age of the young person.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.JT, MW, and MP have made substantial, direct, and intellectual contributions to the work. All authors have approved it for publication.


Background: An Advanced Practice Nurse (APN) is a specialized nurse who has acquired context specific knowledge, complex decision-making skills, and clinical competencies. Previously in Norway, APN education programs had a prerequisite of a minimum of two years of clinical nursing experience. Recently, the government decided to abandon this prerequisite. Objectives: The objectives of this study were to assess APN’s and APN students’ (1) perspectives on the impact of clinical nursing experience on various aspects of nursing practice, (2) perspectives on the association between APN students’ previous clinical experience and the ability to achieve the learning outcomes in the education program, and (3) attitudes towards clinical nursing practice as a prerequisite before entry to APN education programs. Design: An observational, cross-sectional design. Methods: APN and APN students were invited to respond to a researcher-developed questionnaire. A snowballing sampling method was used. The questionnaire included 24 questions scored on a five-point Likert scale, and two questions with text responses. Quantitative data were analyzed using descriptive statistics, and text responses with thematic analysis. Results: In total, 1767 APNs (92.9%) and APN students (7.1%) responded. Between 93.6 and 98.2% of the respondents (n = 1767) agreed that clinical nursing experience leads to experience with communication, collaboration, basic procedures, medical equipment and documentation, and to the development of situation awareness, increased awareness on own role in teams, the ability to provide person-centered nursing, an independent nursing identity, and feeling of security. Over 90% of the respondents agreed that students’ previous clinical experience was associated with the ability to achieve the learning outcomes in the APN program. In addition, 93.7% of the respondents agreed that clinical nursing experience should be a prerequisite before entry to APN programs. Advantages of clinical experience were reported as ‘Professional identity’, ‘Intuitive grasp’, ‘Integration of technical skills’, and ‘See the whole picture’. Disadvantages were reported as ‘Prejudice and bad habits’, ‘The importance of relevant experience’, and ‘Recruitment issues’. Conclusion: This study adds insights into the impact of clinical nursing experience as a prerequisite to APN education programs. The results indicate that clinical nursing experience is an essential contributor to the development of nursing competence and a nursing identity. This study was not registered. In March 2023, the International Council of Nurses (ICN) stated that the worldwide shortage of nurses should be treated as a global health emergency . Among tAccording to the ICN, an Advanced Practice Nurse (APN) is a generalist or specialized nurse who has acquired, through additional graduate education (minimum of a master’s degree), the expert knowledge base, complex decision-making skills, and clinical competencies shaped by central criteria and core competencies in a specific context . The EurPrerequisites for entry to APN programs vary internationally ,15,16,17In 2011, Burns  identifiThe objectives of the current study were to assess APN’s and APN students’ (1) perspectives on the impact of clinical nursing experience on various aspects of nursing practice, (2) perspectives on the association between students’ previous clinical experience and the ability to achieve the learning outcomes in the APN education programs, and (3) attitudes towards clinical practice as a prerequisite before entry to APN education programs.The study had an observational, cross-sectional design, using a researcher-developed questionnaire. The study adheres to the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist .The study was conducted throughout Norway, in various APN settings: anesthesia, cancer, critical care, operating room, and pediatric nursing environments. The study was conducted over eight weeks in July–August 2023.A snowballing recruitment method was used : Informan = 15), perceived associations between APN students’ clinical nursing experience and the ability to achieve the learning outcomes in the APN education (n = 3), and about the necessity of clinical nursing experience before entry to an APN education program (n = 6) were developed. Response alternatives were on a five-point Likert scale, where 1 = totally disagree, 2 = disagree, 3 = neither disagree nor agree, 4 = agree, and 5 = totally agree. In addition, two text-alternative questions were added: ‘What is the advantage of having clinical experience previous to entry to an advanced nursing program?’ and ‘What is the disadvantage of having clinical experience previous to entry to an advanced nursing program?’.A questionnaire was developed based on studies focusing on nursing students and nurses’ technical skills and self-assessed competence ,27,28,29Background variables collected were the type of specialization the respondent had or studied, and, to respondents experienced with supervising APN students, how many students they had supervised. See No sample size calculation was performed, since the aim was to include as many APNs and APN students as possible.The Statistical Package for the Social Sciences (SPSS) version 28 was used to analyze the quantitative data. Descriptive statistics were used, and results are presented as n (%) or mean . No methods for calculation of missing values were used, and the number of respondents is presented for each question.A simplified thematic analysis, in-line with the recommendations of Braun and Clarke, was used to analyse the text responses . First, The study was based on the research ethical principles in the Declaration of Helsinki, on willing participation, informed consent to participate implicated by completion and submission of the questionnaire, anonymity, and confidentiality. According to Norwegian legislations, no approvals are necessary when data is anonymous, no sensitive information is collected, and patients are not included .In total, 1767 APNs/APN students responded to the questionnaire. In total, 1193 respondents answered the question “What is the advantage of having clinical experience previous to entry to an advanced nursing program?” Through analysis, four themes were identified, namely ‘Professional identity’, ‘Intuitive grasp’, ‘Integration of technical skills’, and ‘See the whole picture’.‘Professional identity’ was reported by many of the respondents as linked to a feeling of safety when providing treatment and care, both professionally and personally. One of the respondents wrote: ’One may not see own weaknesses and limitations before gaining more experience, and then look back on how unexperienced one was in different situations.’ Another respondent wrote: ‘Have seen patients in different situations, and learnt how oneself handles stressing and challenging situations’. Other statements were: ‘Build a minimum standard of comptence necessary to understand enough to handle new situations, and feeling safe doing it’, and ‘Experience with critically ill patients, clinical observation skills, safety in the nursing role, situational awareness, team experience, prepared for emergencies, know the equipment, lab results, digital journal systems, different drugs, CPR, emergency procedures and much more. This would be overwhelming for a new nurse and a barrier to acquire new and advanced knowledge and skills’.‘Intuitive grasp’ was reported by some of the respondents as “clinical view” (in Norwegian: Klinisk blikk), something that needed years of experience to be developed. This was described by one of the respondents as: ‘You cannot read your way to a clinical view, and you don’t have enough time during the specialization to learn it. It makes it easier to focus on the essential in the education’. The words “Klinisk blikk” were used independently, and together with other terms, like “observations”, “experience”, “various patients”, or “various situations”. This again led to the fact that nurses knew what to do, based on previous experiences. In addition, this led to an ability to observe and assess the patients’ condition.‘Intergration of technical skills’ was linked by some of the respondents to the development of competence in various technical skills, such as basic and advanced procedures, using various medical equipment, documentation, and drug administration. One of the respondents wrote: ‘Relevant practice will contribute to that the student doesn’t need to use time or energy learning basic procedures or acquire basic knowledge, but may focus on the specialization’. Another respondent wrote: ‘During the bachelor education one learns principles, theory and procedures, but it’s in clinical practice one gets volume training and experience. This is why clinical experience is essential, to be able to take the right decisions when facing critically ill patients, to ensure them safe and secure treatment’.‘See the whole picture’ was related to all of the above themes, including both professional identity, intuition, and technical skills in the provision of person-centered nursing care. One respondent wrote: ‘Whole picture, associations, understanding’. The whole picture was related to both the patient pathway from prehospital, through the emergency department, via surgery to a ward, and then back to the municipality, and the whole patient, seeing individual needs, and being able to observe and assess the patients’ overall condition.In total, 1173 respondents answered the question “What is the disadvantage of having clinical experience previous to entry to an advanced nursing program?” Of these, 548 responded “No disadvantages”. In addition, 13 respondents wrote ‘I don’t know’. Analysis of the remaining answers (n = 625) led to the identification of three themes, namely ‘Prejudice and bad habits’, ‘The importance of relevant experience’, ‘Recruitment issues’.‘Prejudice and bad habits’ was reported as, for example, ‘Having meanings of their own, difficult to correct’, ‘Being colored by previous work culture’, ‘Established an inappropriate behaviour’, or ‘Think they know everything’. One of the respondents wrote: ‘It may happen that you’ve learnt something that must be unlearnt. The culture you take part in as a nurse matters. Different wards have different focus. I’ve experienced that some wards are sloppy with basic nursing…for example hygiene and the importance of proper nutrition in illness’. Another respondent wrote: ‘Experience may lead to prejudice, that they think they know the answer because they’ve seen something before’. These issues were reported as a disadvantage, comprising a barrier to new impressions, and nurses then being difficult to supervise.‘The importance of relevant experience’ was linked to both that it could be difficult to get relevant clinical experience, and that the clinical experience nurses had before entry to the APN education program did not have any relevance to the specialization. Three of the respondents wrote: ‘It depends on what type of clinical experience one has’. Another respondent wrote: ‘If the clinical experience is irrelevant. One would have some experience from specialized wards, so one has seen very ill patients’. However, five of the respondents said that it could be difficult to get such experience because some specialized wards only recruited internally. One of the respondents also meant that the clinical nursing experience should be related to the specialization. The respondent exemplified this: ‘Clinical experience from a postoperative ward or an emergency department would in my opinion be more useful for a student nurse anesthetist, than experience from for example home-based services’. Irrelevant clinical experience was hence reported as a disadvantage leading to a lack of clinical awareness or lack of relatable experiences.‘Recruitment issues’ was linked to both recruitment of APNs and recruitment to the APN education programs. Regarding recruitment of APNs, respondents perceived that requiring experience lead to ‘older nurses’, ‘nurses in the establishment phase, making it difficult economically to be a student’, or ‘nurses not used to study, having more difficulties with the academic level’. Moreover, a few of the respondents stated that requiring clinical experience would lead to longer educational paths for students. One of the respondents wrote: ‘It takes longer time to educate an APN’. Another respondent wrote: ‘It’s a disadvantage for the development of the profession, because we get educational courses so late in life…One may never get started, or start the education late in life’. Regarding recruitment to the education itself, some stated that nurses would choose not to specialize at all due to their age or economic situation. One of the respondents wrote: ‘Can be more difficult to recruit when other education programs allow going directly from a bachelors’ to a masters’ degree’.The majority of the respondents in the current study agreed that clinical nursing experience provides experience with various aspects of nursing, situational awareness, and an ability to work in teams. The majority also agreed that clinical nursing experience leads to the development of an individual nursing identity and a feeling of security in professional work performance. From the respondents’ perspective, this leads to an ability to provide person-centered nursing, increased efficacy, and patient safety. Most of the respondents also reported an association between APN students’ previous clinical experience and their ability to achieve the APN education program’s learning outcomes. In total, 93.7% of the respondents agreed that clinical nursing experience should be a prerequisite before entry to an APN education program in all educational institutions. The advantages of previous clinical experience were related to development of a professional identity, intuitive grasp, integration of technical skills, and an ability to see the whole picture. Disadvantages were related to the fact that students may have prejudice and bad habits, that their experience was not relevant to the speciality, and recruitment issues.The majority of the respondents in the current study agreed that clinical nursing experience provides experience in various aspects of nursing practice, such as communication, medical equipment, basic and advanced procedures, documentation, and independent task solving. This is supported by previous research indicating that newly qualified nurses experience that the clinical demands are complex and overwhelming. They wish for higher competence in context-specific situations, and better knowledge about procedures they are expected to master ,33,34. HMost respondents in this study agreed that clinical nursing experience develops situation awareness, team awareness, and an ability to provide person-centered nursing, which again develop an individual nursing identity and a feeling of security. Skills such as situational awareness and teamwork are central non-technical skills  that havThe majority of the respondents in the current study agreed that clinical nursing experience should be a prerequisite before entry to APN education programs. This may be seen as obvious, bringing the responses to the remaining questions into the calculation. Of course, it may be assumed that APNs or APN students who are mainly positive to such a prerequisite chose to respond to the questionnaire, and hereby represent a selection bias. However, these findings add to the international knowledge base regarding prerequisites to APN education programs. Only two previous studies have been identified exploring similar aspects ,22, bothSeveral advantages and disadvantages with previous clinical nursing experience as a prerequisite for entry to APN education programs were identified. Advantages were related to development of a professional identity, intuitive grasp, integration of technical skills, and an ability to see the whole picture. These aspects align, to some degree, with the above mentioned study of competence and proficiency in nursing , non-tecThe ICN has underlined the importance of structured career opportunities, access to continuing education, and optimizing the workforce by APN roles, as contributors to the retention and attractiveness of nursing . HoweverOne of the major limitations of this study is that no validated questionnaire exists. However, the questionnaire was developed based on previous research findings by an APN professor well experienced with development and validation of questionnaires. A traditional, acknowledged, five-points Likert scale was used. Of course, the questionnaire could have been piloted to increase the face and content validity. Unfortunately, this was not done. As such, one of the respondents stated in text that it was ‘obvious what the questionnaire was intended to report, namely that clinical experience as a prerequisite before entry to an APN education program is necessary’. However, to avoid this, the questionnaire also included negatively loaded questions, as well as text alternatives. The same respondent claimed that nurses without a specialization also should have been invited to participate, since they may have important input.Another major limitation is that the questionnaire was distributed through Facebook and emails. A 2017 systematic review exploring the use of Facebook as a recruitment method concludes that there is growing evidence to suggest that Facebook is a useful recruitment tool and its use, therefore, should be considered when implementing future health research . Still, The text responses were not very extensive, which limited a thorough analysis of the respondents’ perceptions and attitudes. Hence, a qualitative approach would have provided more in-depth information of APN and APN students’ perception of the impact of clinical experience, or lack thereof, before entry to an APN education program. The analysis was conducted by one researcher only, which limits the credibility and dependability of the analysis. However, a transparent description of the analytic steps, as well as the available dataset, will hopefully increase the trustworthiness of the results.The snowballing recruitment method and the lack of sample size calculation may limit the generalizability of the study findings. Some of the specializations had very few respondents, and information about gender, age, or years of experience as an APN was not collected. A systematic review of national and other large-scale user experience surveys in local quality work found that the number of survey participants varied from 11 to 545 , which mThe researcher is a nurse anesthetist with extensive clinical experience and experience as an educator and researcher. It may be claimed that this is a bias. However, the quantitative research design provided data that could be counted and analyzed statistically. The dataset is attached as The results of this study indicate that clinical nursing experience is an essential contributor to the development of professional competence and a nursing identity. APNs and APN students perceive that there is an association between previous clinical nursing experience and the ability to achieve APN education programs’ learning outcomes. Conclusively, the reasons for not including clinical nursing experience as a prerequisite for entry to APN programs should be carefully considered.Even if the results in the current study are unambiguous, more research is needed, including information about respondents’ gender, age, and years of experience as an APN. The perspectives of APNs and APN students who do not support clinical nursing experience as a prerequisite should also be explored. Also, the perspectives of leaders and policymakers should be assessed. Further studies should also assess the outcomes of omitting clinical practice as a prerequisite to APN education, regarding e.g., whether students complete the programs, their competence directly after completion of the program, and also perhaps some years after the APN education.