M age = 86 y/o) hospitalized in a geriatrics unit participated in four individual therapy sessions: one classic therapy (CT) session (patient- therapist) and three RAT sessions (patient-therapist-robot). Outcome criteria for the evaluation of the intervention included: participant's engagement, emotional state and well-being; satisfaction of the intervention, appreciation of the robot, and empathy-related behaviors in human-robot interaction (HRI). Results showed a high constructive engagement in both CT and RAT sessions. More positive emotional responses in participants were observed in RAT compared to CT. RAT sessions were better appreciated than CT sessions. The use of a social robot as a mediating tool appeared to promote the involvement of PwD in the therapeutic intervention increasing their immediate wellbeing and satisfaction.The interest in robot-assisted therapies (RAT) for dementia care has grown steadily in recent years. However, RAT using humanoid robots is still a novel practice for which the adhesion mechanisms, indications and benefits remain unclear. Also, little is known about how the robot's behavioral and affective style might promote engagement of persons with dementia (PwD) in RAT. The present study sought to investigate the use of a humanoid robot in a psychomotor therapy for PwD. We examined the robot's potential to engage participants in the intervention and its effect on their emotional state. A brief psychomotor therapy program involving the robot as the therapist's assistant was created. For this purpose, a corpus of social and physical behaviors for the robot and a “control software” for customizing the program and operating the robot were also designed. Particular attention was given to components of the RAT that could promote participant's engagement . In the pilot assessment of the intervention nine PwD (7 women and 2 men,  Psychosocial interventions, such as cognitive stimulation, physical activities and art-mediated therapies, play a key role in dementia care. Several studies show a positive impact of these interventions on the well-being, cognition, social life and daily functioning of persons with dementia (PwD)  for PwD have used the seal robot PARO . Several studies have reported beneficial effects of PARO in PwD, such as an improvement on general well-being and social interaction  between PwD and humanoid robots.engagement in RAT could prove useful. Indeed, one of the factors contributing to the effectiveness of dementia care interventions is their ability to engage participants and ensure their adherence. Engagement in this context has been defined by the act of being occupied or involved with an external stimulus  , a specific approach, particularly useful for RAT, to assess engagement in PwD using video coding.In this respect, the assessment of participant's Another aspect that has been little discussed is how to program a humanoid robot to provide PwD with a natural and positive interaction, and consequently, to improve the acceptance of the robot. The work by Hamada et al.  providesIn their analysis of main challenges of socially assistive robotics, Tapus et al.  explaineThe main objective of the present study is to investigate the feasibility of using a humanoid robot as an assistant in psychomotor therapy for PwD. The robot's potential to incite the engagement of PwD in the activity and its effect on their emotional state will also be studied. In order to increase RAT acceptance, particular attention will be given to the definition of some components of the RAT: defining a highly acceptable and empathic interaction style for the robot, tailoring the program contents to the preferences and capacities of participants, and creating a framework for RAT based on the triad composed by the therapist, the patient and the robot.This paper is structured as follows; first we describe the design process of the robot-mediated psychomotor therapy program, including general technical aspects of contents creation and robot programming. Then, we present the experimental pilot study conducted to assess feasibility and immediate effects of the intervention. The last section of the paper provides a general discussion of results and some suggestions for future studies in RAT for dementia care.Introduction: Time for greetings and introduction of the robot (RAT).Motor section: The section begins with a warm-up exercise by which the person is brought to rediscover and move different parts of his/her body . This exercise should contribute to raise patient's alertness and allows him/her to be physically and mentally available for the session. Then, a sequence of gestural movements is modeled by the therapist (CT), or the robot (RAT), to be repeated step by step and learnt. By stimulating the patient's motor capacities, the therapist also seeks to improve his/her awareness of preserved functional and interaction abilities.Cognitive stimulation section: The section begins with some personalized questions tailored to the patient's life history and interests being formulated by the therapist (CT) or the robot (RAT). The second part of this session is devoted to ask the patient some questions about his own body. The purpose of this activity is to elicit verbal exchanges in fields that were familiar to and enjoyed by the patient and to help him/her increase his/her body awareness.Body expression section: The patient is invited to imitate a choreography in three steps, associating a sequence of movements to a series of brief meaningless sounds such as “BA, DA, KA.” The sequence is presented and modeled by the therapist (CT) or the robot (RAT). The aim of this section is to stimulate body expression through movement, voice and emotion.Conclusion: The session ends with a series of breathing exercises allowing the participant to relax. The exercises are presented and modeled by the therapist (CT) or the robot (RAT). A time of verbal exchange is proposed to the patient at the end of the session.A psychomotor therapist conceived a short therapeutic program for PwD structured in four individual sessions: a classic therapy (CT) session, in which the patient was alone with the therapist, and three RAT sessions, in which the therapist was assisted by the robot NAO. Each session comprised five sections described as follows:Different scenarios were created in order to anticipate possible interaction sequences involving the patient, the therapist and the robot. Verbal and non-verbal robot behaviors required for each sequence were carefully defined taking into account the technical possibilities of the robot Figure . During Once the therapeutic program was defined it was submitted for validation by a multi-disciplinary team . Then, a computer engineer proceeded to program the robot including its behaviors and personality features. A “control software” allowing the personalization of the therapy sessions and the operation of the robot was also created. During this conception and development phase of the program, the psychomotor therapist and the engineer worked together enabling continuous feedback on the quality of the robot's movements and interactions.customization and intuitiveness. Regarding customization, the software was designed to adapt the contents of the therapy program and some robot's features to each participant's capabilities and preferences. Customization is a key aspect in dementia care interventions to foster engagement and positive emotional responses. With this purpose, the following customization parameters were implemented: (a) adding the person's name so the robot could use it to address each person in an individualized manner, (b) selecting individual and familiar contents for the therapy activities ; (c) adjusting some general robot parameters  according to each person's preferences and needs to provide the best possible user experience. Intuitiveness of the control interface was highly desired to ensure an easy navigation during therapy sessions, and so to allow the operator to smoothly initiate and stop robot's behaviors. The control software was created using Python language and the user interface was created with the program Qt Designer.The design of the control software for operating the robot took into account two main criteria: structure files which contained the raw code to run the software were: (a) the core module, and (b) the associated modules, used to define the functionalities related to movements, audio contents, properties, and software buttons. Design files contained the code to set and view the user interfaces. The connection to a virtual NAO robot (Choregraphe software) was set up in order to facilitate the implementation and testing of the robot's behaviors without having to connect the robot in real-time. Figure The control software encompassed two kind of files: structure and design files. The central menu .The control interface, at the top of the screen, included a menu ,” “Look at me X (name of the person)”), to regularly encourage and praise the user , to react when the user requested the robot to make something the robot wasn't programmed for , and finally to operate other robot's behaviors .Additional options were proposed to deal with the loss of attention of the user . See Each tab of the main interface Figure  correspoThree managers were accessible from the “Settings” menu on the main control interface to handle mime exercises, music and audio settings in an easy way Figure . For exainteractivity, the robot coexists with an interactive person in the same time-space continuum; (b) equifinality, the robot is able to adapt to each person and the same objective may be reached in different ways; and (c) multimodality, the robot is able to interact with a human using different communication channels  . Some empathy signs, such as (a) the ability to recognize other person's emotions; (b) to communicate with persons; (c) to display emotions; and (d) to take perspective . The intervention program consisted in 4 individual sessions of psychomotor therapy including: one classical psychomotor therapy session (CT) (therapist-patient) and 3 RAT sessions (therapist-patient-robot).Nine persons  hospitalized in a geriatrics unit, took part in the study. Inclusion criteria were: having a clinical diagnosis of neurodegenerative dementia and having signed a consent form. Exclusion criteria were: severe dementia (MMSE <10/30), sensory deficit (vision and hearing) and severe acute illness impeding the participation in RAT sessions.A NAO robot, Version V4 (Softbank robotics).The “Choregraphe” software (Softbank robotics), a multi-platform application allowing the creation of behaviors for the NAO robot, its monitoring and control (version 2.1).A “home-made” software developed to create robot's behaviors, customize sessions, and monitoring and control the robot. The software is described in Section The Psychomotor Therapy Program.“The Observer XT” software, version 11.5 (Noldus), for video-based behavioral analysis.The “Mini Mental State Examination” (MMSE)    , for assessing immediate wellbeing and quality of life of elderly people in nursing homes , (b) an “at ease/relaxed” category was added to the emotional engagement dimension in order to take into account the flat affect and limited facial emotion responses commonly observed in PwD. Table The “Menorah Park Engagement Scale” (MPES) ; and the other to evaluate the pleasure while using the robot in RAT sessions (Question was: Did you enjoy the presence of the robot?) Each VAS was scored between 1 and 5 .Additionally, two Visual Analogic Scale (VAS) were built for the purposes of this study. One to assess the satisfaction of participants regarding each therapy session (Question was: The protocol of the study was explained to the Geriatrics Unit nursing staff and the geriatrician (MD) responsible for the unit who helped to identify the patients who met the criteria to take part in the trial. Two researchers contacted each potential participant and his/her relatives and gave them details on the study and the intervention. If the patient had given verbal consent to participate, an appointment was scheduled in order to make the inclusion. This study was carried out in accordance with the recommendations of Paris Descartes ethical procedures and included written informed consent from all subjects according to the Declaration of Helsinki.On the day of the inclusion, after written consent was obtained, a clinician collected socio-demographic data and conducted the baseline neuropsychological assessment for the definition of the participant's profile  who operated the robot was sitting back in the room with the computer which remained visible to the participant. The experimenter used the Wizard of Oz (WOZ) technique to remotely control the robot's movements, speech, and gestures Kelley, .The encoding and analysis of the video recordings was carried out by two researchers using the adapted form of the MPES  was observed in RAT but its duration was very short to consider the robot as a source of distraction.r = 0.68, P < 0.05, Spearman's rank correlation), showing that patients presenting behavioral symptoms such as apathy or agitation responded well to RAT. The correlation between Constructive Engagement and neuropsychiatric symptoms was not observed for the CT session. Furthermore, no association was observed between cognitive status (MMSE) and Constructive Engagement (independently of the condition).We analyzed the relationship between Constructive Engagement, cognitive status (MMSE) and neuropsychiatric symptoms (NPI). The levels of Constructive Engagement in RAT sessions and the severity of neuropsychiatric symptoms were positively correlated , relaxed/at ease , and pleasure-related . In both conditions participants appeared to be most of the time relaxed and at ease (91% of the time in CT and 87% in RAT). Negative emotional responses were practically non-existent. Obvious pleasure-related responses were noticed during short periods of time, compared to the prevalent neutral/relaxed facial expression of participants during the therapy sessions. Nevertheless, results showed a significant statistical difference (p = 0.018) between CT and RAT sessions regarding the duration of pleasure-related responses (9 and 13% respectively)  was assessed using the difference in the EVIBE score after and before each therapy session. Highest scores indicate a highest improvement in immediate wellbeing. EVIBE scores showed a greater improvement in wellbeing in RAT sessions than in CT sessions (0.56 vs. 0.22 respectively), but this difference was not statistically significant.positive affects   and a decrease of negative affects   that was not statistically significant.The person's emotional state in the short term was analyzed by comparing the PANAS score at the baseline (baseline) and at the end of the intervention program. Results showed a significant improvement of p = 0.027). The robot was very well accepted by all participants as shown by a satisfaction score of 4.7/5.Globally, all participants were satisfied with the intervention program. However, PwD preferred the RAT sessions rather than the CT one (RAT 4.31/5 vs. CT = 3.63/5). This difference regarding the modality of the therapy was statistically significant  and initiated little or no dialogue with it. Among those three PwD, one participant rarely responded to the robot with a nod of his head and mostly answered the question looking at the therapist. The other six participants responded to the robot questions with complex sentences and spontaneously initiated conversations with it. As shown in Table Qualitative analysis of video recordings showed that, when talking directly to the robot, three out of nine participants mostly used short sentences . The operator would then select the category wanted and a menu would display a page grouping again various subcategories of actions according to the choice. Adding a random option for some behaviors, such as the “Encouragements,” that would be operated by using a single button instead of using a specific button for each phrase also goes in this direction;Defining a decisional tree of actions allowing to link automatically one action with the previous one, as proposed in the study of Sehili et al. . It would be interesting to adapt the control software to allow its use on a tablet, a smartphone, or any other mobile tool. After simplifying the software, the therapist could be able to operate the robot by himself. This solution has already been put into practice in other studies , increased manifestations of pleasure in RAT sessions, compared to CT sessions, a better appreciation of RAT sessions over CT sessions, and the exhibition of a wide range of empathy-related behaviors of PwD during RAT. All these findings represent good indicators of the advantage of using a humanoid robot for this kind of therapeutic intervention.choice of a humanoid robot: The humanoid aspect of NAO is a factor that facilitates its acceptance. Previous studies in this area had already confirmed the acceptance of this humanoid robot among elderly users  the direct empathy, allowing the attribution of emotions and views to others; (c) the reciprocal empathy, thinking that another is able to feel our own emotions; and (d) the intersubjective empathy, thinking that others can bring us knowledge about ourselves and our emotional states. In our study eight participants showed direct empathy with the robot, that is, they attributed the robot emotional states and its own perspectives. Two persons showed reciprocal empathy, imagining that the robot was able to guess their emotions, or that the robot had emotions in their regard. One participant, showed intersubjective empathy by telling NAO that his compliments made him proud.In order to better understand the quality of the interactions of PwD with NAO in our study, we used the model of empathy applied to HRI, proposed by Tisseron et al. . This moWe observed conversely that when empathy-related behaviors toward the robot were absent, or uncommon, the adherence to the RAT appeared to be lower. In our study, the only participant who did not address the robot directly, did not attribute emotions to it, neither used qualifying adjectives when talking to/about the robot, appeared disengaged from the therapeutic activity. In sum, empathy toward the robot seems to be associated to engagement in RAT, but more research is needed to better measure and understand this association.The therapeutic framework: In our study, the therapist was a vehicle for constructive engagement in the CT sessions. The NAO robot, by its social characteristics, its humanoid aspect, and its social and affective behavior, also had the effect of engaging actively PwD. However, it is not possible to conclude that engagement observed in RAT is entirely due to the NAO itself. We observed that the therapist had an essential role in facilitating HRI as well. Indeed, at several times the therapist showed the participant how to talk to the robot or to touch it. The therapist in our framework created a true collaborative relationship with the robot as her assistant, contributing probably to help the participant accept and collaborate with the robot in a similar way. Further studies should explore this finding by comparing engagement of PwD in the three conditions: the therapist alone, the robot alone, and the therapist and the robot working together.(e) Overall results of this pilot study showed elevated levels of constructive engagement in both conditions (CT and RAT) comparatively higher in the first one. Conversely, passive engagement was more pronounced in RAT sessions. Though these results did not reach statistical significance, they are consistent with Cohen-Mansfield et al.  study inFrom a methodological perspective, we found video-analysis to be a suitable method to examine and measure behavioral and emotional engagement in PwD during the course of an activity. However, the categories of engagement originally used in the MPES . Since the assessment of clinical effects of the intervention was not the objective of the research, we accepted to keep the disparity between the two conditions; however, this choice impacted the quality of the results and limited the possibilities of analysis. Further studies should include a control condition truly comparable with the experimental one in terms of contents and frequency.Finally, the results of this research should also be interpreted taking into consideration the technical possibilities of social robots today. In our experiment the robot NAO was completely controlled by an external operator who used the WOZ technique. Consequently, the observed interactions between NAO and the patients who took part in the study do not reflect to the current capabilities of such a robot. Indeed, we observed very positive HRI during RAT sessions. However, most of these interactions took place between humans: the patient, the therapist and the “wizard” who operated the robot. The fact that the robot behaved very “humanly” could explain why levels of engagement were very similar in the CT condition and in RAT sessions. We believe that this kind of “controlled” experiments are necessary to progress in the definition of the framework of RAT. Nevertheless, it seems important that future studies integrate progressively robot automation in order to examine the real possibilities of HRI with persons with cognitive impairment.The results of this exploratory study confirmed the feasibility of robot-assisted psychomotor therapy for PwD. We were able to identify some encouraging indicators in favor of using the NAO robot in such kind of therapeutic program: a very good appreciation of the robot within this context, high positive emotional responses in RAT sessions, a better appreciation of RAT sessions, and a positive correlation between engagement of PwD in RAT sessions and the level of neuropsychiatric symptoms. Indeed, the robot NAO can be considered as a mediating tool favoring patients' engagement in psychomotor therapy when the therapist finds it difficult to motivate and involve the person in the intervention.After improvement and simplification of the control software a larger trial would help to examine the clinical benefits of this kind of intervention, and to better understand the emotional impact of social robots in PwD. Future studies should also focus on the conception and assessment of other kinds of RAT for dementia care, such as physiotherapy or speech therapy.NR and LR have equally contributed to the development of the study, data acquisition, analysis and interpretation. MP conceived and supervised the study. MP, NR, and LR drafted the article, AR, CM, and HL participated in revising it critically. All authors read and gave final approval of the version submitted.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Social Prescribing is a service in primary care that involves the referral of patients with non-clinical needs to local services and activities provided by the third sector . Social Prescribing aims to promote partnership working between the health and the social sector to address the wider determinants of health. To date, there is a weak evidence base for Social Prescribing services. The objective of the review was to identify factors that facilitate and hinder the implementation and delivery of SP services based in general practice involving a navigator.We searched eleven databases, the grey literature, and the reference lists of relevant studies to identify the barriers and facilitators to the implementation and delivery of Social Prescribing services in June and July 2016. Searches were limited to literature written in English. No date restrictions were applied. Findings were synthesised narratively, employing thematic analysis. The Mixed Methods Appraisal Tool Version 2011 was used to evaluate the methodological quality of included studies.Eight studies were included in the review. The synthesis identified a range of factors that facilitate and hinder the implementation and delivery of SP services. Facilitators and barriers were related to: the implementation approach, legal agreements, leadership, management and organisation, staff turnover, staff engagement, relationships and communication between partners and stakeholders, characteristics of general practices, and the local infrastructure. The quality of most included studies was poor and the review identified a lack of published literature on factors that facilitate and hinder the implementation and delivery of Social Prescribing services.The review identified a range of factors that facilitate and hinder the implementation and delivery of Social Prescribing services. Findings of this review provide an insight for commissioners, managers, and providers to guide the implementation and delivery of future Social Prescribing services. More high quality research and transparent reporting of findings is needed in this field.The online version of this article (10.1186/s12913-018-2893-4) contains supplementary material, which is available to authorized users. Psychosocial problems impact on the health and wellbeing of people . PrimarySocial Prescribing (SP) is a relatively new approach in primary care that promotes partnership working between the health and the third sector . FurtherModel 1: Information serviceThis service is an information only service, with advertising and directory access to SP in a primary care practice.Model 2: Information service and telephone lineThis service advertises SP on leaflets and notice boards in a primary care practice. Based on this information, patients can self-initiate a telephone discussion with a worker.Model 3: Primary care referralPrimary health care professionals assess patients during consultation and refer them to SP services if appropriate, for example if patient have non-clinical issues and require psychosocial support. Referrals to SP services are opportunistic.Model 4: Practice based generic referral worker:Primary care patients can be referred by health workers, or self-refer to a SP link worker. Clinics are held in the GP surgery, so that it can act as a “one stop shop”.Model 5: Practice based specialist referral worker:A specialist worker works from primary care practice and patients can be referred through primary care referral or self-referral. Direct advice and specific services, such as Citizens Advice, may be offered, as well as referral or signposting onwards.Model 6: Non-primary care based referral worker:Patients are referred to an external referral centre by primary care practice staff, offering one-to-one facilitation, for example an outreach service or set in the community.SP models with different referral routes exist, for example, primary and social care patients may self-refer or be referred by a healthcare or other professional. Models may include a navigator . The navigator’s role is to identify the non-medical needs of patients referred to a SP service and to refer, or signpost, them to sources of support within the third sector. Workshops hosted by Bromley Primary Care Trust (PCT) established the following six SP models :Model 1:In addition to these six models, Kimberlee et al. 2014) delineates SP interventions into the following four types: signposting, light, medium, and holistic. More information on these four types can be found somewhere else . It is c014 delinPrevious reviews have assessed the effectiveness of SP , 12, 13.The identification of barriers and facilitators to SP programmes in the UK can inform policy and practice, and potentially improve future implementation of such programmes , 21. A wThe current review focused on facilitators and barriers to the implementation of SP models based in general practice involving a navigator. In this model, general practice staff refers patients to a navigator, who assess the non-medical needs of patients and refer, or signpost, them to sources of support within the third sector.The objective of this review was to identify factors that hinder and facilitate the implementation and delivery of SP services based in general practice and including a navigator in the UK.Methods of the analysis and inclusion criteria were specified in advance and documented in a protocol. The protocol is part of a PhD study and will be made available once the thesis is made publicly accessible.We conducted a systematic literature review of studies assessing SP services based in general practice and involving a navigator. Data synthesis built on a narrative synthesis, using thematic analysis for categorising data. Narrative synthesis is a commonly used method to synthesise data in the context of a systematic review , 23. As SP is an emerging field of research and there is limited evidence on SP interventions in the UK to date. To maximise the inclusion of the available evidence on factors that hinder and facilitate the implementation and delivery of SP interventions, this review was not limited to a specific study design. Hence, all types of study designs, qualitative, quantitative, and mixed-methods, were included in the review. As the review focused on SP services that are based in general practice and involve a navigator (see description in introduction), studies that did not meet both criteria were excluded from the review. Studies involving SP services had to be implemented in the United Kingdom (UK), and so all SP services outside of the UK were excluded. Any studies that met the inclusion criteria and referenced any factor that hindered or facilitated the implementation or delivery of SP services were included in the review.‘Web of Science’. To get familiar with relevant terms, the authors attended steering group meetings supporting the implementation of a SP service in England, attended workshops on SP, and reviewed the search strategies of previous literature reviews related to SP. This, together with the objective of the review, informed the terms of the search strategy and supported the development of an inclusive and rigorous search strategy. Searches were conducted in June and July 2016. Detail of the search strategy is provided in Additional file Several articles and evaluation reports of SP services were identified through an initial exploratory online search using the search engine ‘Google’ and the electronic database Eleven databases were searched from their start dates to July 2016: CINAHL , ASSIA , British Nursing Index, Web of Science, Cochrane library, Medline, PsychInfo, Sport Discuss, HMIC , and University of York Centre for Reviews and Dissemination . The searches were limited to literature written in English. No date restrictions were applied.The Kings FundThe Health foundationNESTANICENuffield TrustDepartment of HealthTo identify relevant evaluations in UK settings, the websites of the following organisations were searched:Additionally, grey literature was searched in OpenGrey, Google, and Google Scholar. The search terms “social prescribing” and “social prescription” were used to identify the grey literature. The grey literature search was conducted in June and July 2016. In addition, the reference lists of all relevant studies, reviews, and reports were searched.After eliminating the duplicates (studies that were identified more than once by the search engines), an initial screening of titles, abstracts, and summaries (if applicable) was undertaken by one reviewer with a random 25% of the sample checked by a second reviewer. The full text was obtained for all the records potentially meeting the inclusion criteria (based on the title and abstract/summary only). In a second step, one reviewer screened the full papers against the inclusion criteria, with a random 25% of sample checked by a second reviewer. Any discrepancies were resolved through discussion between the first and second reviewers and, if consensus was not reached, with a third reviewer.Data extraction of the included studies was conducted by one reviewer and checked by a second reviewer, using data extraction forms tailored to the requirements of the review. The extraction form was tested on three included papers and, where necessary, it was revised to ensure it can be reliably interpreted and can capture all relevant data from different study designs. Extracted data included authors, year of study/report, type of paper , study design, description of the SP service , study sample, and factors that facilitate and hinder the implementation and delivery of SP services. Any discrepancies were resolved through discussion between the first and second reviewers and, if consensus was not reached, with a third reviewer.From the literature review it is clear that the evidence base of SP services in the UK is weak. Therefore, to capture the available evidence on the implementation and delivery of SP services, for which more rigorous studies are lacking, no exclusion on the basis of methodological quality was made. The authors recognised that some studies may have poorly documented methodological quality but may have contextually rich detail that contributes to the overall narrative synthesis. Assessment was undertaken to ensure transparency in the process and to make the limitations of poor quality studies explicit to improve future research.The methodological quality of included studies was appraised independently by two reviewers using the Mixed Methods Appraisal Tool Version 2011 (MMAT-V 2011) . The conFindings from included studies were synthesised narratively. The ‘Guidance on the Conduct of Narrative Synthesis in Systematic Reviews’ was used to advise the narrative synthesis in this study . First, In total, the titles and abstracts/summaries of 6558 records were screened. Of these, 213 records were considered potentially eligible and were assessed in full text. Eight records met the inclusion criteria of the review. An adapted PRISMA  flow-chart of study selection is presented in Fig. In total, the included studies comprised of one conference report  and seveFindings from included records were classified in two major groups for this review: (i) facilitators, and (ii) barriers to the implementation and delivery of SP.The qualitative research findings of seven mixed methods studies and one conference paper have been used for the thematic synthesis. The following section will present the facilitators and barrier by the identified themes.Applying a phased roll out approach to implement SP interventions, i.e. changes are made over a period of time with a scheduled plan of steps, was identified as a facilitator to the implementation and delivery of SP . It has Organising a series of workshops to design and discuss a SP service prior to its implementation and standardised training for involved partners, briefings, and networking events to share best practice were identified as facilitators to implementation and delivery of SP services , 33. TraIn addition, flexibility, i.e. hearing what stakeholders need from the service and altering systems, processes, and communications accordingly, during the development, implementation, and delivery stage was identified as a facilitator to implementation and delivery , 35. A fShared understanding among clinical and non-clinical staff of what can be expected by each partner, the scope of the SP service, which patients to refer, how patients can be helped, and the capacity and skills offered by a navigator facilitates the implementation and delivery of SP services . Shared Creating new relationships between partners based on reciprocity and trust may facilitate the implementation and delivery of SP services . A good Regular feedback and effective communication between the navigator and service providers in the third sector facilitates the implementation and delivery of SP services, as it allows to react to emerging challenges and promotes shared delivery and partnership working , 35.It is important that the SP team meets the whole practice team  before SP commences. This could happen during a training session or practice meeting. The SP team should ensure they work flexibly when arranging a visit.A partnership agreement needs to be signed between the SP service and the GP surgery hosting it.GPs agree to make regular referrals to the SP service. Numbers depend on navigators’ capacity.Navigators should be treated as a member of the primary care staff team. To ensure this happens, surgery staff need to:Understand the scope of the SP programme and the navigator’s role and skillsProvide a room for the navigator, which are accessible for patients and allow meetings without interruptionsProvide an induction including available staff facilities, safety procedures, computer login details, and telephone accessInvite the navigator to relevant meetingsClarify how and when the navigator can contact the GP directlyProvide a lead staff member who can answer queries relation to surgery systems and communicationsProvide a secure space for navigators to keep their files, working material, and confident records in the general practiceLessons learnt form the SP pilot in Brighton and Hove show that general practices need to be ‘Navigator ready’ before a navigator can start to work in a practice. The following is recommended by Farenden et al.  for a GP‘Navigator ready’ practices are crucial to facilitate the implementation of SP and to ensure that an effective and equitable service is delivered to service users .A key lesson learnt from the SP programme in Maryfield is that GPs are more likely to make regular referrals to SP when the practice culture supports holistic and psychosocial approaches . Moving Health professionals and practice staff engagement, involving regular referrals to SP, is a facilitator and crucial for the implementation and delivery of SP services . StrategThe support of the practice manager is vital for arranging meetings with GPs, to build relationships between the SP team and the general practice, and to increase awareness about SP during the ‘lead in’ time, implementation, and delivery . A suppoA wide range of good quality third sector based services and activities, that are easily accessible with pubic transport, facilitate the implementation and delivery of SP services , 32.A collaborative multi-sector approach to project management, i.e. involving a diverse group of stakeholders, contributed towards a delayed implementation and delivery of SP . The lacThe absence of a robust risk management system, to be prepared for scenarios that could disrupt implementation and delivery, was identified as a further barrier to the implementation and delivery of SP .Operating a SP service with volunteers as navigators may delay the implementation and requires a higher level of flexibility than is necessary with paid staff . ChangesA lack of a partnership agreement between the SP service and the GP surgery hosting it, outlining the scope of the programme, the role, and what can be expected from each partner, was identified as a barrier . It may A ‘go live dates’ approach to initiate SP in general practices, i.e. following set dates to initiate SP in surgeries, was identified as a barrier to the implementation and delivery of SP services . NavigatIn markets where there is high employee mobility, staff who are employed via temporary contracts to support SP pilots (e.g. navigators or project managers), may seek alternative more stable employment, as the future or prospect of their roles might be unclear , 35. LimThe lack of shared understanding of a SP service and pathway among stakeholders, including prescribers, navigators, service users, and service providers, was identified as a barrier to the implementation and delivery of SP services , 31, 33.Low or no practice staff engagement is a key barrier to the implementation and delivery of SP, as the SP pathway starts with a referral from practice staff to the SP service . Lack ofThe continuity of the SP programme in City and Hackney was affected when two of the navigators left the SP project after the first year . The CCGNo or low patient engagement is a major barrier to the implementation and delivery of SP services , 30, 32.There is a risk that available services and activities in the third sector may be cut below the level of service users’ needs, which could hinder the delivery of SP services. Navigators have reported difficulties to refer service users to appropriate services and activities because of reductions in scope and long waiting lists , 32.The results of the systematic review are summarised in Table Most of the included records failed to attain higher quality scores as a result of lack of detail on methodology. Most of the included evaluation reports lacked clear and well-focused objectives and did not provide detailed information on data collection tools, recruitment and sampling strategies, and data analysis methods. Methodological information tends to be spread over evaluation reports and can be found, for example, in footnotes in small print or in the Appendix. There is a lack of a structured and detailed methodology section in most evaluation reports of SP in the UK, which creates a challenge to the quality appraisal of available evidence. The quality scores of each study are presented in Table To our knowledge, this is the first systematic review identifying factors that facilitate and hinder the implementation and delivery of SP programmes based in general practice. The review has identified a range of barriers and facilitators, which are summarised in Table Findings of this study indicate that many barriers and facilitators to the implementation of SP programmes are similar to those of other integrated care pilots and any large-scale organisational change . HoweverConsistent with the findings of other reviews of SP services, this review has found that the quality of the majority of included studies was poor , 12–14. The publication date of the included AGE UK report is unknown . All of Through the thematic analysis, the interrelationship between identified facilitators and barriers was exemplified. For example, a phased implementation approach affects other factors that were identified as facilitators, namely shared understanding, relationships, and navigator ready surgeries. Figure There are important limitations to this review. A first limitation is the potential publication bias. Other studies may exist but have not been accepted or submitted for publication and therefore were not identified through the authors’ searches. Second, not all findings can be generalised to other SP models. Generalisation of findings between different SP models has to be made with caution, as some findings are context and intervention specific and may not be transferable to other settings and interventions. Another limitation is that all eligible records were included in the review independently of their appraised methodological quality. Poor quality studies were retained because more rigorous studies are lacking. Although the quality of included studies and reports is considered to be low, they contain relevant information that could contribute to improved future practice.This review identified a range of facilitators and barriers to the implementation and delivery of SP services based in general practice involving a navigator. Some of the identified themes are similar to those of other integrated care interventions, whereas others appear to be specific to SP interventions, and SP models. Findings provide valuable and unique insights that commissioners, managers, and providers can use to guide the implementation process and delivery of SP interventions. The lack of published studies in this field and the poor methodological quality of available evidence highlight the need for rigorous and high quality studies that evaluate factors that influence the implementation and delivery of SP services.


In mental health services what is commonplace across international frontiers is that to prevent aggressive patients from harming themselves, other patients or staff, coercive measures and foremost, violence management strategies are required. There is no agreement, recommendations or direction from the EU on which measures of coercion should be practiced across EU countries, and there is no overall one best practice approach.The project was conceived through an expert group, the European Violence in Psychiatry Research Group (EViPRG). The study aimed to incorporate an EU and multidisciplinary response in the determination of violence management practices and related research and education priorities across 17 European countries. From the EVIPRG members, one member from each country agreed to act as the national project coordinator for their country. Given the international spread of respondents, an eDelphi survey approach was selected for the study design and data collection. A survey instrument was developed, agreed and validated through members of EVIPRG.n = 1511); outpatient departments, 10.5% (n = 295); and Forensic, 9.3% (n = 262). Other work areas of respondents include Rehabilitation, Primary Care and Emergency. It is of concern that 19.5% of respondents had not received training on violence management. The most commonly used interventions in the management of violent patients were physical restraint, seclusion and medications. The top priorities for education and research included: preventing violence; the influence of environment and staff on levels of violence; best practice in managing violence; risk assessment and the aetiology and triggers for violence and aggression.The results included a total of 2809 respondents from 17 countries with 999 respondents who self-selected for round 2 eDelphi. The majority of respondents worked in acute psychiatry, 54% (In many European countries there is an alarming lack of clarity on matters of procedure and policy pertaining to violence management in mental health services. Violence management practices in Europe appear to be fragmented with no identified ideological position or collaborative education and research. In Europe, language differences are a reality and may have contributed to insular thinking, however, it must not be seen as a barrier to sharing best practice. In the modern Europe with frontiers continuing to expand, EU Directives and regulation are promoted as a means of unifying and enforcing best practice in many diverse fields such as agriculture, education and social services. However, EU Directives and regulation on mental health remains light touch and without any overall agreement on best practice and standards. Such a position is difficult to comprehend, given that in agriculture the use of land and the health and welfare of farm animals and fishing is regulated, yet in mental health services, a vital and controversial human intervention such as coercion and violence management is devoid of EU direction on best practice. In the European region there is much variance in the level of investment and available services for the care and treatment of mentally ill persons, one of our most vulnerable groups in society. Mental health problems may account for nearly 20% of the total burden of ill health in Europe, yet it has been estimated that some mental health budgets are less than 5% of the health budget, with no uniformity across Europe . Across In some areas of health care there are EU Directives implemented to govern standards; most notably since the 1970s there are EU directives for the undergraduate education and training of medical doctors  and direIn the light of such direction on education and training of health professionals, the lack of an EU policy position on standards of care and clinical practice in mental health care is difficult to comprehend. The lack of a unifying direction and strategy on the treatment and management of mentally ill people has often resulted in individuals and families appealing to the EU Court of Human Rights to resolve outstanding issues related to the mentally ill. Article 3 of the Human Rights Act is the only absolute European Convention right and it implies that - no one shall be subjected to torture or to inhuman or degrading treatment or punishment. There is a developing range of case law evolving in relation to Article 3 and issues of psychiatric treatment .The management of acute mentally ill people, during psychiatric crisis, poses particular difficulties for mental health professionals, given the increased risk of violent behavior. This paper outlines approaches to the management of violence across the mental health services of 17 European countries, and the education and research priorities as reported by staff working in those services. The results provide a substantial basis to guide best practice, education and research for violence management in mental health services across Europe.Historical accounts of mental health services, document a prominent evolving role for staff in violence management in the traditional psychiatric hospital setting. In those early days a major element of the mental health role involved the enforcement of rules . The evoIn mental health, crises are created through psychotic episodes, suicidal and self-harming behavior, alcohol and drug abuse, attempted absconding, and sometimes over-stimulation by the ward environment. Such factors may create a danger to staff and/or other patients and the challenge for staff is to maintain their own safety and that of people and other patients whilst providing a safe and therapeutic environment .Aggressive and angry behavior may escalate in a predictable and orderly manner, thus providing opportunities for the healthcare professional to risk assess and intervene in the short-term though a process of de-escalation, thus avoiding confrontation. However aggression may also occur in a violent and abrupt pattern requiring emergency management and a coordinated staff response. The use of risk assessment methods helps determine the best intervention in order to reduce the potential for violent behavior. Also, the effectiveness of risk assessment lies in its advantage of reducing many un-necessary coercive measures like: seclusion, chemical and mechanical restraint .In mental health services what is commonplace across international frontiers is that to prevent aggressive patients from harming themselves, other patients or staff, coercive measures and foremost, violence management strategies are required. By definition, coercion is in contravention to autonomy and informed choice by forcing a patient to undertake a course of action over which they have little or no control . There iThe European Working Conditions Survey, (EWCS)  includedIn mental health services there are many methods used to manage violence and there is a broad literature on the use of coercive methods by mental health professionals. The predominant containment methods used in the management of violence and aggression include; physical restraint, seclusion rooms and pharmacological methods. Other action based activities focused on violence management include, risk assessment, observation, including staff vigilance and the use of CCTV, locked wards, increased staff patient ratios, de-escalation techniques and behavioral contracts. Mental Health Act legislation and, in particular, court mandated psychiatric treatment orders that require patients to accept psychiatric treatment with restrictive accompanying interventions will serve to reduce an individual’s movement and liberty. Court mandated patient admissions are becoming increasingly common and such patients are required to accept the mental health regimen, including restrictive movement and coercion. Mental health professionals are challenged on how to practice and research psychiatry within the current social and legal frameworks . The attThere is very little evidence supporting the use of coercion in mental health and more worrying is the lack of evidence supporting one method of containment over another. There are some studies recommending that a systematic risk assessment/management approach could contribute to a reduction in the use of coercion , 17.Muralidharan & Fenton  undertoowww.eviprg.eu). Members of this group embrace a mental health research agenda and there are members from 27 countries including non EU countries Australia, India and Canada. From the European EVIPRG members, the lead author of this paper (SC), invited at least one member from each country to act as the national project coordinator for their country. Agreements were obtained from 17 countries to participate in the study including: Ireland, England, Wales, Sweden, Netherlands, Germany, Norway, Switzerland, Denmark, Belgium, Turkey, Portugal, Romania, Iceland, Serbia, Bulgaria and Greece.The study emanated from an expert group, the European Violence in Psychiatry Research Group (EViPRG). . The tool was hosted off-site from the server of the host academic institution, with the questionnaire design and analysis of the full data set being available to one named administrator (EC).The eDelphi approach had been used previously, by the lead author, (SC), in an international priorities study . In thisA survey instrument was developed, agreed and validated through members of EVIPRG over two international meetings of the group. Members of EVIPRG include leaders and researchers in violence management, and at a convened meeting, members through the facilitation of the lead author of this paper (SC), agreed the content and structure and layout of the survey instrument. The National project coordinators translated the instrument into their native language, and when required with the assistance of fellow country members. As the instrument did not include any narrative or qualitative content and minimal wordage, back-translation was not conducted. Overall, there was a total of 14 languages.The sampling approach to data collection was convenience with respondents self-selecting. Standard letters of introduction, study information and the URL link, in the native language of each country were then sent by the national coordinator to a cross-section of mental health professional and service organizations in the country. Each organization was requested to forward the email URL survey link to its individual members. Consent was obtained through the process of each individual on receipt of the email, could decide if they wished to participate by clicking on the URL link to the study provided in the email, therefore self-selecting themselves for the study. A limit to the number of participants was not set. This link included instructions on how to complete the study with a further link to the research ethics approval documents. Once the URL link was activated, the participant was directed to the study that had three screens (pages). The instrument included 12 questions arranged as: demographics, training, common interventions, education and research priorities, challenges, and self selection for round 2.To encourage the identification of a wide array of views, the first round of the eDelphi study was qualitative in orientation, thus generating a large number of widely divergent statements . Consist20]. In ensuring reliability, one of the national coordinators (AB), undertook a separate analysis of the Swedish data, which was the largest data set. This analysis subsequently was found to be consistent with the analysis undertaken by the other two members of the team. Data were analyzed by grouping similar items together. Where several items were identified to relate to the same issue, the researchers grouped them together to provide one universal description. The results of round one, including descriptors and groupings, were verified at a meeting of the EViPRG including the national project coordinators, so as to ensure agreement on analysis and representation of data.The results of round 1, when returned by the respondents to the administrator, (EC), were collated, and all email addresses and unique identifiers removed. The various lists of statements from participants, together with comments were then distributed to national coordinators for translation to English and cross-checking. When translated to English, the documents were returned to researchers, . Thematic content analysis of the data was commenced by two members of the research team  working independently, and jointly, using an established format [n = 718) and the Netherlands 15.5% (n = 434), (Table n = 1598), with Psychiatrists 10.6% (n = 295), (Table n = 1511); outpatient departments, 10.5% (n = 295); and Forensic, 9.3% (n = 262). Other work areas of respondents include Rehabilitation, Primary Care and Emergency.The results included a total of 2809 respondents from 17 countries and 999 respondents who self-selected for round 2 eDelphi. The highest number of respondents were from Sweden 25.6%  of respondents reported that they had not received training in the management of violence and aggression. Patterns of training varied across EU countries, and based on the number of responses to the question, the countries with the highest non training rates included; Romania; 88.5% (n = 23); Turkey 83% (n = 20); Portugal 44% (n = 25); Norway 32% (n = 75).It is of concern to note that, overall, 19.5% (n = 521) indicated that they had received training in the last year, with 9% (n = 157) reporting that it was longer than 5 years since training was received, (Table n = 6); Iceland 25% (n = 3); Norway 22.8% (n = 34).Participants were asked when they last received education and training in the management of violence and aggression, the majority reported that they had received training within the previous year, however, only 30% ; administering medications 14% (n = 795). Talk therapy 11% (n = 609), and de-escalation 7% (n = 393) were the next most commonly used interventions, . In an effort to gain consensus, individuals were invited to rank each statement individually on a seven-point Likert scale. Seven represented ‘top priority’, while 1 represented ‘not a priority’. Reminders were sent after 30 and 50 day periods to all participants.Following round 1 analysis, the round 2 circulation list which included 40 education priorities and 40 research priorities, was sent via email back to respondents who consented for round 2 (The results for round 2 consensus on top priorities for education and top priorities for research in violence management are outlined in Tables The central hypothesis of this study, is that within the European region there is no clear direction or uniformity on best practice in the management of violence across mental health services. The enlargement in the number of countries in the European Union in recent years has further exacerbated the lack of commonality in areas of service development, standards, education and the role of the mental health professionals. Freedom of movement, conflicts and complex emergencies have created a large number of refugees and asylum seekers across Europe. Such migrants include vulnerable people who are at an increased risk of psychosocial trauma following acts of ethnic cleansing, murder, sexual violence, torture and mutilation. Europe at the moment is struggling to find ways forward in the ongoing humanitarian catastrophe of refugees and asylum seekers and as part of any response to the crises European mental health services must be prepared to meet needs, in terms of violence prevention and management. It may be suggested that refugees and asylum seekers are an evolving mental health grouping requiring dedicated resources for services and specialist staff training and researching.From an EU perspective, the validity of the findings of this large scale study is supported by the spread of countries, from across the EU, and the opinions of respondents from all the major professions involved in the delivery of mental health services. A major benefit of this study is the richness of the results which provides us with consensus on the significant issues that are confronting mental health professionals in the EU, at present, and into the future.Whereas the majority of respondents were from Western Europe, the inclusion of respondents from Turkey, Bulgaria and Serbia is a rather unique, but important addition. As the majority of mental health professionals in Europe are nurses, it was an expected finding that nurses would form the largest group of respondents. Generally, other professionals as respondents are proportionate to numbers employed in a typical mental health service, Table . There hThere is a vast mental health literature, mostly non-empirical, on assault and violent behavior and the importance of education and training in violence management. However, the impact of such literature is dubious, given the sustained increase in assaultive behavior and violence and a major failing appears to be the translation of training to the practice setting. Many authors have commented on the absence of an empirical evidence base on which to base either the training or practice of violence prevention,  In this Definitions of the term coercion apply to a wide range of interventions and involve the use of authority to override the choices of an individual . The ranThere is a strong tradition of institutional care in Europe and primarily, because of this, it may be argued that mental health professionals are trapped within an institutional model, which adversely affects the type and level of service that they can provide. In the early 1970s, governments across Europe became increasingly concerned about the large mental institutions and the custodial nature of mental health services. A Mental Health Declaration for Europe and a Mental Health Action Plan were endorsed by the Ministers of Health of the 52 member states in the European region of the WHO in 2005. The Declaration favoured community-based mental health care settings. However such a utopian aspiration is hampered by the lack of a single and unifying ideological approach to mental health services in Europe, and a prevailing dominant country national policy approach, which arguably contributes to ideological eclecticism across Europe [A greater understanding of the mental health challenges common to all countries must serve to drive developmental initiatives to determine the nature and scope of professional practice in Europe. In this study, it is interesting that management issues rather than clinical issues are dominant in the results of the greatest challenges, with staff management and team work identified as the major challenge. This finding in consideration with other top challenges identified such as management support; clear policy, procedure and protocol, raises concerns about leadership and management and may suggest the need for change in how mental health services are managed and governed, and for employers/service providers to be more strategic in planning service developments.A key factor in planning any service is to determine the education and research priorities of the professionals who are accountable for providing the services. The respondents from across all professional disciplines expressed a strong theme for education in violence prevention. Top priorities for education and research include violence prevention, risk assessment, and the aetiology and triggers of violence and aggression. The agreement on priorities among all mental health professionals supports the case for multidisciplinary training in violence prevention and management. The influence of the environment of care, staffing levels and best practice in managing violence are priorities. There is sufficient evidence available to suggest that the culture of the clinical environment of care can influence the development of violent incidents. Since 2000 and most recently,  the RoyaThere are some limitations to the study and these in the main relate to translation. When translating and adapting instruments across languages, there is no guarantee that the different language versions are equivalent. Back-translation was not conducted, however in this study, reliability is introduced by the fact that all translators were bilingual and that the content to be translated were lists of words, rather than long narrative passages. Whereas the use of online methods of enquiry are economic and efficient, the lack of the traditional relationship between the researchers and the respondent may impact on ability to encourage a response.The increased concern among employees, employers and professional organizations over the escalation in violence and aggression has created an urgent requirement for proactive national and international strategies in safety and violence prevention. Despite improved initiatives in areas such as risk assessment, and staff training there remains a paucity of readily available data regarding the safety of mental health services.Despite the growth in legislation and in the number of Health & Safety Authorities in various EU member states, in many European countries there is an alarming lack of clarity on matters of procedure and policy pertaining to ward safety and security in psychiatric hospitals. Across the psychiatric services there is a bewildering array of practices ranging from an open door policy to locked wards and doors and confiscation of patients clothing and personal property, some of which borders on the infringement of human rights, liberty and the rights and choices of patients .Psychiatric services across Europe appear to be fragmented with no identified ideological position and there are few links, with little sharing, comparisons or collaborative research. In Europe, language differences are a reality and may have contributed to insular thinking, however, it must not be seen as a barrier to sharing best practice. There is a need to grow a formal communication mental health communication network in Europe.Historical accounts of mental health services, document a prominent evolving role for staff in violence management in the traditional psychiatric hospital setting. However there is now a greater emphasis on the use of risk assessment methods, and this helps to determine the best intervention in order to reduce the potential for violent behavior, and reduce unnecessary coercive measures. However, European standards for violence management in mental health can only be achieved through political initiatives, promulgated at parliamentary level and engaging a stakeholder model. Central to discussions are the regulatory, professional, patient-representative and legal obligations of health authorities and employers in ensuring best practice in violence management for the benefit of patients and staff.The publication of position papers on violence management from the EU parliament to advice governments, employers and appropriate professional bodies in each EU member state;Establishment of a European forum which includes stakeholders to develop, agree and publish best practice guidelines on violence management;Establishment of EU directives on risk assessment and staff training in the management of workplace violence;The availability of EU funding for research on best practice in violence management.Arising from this study a number of actions are recommended:


The LifeWatchGreece Research Infrastructure (LWG RI) stores biodiversity data and information from all biology-related disciplines derived from the Greek territory (or the Mediterranean Sea for the marine data). The aim of LWG RI is to facilitate data sharing and dissemination under harmonised standards in order to maximize the socio-economic benefits of research and knowledge transfer to the public. This publication describes the rationale behind the data policy of LWG RI, outlines the current legal situation for sharing research data and presents the Data Sharing Agreement which is signed between the data owner/provider and the LWG RI for each dataset, describing in detail the rights and duties of each party, as well as the license type and the embargo period under which the data are released.LifeWatch, Biodiversity data, Greece, Copyright, Data policy, Data sharing, Data licenses, Agreement, Rights and dutiesDirective 92/43/EEC classification scheme, there are 25 habitat types in Greece, including maquis, phrygana, forests, grasslands, marine areas, wetlands, lagoons, salt marshes and sandy beaches. With the longest coastline in the Mediterranean , marine and coastal habitats are the largest of these. Although most probably the largest part of Greek biodiversity remains non-described , species and ecosystem level. This is a result of its geological and evolutionary history, its complex geomorphology and topography, the relatively mild human pressures received until recently, and its range of 29 climatic classes . Accordescribed , existinescribed . The mosLifeWatch, is designed to provide advanced research and innovation capabilities on the complex biodiversity domain. A Research Infrastructure (RI) refers to the strategic installation of facilities, resources and related services for the benefit of the scientific and other user's communities (LifeWatchGreece Research Infrastructure (LWG RI) is the national node of LifeWatch in Greece, which has been constructed and operated by the Hellenic Centre for Marine Research at the Institute of Marine Biology, Biotechnology and Aquaculture and aims to establish a Centre of Excellence for biodiversity research in the Southeastern Europe. The LWG RI stores biodiversity data and information from all biology-related disciplines and it is open to all potential users, such as the scientific and academic community, environmental managers, policy makers, students and citizen scientists. The purpose of LWG RI is to accelerate international data-driven innovation and discovery by facilitating data sharing and exchange, data use and re-use, harmonization of standards and discoverability.The European e-Science Research Infrastructure for biodiversity and ecosystem research, munities . An e-ScEuropean Strategy Forum on Research Infrastructures (ESFRI) policy on research and innovation RIs, which seeks to maximize the socio-economic benefits of research and development for the public. According to the Communication from the Commission to the European Parliament, the Council and the European Economic and Social Committee on “Scientific information in the digital age: access, dissemination and preservation ({SEC(2007)181}/*COM/2007/0056 final): "All research builds on former work, and depends on scientists’ possibilities to access and share scientific publications and research data. The rapid and widespread dissemination of research results can help accelerate innovation and avoid duplication of research efforts”. The European Commission supports open access as the standard way of disseminating publicly funded research in the European Union and includes open circulation of knowledge as one of the five priorities of the European Research Area. Open access is required for all the peer-reviewed publications resulting from Horizon 2020 funding. Recent EU activity on data policy shows that future public funded research will focus on open access requirements, making the adoption of such policies essential both for the sustainability of the LWG RI, as well as for the participating researchers. Under this context, LWG RI seeks to aggregate and disseminate biodiversity data according to the RDA principles of non-profit, openness, consensus-based decision making, balanced representation, technical neutrality and harmonization across communities and technologies , the Berlin Declaration (October 2003) and the Bouchout Declaration for Open Biodiversity Knowledge Management (2014). Sharing of data comes with a number of benefits for the scientific community and the data provider:Milestone definitions of open access data include those of the Data are securely archived and stored in a format which ensures their readability in the future.Data are quality controlled concerning taxonomy, geography and general integrity.Datasets are fully documented with the appropriate metadata so that they can be easily located and retrieved through online search engines. These metadata are "data about the dataset" and they consist of a minimum set of information describing the scope, purpose, content, involved persons and the terms of use (licenses and embargo period) of the actual dataset.Data are disseminated through major data aggregators, ensuring a global and perpetual visibility, and thus promoting the scientist's work and increasing their potential for attracting collaborations and funding.Shared data are citable, giving due credit for each use of the dataset to the data provider. Downloading metrics will allow scientists to assess how often their data are viewed/ downloaded.Re-use of data in a wider context can provide new insights; small datasets from projects, when integrated, can answer global questions.Open access of data can address the problem of limited access to scientific research information  so that they can be further used and exploited by researchers, industry, relevant markets, and the general society . PublishAccording to Species occurrence data: marine distribution data  and terrestrial distribution data Taxonomic checklistsGenetic dataGenomics data (including meta-barcoding and metagenomics data)Protein data (including those resulting from proteomics)Morphometric and three-dimensional morphological dataFunctional trait dataHabitat mapsMuseum collection data: any data on specimens that were collected within the boundaries of the Greek territory or are held within Greek Natural History MuseumsSeaDataNet and EMODnet, already exist for the submission of marine physiochemical data) and terrestrial environmental data Environmental data: marine environmental data LiteratureSound, video, photos, 3-D mapping of environmentsCitizen Science dataIn case of submission of a non-Greek dataset (or non-Mediterranean in the case of marine data) collected or owned by a researcher associated with a Greek institution, the LifeWatchGreece RI data managers will submit the data to the appropriate repository (if this exists) and store the link as an external dataset together with the metadata. If no such appropriate external repository exists, the data will be stored within LifeWatchGreece RI, without being available by default through its portal.copyright, which is a legal concept that grants the creator of an original work the exclusive rights to its use and distribution  rights are the legally recognized exclusive rights to creations of the mind . Under iribution . The teries, etc . Copyrigies, etc . Data owo others . Copyrigo others . The datEU Directive 2006/116/EC). European copyright legislation is well aware of the fact that copyright may present a barrier to scientific work, therefore exceptions and limitations to the respective copyrights are applied in such cases. For example, while databases as a whole may be protected by copyright law, if they “by reason of the selection or arrangement of their contents, constitute the author's own intellectual creation" (EU Directive 96/9/EC), the single data points, measurements and observations within the database cannot be copyrighted: “The copyright protection of databases provided for by this Directive shall not extend to their contents and shall be without prejudice to any rights subsisting in those contents themselves” (EU Directive 96/9/EC). The Copyright Directive (EU-Directive 2001/29/EC) allows EU Member States to provide exceptions or limitations to the rights of reproduction and communication to the public when a work is used "for the sole purpose of illustration for teaching or scientific research, as long as the source, including the author's name, is indicated, unless this turns out to be impossible". However, as suggested by the Green Paper on Copyright in the Knowledge Economy published in 2008, different treatments of the same act in the different countries may lead to legal uncertainty regarding permissions and exceptions, especially when research is carried out within transnational projects.Usually anyone creating an original work automatically holds the copyright on it, which normally expires 70 years after the death of the creator (Creative Commons (CC) as a legal instrument to define the usage rights of the data. Creative Commons is legally binding, simple to use, globally accepted and its licenses are both human and machine-readable, the latter being especially important in the digital era. Licenses are legally binding texts that define what can be done with a work by a third party and they can change the content of the work from “all rights reserved” (copyright) to “some rights reserved”. The LifeWatchGreece RI data are released under two different conditions: 1) CC-Attribution (CC-BY): “You must give appropriate credit, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use”; and 2) CC-Zero : “The person who associates a work with this deed has dedicated the work to the public domain by waiving all of his/her rights to the work worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.” A waiver is a declaration for complete copyright removal, meaning that the content will have “no rights reserved” and will be released into the public domain. In that case, the original owner abnegates all his/her rights to the data, but also the responsibility, and becomes a “donor”. The users of CC0 data should make the appropriate attribution to the data donor for the work done and released as free to be used by the society.LifeWatchGreece RI uses The Creative Commons organisation does not recommend the use of “non-commercial”, “no derivatives” and “share alike” licensing types for licensing scientific data, therefore LifeWatchGreece RI does not offer them. The distinction between commercial and non-commercial research is not applicable, useful or even possible . The proAll the data submitted to LifeWatchGreece RI can be subjected to an embargo period determined by the data owner/provider. This selection applies in cases when the data owner/provider requests a sufficient time period for exploiting the data and publishing the results before making them publicly available. The maximum time for an embargo can be 5 years; however, this time can be renewed repetitively until the copyright expires (i.e. 70 years after the owner’s death). If no embargo renewal is requested the data will automatically be released under the specified CC-license or waiver. During an embargo period, only metadata that describe the dataset will be available online.LWG RI website). In general, LifeWatchGreece RI adopts the following Canadensys norms which are not a legal document but in the form of simple instructions they describe the general principles for data publication, sharing and fair use:Biodiversity data accessible via the LifeWatchGreece RI are openly and universally available to all potential users within the terms and conditions that the data owner/provider has identified for his/her data under the framework of the LifeWatchGreece RI Data Sharing Agreement  or provide misleading information about the copyright status.The data providers/owners retain some rights to their data according to the CC license they have selected when submitting their data. Unless data are released into the public domain with a waiver (CC-Zero), the data are considered as the intellectual property of the data owner/provider. Copyright therefore remains with the data owner/provider. They also have the right to choose an embargo time, although this right should be exercised with diligence and without eventually hampering the use of the datasets. They are able to change their license type, from CC-By to CC-Zero; however, waivers cannot be changed. The data providers/owners also have the right to withdraw a published dataset from the LifeWatchGreece RI if this action is well justified (i.e. the dataset will not be visible to the public), however in this case the data will remain in the system for archival. Even if a dataset is withdrawn, its metadata will remain always public and visible.The data providers/owners have the duty to make reasonable efforts to ensure that the data served are accurate. 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They have to collaborate with the data management team of LWG RI to maintain and manage their datasets and to improve their quality where possible. Versioning is supported for changes in data files and/or metadata.The LWG RI team has the right to annotate datasets and to mark inconsistencies, where appropriate, in order to ensure data quality. However, no data values can be replaced or corrected without retaining the original data value and without consent by the data owner/provider. Data can be disseminated through other relevant databases  using the same licenses and conditions as signed in the LWG Data Sharing Agreement. LWG RI has the right to reformat the data if necessary in order to make them compliant with international standards for integration with other datasets, infrastructures and storage systems.GBIF data publishing guidelines and the Joint Declaration of Data Citation Principles. LWG RI needs to work in close collaboration with the data owner/provider in order to assemble and publish the relevant metadata. They must conceal and protect sensitive data in accordance with the data owner/provider. They need to inform the data owners/providers about the available license options, their rights and duties, the approaching of an embargo expiration, as well as the options for its renewal. They should encourage and facilitate free and accessible data sharing and reusability by assigning default open data licenses to both metadata and complimentary files, but they have to allow the application of terms of use and restrictions when needed. LWG RI needs to ensure that the licenses and embargos are not violated (data protection) by the technical infrastructure and that the original dataset is not lost or any original values are overridden. They have to keep track of the data usage by using a tracking metrics system and provide the data owner/provider with this information upon request. They should assist the data owner/provider in data versioning, assignment of a DOI and tracking citations of datasets through literature. Also, they need to ensure that the data owner is properly acknowledged and to inform the data owner/provider in case the terms of use are violated.LWG RI has the duty to ensure the smooth integration of datasets into the LWG RI and is responsible for the technical aspects of data publication. The LWG RI data managers have to perform data quality control and to provide quality assurance annotation before data publication. They have to create a citation  for each dataset according to the LWG RI does not assert any intellectual property rights in the data made available through its portal. The ownership of the data belongs to the data owner/provider, unless the data are released under a waiver (CC-Zero) to the public domain. LWG RI, its employees and its contractors are not liable or responsible for the data contents or their use, or for any loss, damage, claim, cost or expense however this may arise from a third party's inability to properly use the LWG RI. No financial claim can be made by any of the parties concerning the submission, publication, curation or subsequent use of data and datasets. The use of LWG RI always takes place on the basis that the accuracy and reliability of any data hosted are under the responsibility of the data owner/provider, unless the data are provided under the CC-Zero license for which no such responsibility exists.The EU is moving towards the deployment of an open knowledge management system and LWG RI could offer a useful contribution to this direction regarding the biodiversity field. The current legal situation can be considered as unsatisfactory due to the existing inconsistencies between the different countries . The int