Front-line nurses have played a critical role during the coronavirus disease 2019 (COVID-19) pandemic. A number of qualitative studies reported front-line nurses' experiences and needs in caring for patients with COVID-19. However, the application of evidence from a single qualitative study to guide clinical practice has limitations. This study aimed to explore front-line nurses' experiences and needs during the COVID-19 pandemic through a qualitative meta-synthesis.Seven databases were searched from 1 December 2019 to 20 January 2022, including PubMed, Web of Science, Cochrane COVID-19 study register, CINAHL, PsycINFO, MedRxiv, and bioRxiv. The quality of included studies was appraised using the Critical Appraisal Skills Program (CASP) qualitative research appraisal tool. Meta-synthesis was used to synthesize the data from included studies.A total of 70 studies were included, and five synthesized findings were developed: (1) Although nurses actively devoted themselves to fighting against COVID-19, considering their professional responsibility and historical previous experience with mankind, they were not invulnerable; (2) There were various difficulties and challenges in caring for patients with COVID-19, including fear related to providing patients with care, shortage of protective equipment and manpower, and negative attitude of family members; (3) Facing difficulties and challenges, nurses could only partly cope by using mixed means to overcome those, including media, learning, gaining skills, responding together, and organizational assistance; (4) To better respond to the COVID-19 pandemic, nurses' needs should be paid attention to. Counseling, training, information, resources, and investment are pivotal; (5) Despite the hardships, nurses became stronger and gained gratitude, positivity, mental peace, and confidence.This study reveals that the psychological experiences of front-line nurses varied, and they faced a variety of challenges. Although nurses had some coping strategies, they still needed multifaceted support to meet the challenges.https://www.crd.york.ac.uk/PROSPERO/, PROSPERO: CRD42021255468. In December 2019, a novel pneumonia with unknown clinical and therapeutic aspects emerged in Wuhan, Hubei Province . Up to MEarly in the pandemic, Hubei, China was the worst infection area in the world, and the government assigned more than 42,000 medical staff to assist Hubei in responding to the sudden crisis. Notably, nurses accounted for 68% of the total number of medical staff . As the To obtain a rich detail of front-line nurses' experiences, some researchers carried out qualitative studies. For some nurses, front-line work had negative impacts on their mental status during the COVID-19 pandemic . MeanwhiTo better understand front-line nurses' experiences for further practice, qualitative meta-synthesis needs to be performed. Recently, Joo and Liu  conducteThis meta-synthesis has been conducted according to the reporting guideline, Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) . The pro*; 2019 novel coronavirus disease, COVID-19, SARS CoV-2 infection, COVID-19 virus disease, 2019 novel coronavirus infection, 2019-nCoV infection, coronavirus disease-19, COVID-19 pandemic, COVID-19 virus infection, 2019-nCoV disease; interview*, focus group*, view*, experience*, perception*, need*, feel*; qualitative research and mixed methods. Truncation symbols and Boolean operators (“or” and “and”) were used to combine synonyms and index terms. The search terms were modified in the databases, and search results were refined using filters. All databases were searched from 1 December 2019 to 20 January 2022. The reference lists of included studies were screened manually to identify additional possible studies not identified in the electronic search.For this review, a systematic literature search was conducted by two authors (SD1 and SD2) to ascertain studies about experiences of front-line nurses caring for patients with COVID-19 on PubMed, Web of Science, Cochrane COVID-19 study register, CINAHL, and PsycINFO. MedRxiv and bioRxiv were also searched for gray literature. The SPIDER tool was used to frame the search terms  Table 1Table 1. Studies were included if they met the following criteria: (a) explore experiences of front-line nurses caring for patients with COVID-19; (b) primary qualitative studies ; (c) published in English between 2019 and 2022; (d) peer-reviewed journal articles or preprints. Exclusion criteria were as follows: (a) review articles, editorials, clinical case reports, or commentary articles; (b) no full-text or republished articles; (c) quantitative studies or mixed studies focusing on quantitative studies.All articles were assessed by two authors (SD1 and SD2) independently according to the inclusion and exclusion criteria. Any disagreements regarding studies selection were resolved by discussion or by resorting to the judgment of a third author (JH) when needed. If the eligibility was still not clear, the entire research team discussed to reach a consensus.The quality of included studies was evaluated by the Critical Appraisal Skills Program (CASP) with ten criteria . The stuTwo authors (SD1 and SD2) collected the following information: first author, year of publication, country, study aim, study design, time period of study, sampling, sample characteristics, data collection and analysis, and key findings. A standardized form was used to extract data of the included studies. Any discrepancies were resolved by discussion between the authors or by resorting to the judgment of a third author (JH) until a consensus was reached.Meta-aggregation was employed in this study to synthesize the findings of included studies. This synthesis approach was done in a three-stage process: (1) the authors repeatedly read the included studies and extracted all the relevant findings; (2) the authors repeatedly read and analyzed the findings from included studies and categorized them on the basis of similarity in meaning; (3) the authors grouped categories into synthesized themes . For quaA total of 5,091 studies were identified. After removing duplicates by importing into Note-Express software, 887 duplicate publications were identified and removed. The remaining 4,204 studies were screened by reading titles and abstracts, and 212 studies met the inclusion criteria. After screening the full text, 70 studies were finally included .Of the 70 included studies, nineteen were from China , 22–39, According to CASP criteria, the 70 included studies had good quality by clearly describing at least 8 of the 10 items. All of the studies had a clear statement of their aims and findings. All of the studies used appropriate qualitative methodology, research design, data collection, and data analysis. The majority of the studies clearly stated recruitment strategies and took ethical issues into consideration. Only eleven studies considered the relationship between the researcher and the participants. No study was excluded, and all details of quality assessment are provided in Two hundred eighty-five findings were extracted from the included studies, and were classified as Unequivocal or Credible. From a meta-synthesis analysis of the data, five synthesized findings were developed from 26 categories see .Synthesized finding 1: Although nurses actively devoted themselves to fighting against COVID-19, considering their professional responsibility and historical previous experience with mankind, they were not invulnerable.Category 1: Fighting on the front-line with the spirit of Nightingale.During the COVID-19 pandemic, nurses showed a strong sense of responsibility, and they were proud to provide nursing care for patients with COVID-19 , 80, 84.I am a nurse, [and] nurses were needed there [Hubei Province]. There was not much to think about. It was my passion for my profession, and a sense of responsibility.... I really wanted to go. I hoped I could do something to help others, so I signed up.”  “As a Communist party member, in the face of this kind of emergency crisis, it was natural to have the courage to go to the front-line; what's more, our duty was lifesaving; this task was our responsibility and mission.” “Despite being aware of the shortage of facilities and PPE, nurses were willing to take care of patients with COVID-19 . Even noOur masks and protective clothing are, indeed, nonstandard, but this is not a reason to abandon patients. I go to the patients and feed them, give them their medicine on time, and I am not worried about getting infected...” “There is a big shortage of nurses, so I volunteered to go because I was young.”  “This is my duty because I am a medical worker. No matter what will happen…”  “Category 2: Early psychological experience.Due to the urgent recruitment, nurses did not prepare well for the emergency task, and they feared about the uncertainty and possibility of infection in the early stage , 83, 84.When went to the ward first time, we were afraid to enter the room to contact patients, only standing in the corridor.”  “We only knew that we were going to Huangshi, we did not know to which specific hospital. Actually, we did not understand what lay ahead. Uncertainty made us psychologically uneasy.” “I don't know about infectious diseases, and I encountered it for the first time, so what should I do...”  “On the first day of work, when I found out that my patient had coronavirus, after going back home, I cried all my off day, lest I get sick and transfer the virus to my family. Because I really didn't know much about it, and I thought I would get infected if I came to direct contact with the patient.” (Pe85) “Category 3: Negative psychology peaked in the process of adapting to work.Novice nurses were under great pressure due to lack of experience, and they were afraid of becoming a burden , 79. WheI went into the COVID-19 patient's room by myself …I had to go by myself because going in with other people would have cost the hospital too many PPE sets. I had to drill to do it alone by myself and complete my responsibilities since I did not want to be a burden to the team.”  “The other big fear is bringing the virus home and infecting the people you care about, which is why I've been self-isolated [speaks with a trembling voice] and decided to rent a house and go live alone where I am now.”  “I was a little scared that it would happento me, but I scared, I would give this terrible disease to my husband, then to his family, the mother is too old...”  “It was found that the nurses felt unfair in work distribution or awards compared with other medical staff because they contacted patients more frequent than others , 55, 59.We frequently needed to deal with patients, which increased the chance of infection, but doctors spent much less time in the ward. “ “I have been most concerned about my family since this period began. Anyway, every time I come here, the environment is polluted, and there is a possibility that I will be the carrier of this disease.”  “I did not want to emotionally burden my husband during the pandemic. I did not let him know that I was working in an isolation ward... I applied for subsidy from my hospital so that I could rent an apartment...” (P8) “When working on the front line, informing good news to patients was the happiest moment for both patients and nurses . HoweverAnd at those moments, there's nothing to do…you have to stand there…be helpless (crying).“  “During the difficult time, my colleagues had crashed, including feeling depression. I felt that I was powerless and collapsed due to high-intensity work and patients kept passing away in front of me. Many people (nurses) burst into tears after getting off work and felt that they could not keep going.” (P5) “My colleagues passed away, will we be the next one?” (P5) “Everyone is dying, who cares, this is too much work, the death rate is increasing, I wish no one would be sad, many of our colleagues died, it is hard to believe this number of deaths, the cemeteries have no place anymore. ”  “The situation is such that many colleagues don't want to come to their shifts.”  “Category 4: Being positive gradually.As time went on, nurses became relaxed and confident because of the experience of successfully managing patients with COVID-19 and correct use of PPE , 78, 81.In the end, you slowly start to come to terms with the situation. This is part of our job. Now, we are more comfortable than before, believing that at least we have done our best by taking protective measures. I mean, we have embraced it a bit more. We started to see the good and bad courses of the disease. Now, we feel a little more at ease.”(P7) “Now, there is a lot less fear. After caring for infected patients for seven months, I believe I've gained a certain level of competency in caring for infected patients, and I can do the job when such an infectious disease outbreak occurs again.”(P14) “…On the one hand, I feel grateful to be working, to contribute professionally. On the other hand, I feel apprehension, frustration, impotence, and anger at living with the uncertainty of not knowing who is a suspect for the coronavirus, be it patients, co-workers, and even myself.”(P5) “Many people donate food and fruits to us. I appreciate it.”  “Synthesized finding 2: There were various difficulties and challenges in caring for patients with COVID-19, including fear related to providing patients with care, shortage of protective equipment and manpower, and negative attitude of family members.Category 5: Nursing care during the COVID-19 pandemic.For novice nurses, they had to learn how to work before their shift started . Due to I went to the unit days before my shift started, to get settled in and check out how the unit works. However, it is impossible when they call you like this, at 10 a.m. to be at the hospital at around 11 a.m.”  “When the patients with COVID-19 were admitted to the hospitals, routine nursing practices, such as measurement of vital signs and patient education, were provided by nurses . During The first time the patients are assigned a room, they are informed about the use of nurse call buttons at the bedside. We tell them that when they want to contact us, they should not leave the room but use the nurse call buttons, and that, when they press the button, we will take the necessary precautions before coming to their room.” (N1) “They cough while connecting the valve during the aspiration procedure. Therefore, we perform this procedure with fear.”  “The patients with COVID-19 suffered too much due to the nature of disease and isolation, and they needed support in many aspects , 66. TheWe need to help patients stay positive…[some patients] start crying, and we need to go into the isolation room in full gear to help them calm down…They feel scared as they don't know what's going on…stressed as [there are] a lot of unknowns…need to spend some time with them. “ “Some jobs we did should have been finished by the doctors. Some doctors even asked us to do it through phone calls.”  “Category 6: Negative social experience.The great majority of nurses are supported by family, friends, patients, and community , 51, 84.It's interesting that my father asks me to get away from these patients and recommends me to leave my job. He asks me if I am short in money that I have to care for these dying patients in the deathward. He says I would lose my life. For these stigmata, all my colleagues want to change their workplace and go to another ward”.  “When I left the ward, everyone was running away from me, even my relatives were staying away from me, and it was not pleasant.” “They treat us like lepers, they think we are infecting them” . “I can't tell others about working at this hospital because when I asked the taxi driver to take me to the hospital, he asked me if I worked there, and then he told me to get out. They don't even deliver food to the hospital. I wasn't infected with COVID-19, and I didn't do anything wrong, but I had to stay at home. Because people don't want contact with me.”(P9) “To avoid the risk of transmission, they spent much time staying at the hospital or had to be self-quarantined , 83, 84.When I come home from work, I isolate myself at home. I don't eat with my family; I don't hug my baby”  “I cannot meet my family, we are all in the ward, it is very difficult to be away from my family, everything weighs on me, it is very hard, now think that I will come and think about my care theory, no one can think about these things in this tragedy. “ “I've made sacrifices when it comes to my children, for example… Unfortunately, because lessons and school attendance were all online, I couldn't help my children at all, because I had to stay away. They had to do some things by themselves.” (P6) “Homesickness is always there. I miss my child.”(N4) “Category 7: Ethical issues in caring for patients with COVID-19.In the initial days, the number of patients increased sharply, and PPE was inadequate. The patients' emotional needs and patient rights, such as the rights to know and the rights to personal security, were always neglected . SpendinSome of the critical patients were not able to communicate, so we could not explain treatment plans to them. They could only accept what we offered.”  “Because patients have coronavirus, I can't stay with them long. Talking with a mask also makes me short of breath and, I can't communicate verbally with them as I do with other non-coronavirus patients, and that upsets me a lot.” “The patients in this ward are in dire need of spiritual care, which unfortunately is not available right now, and that is why COVID-19 patients suffer from spiritual distress”.  “Seeing these people die in total solitude struck me very much as they had absolutely no way to communicate with relatives or with the people important to them. There were only us.”  “Nurses reported that nursing care and treatments provided for patients with questionable benefits needed to be discussed more . These t... Constant ethical dilemma of keeping someone alive when there is no hope for recovery and keeping patient alive at the cost of the patient's comfort, i.e. constantly inflicting painful procedures.” “Category 8: Challenges related to PPE.There was a severe shortage of PPE and facilities, and some PPE were not qualified for the protective purpose and were of poor quality , 80, 81.We do not have enough facilities, there are few basic facilities, this ward is not similar to an isolated ward.”  “When you enter the ward, all you get is an apron, a pair of gloves, and a mask, and throughout the shifts, they keep saying that we are short of equipment. I agree that in these conditions we need to conserve, but lack or unavailability of equipment makes caring for coronavirus patients a challenge”  “I was angry about it [PPE re-use] and upset about it, but now that we've been doing it for months on end, it's kind of just become the norm.” “... It's very hard to work in coveralls. I don't even drink water to avoid going to the bathroom.”  “Putting on and taking off PPE took nurses' a lot of time and energy, resulting in fatigue , 67, 75.I sweat after wearing the protective gear for a while or when I move, such as turning patients. Then I feel clammy.”  “...that goggle.., put on a cap.., it's too much to bear, the day before I had a headache for a day and a half or two... and back pain, we walked in boots..., It's hard.., there is a big discomfort in the body...” “The equipment they gave us was of poor quality. Meanwhile, in long-term use, we have problems with nutrition and rest. Most of the time, we get headaches, nausea, skin allergies, and heavy sweating at the end of the shift. It's hard, and I felt like I was dying.”  “... Because the safety goggles and the face shield are misting up, I find it very difficult to see during procedures such as starting an IV.” “Category 9: Challenges related to the staff shortage and workload.Due to the surge in the number of infections and a lack of manpower, nurses reported the nurse-patient ratio was unbalanced and workload was overwhelming , 76, 84.First, there is insufficient staff, because a lot of patients are very heavy, and they need us to care for them…” “There are more than 50 beds. But only two staff are on duty at night.” “Sometimes, I felt very hungry but had no appetite, and I had lost 5 kg in the last month.”  “COVID-19 originates physical overload, so it requires more from professionals. Every day we have prone position, supine position, patients have skin injuries, it is really hard.” “Deployment of nurses could alleviate the staff shortage, but it disrupted the maintenance of staff relationships . The newAnew group of nurses has been transferred in so that we can take turns off. However, their major is different from us. The cooperation is not very smooth, sometimes messy.” . “I think communication was definitely a challenge at first, being able to have two cooks in the kitchen and understanding what role each of them played in the patient care I think was difficult.”(P3) “Category 10: Limited knowledge and skills of nurses.According to the severity of COVID-19, many patients required mechanical ventilation with a ventilator or advanced life support. For most nurses, providing care for patients with COVID-19 was different from their previous work. All of these challenged the knowledge and skills of the nurses, especially for those who were newly graduated nurses or lacked working experience in infectious disease or intense care unit , 79, 81.I don't have the experience of working in the Intensive Care Unit, and I don't know much about the use of the ventilator… Under pressure and on the verge of collapse, we all have to work in high concentrations.” “Because the diseases of critical patients are also very complicated, some patients, for example, have leukemia, we don't know how to do with it.”  “The majority of the population do not speak English, enough to communicate to have a conversation, but not enough with the tools we have to understand that ‘hey' you're very sick.” “Category 11: Insufficient public education.The authorities failed to control the situation by timely public education and taking measures in the initial days , 43, 44.Now we know that the virus is spread by droplets…but people [the general public] don't have any clear information on what precautions to take against this…I always see people in the bus…touching everywhere and not being that aware.”  “When nurses saw careless people, they thought that these people put them at a risk of infection , and the...it is maddening how everyone is being careless and mindless...the people are still acting as if nothing is wrong with the pandemic and the country and they just want to go to cafes and the government has been only taking impulsive decision that is only making things worse not only for us but also for the people... no one is helping... no one”  “Working conditions are very difficult, and it'll be harder if people don't cooperate. We expect people, by staying at home, and observing personal health and social distancing, to help us and not let the treatment staff's effort be in vain.”(Pe87) “Category 12: Inefficient management of healthcare system.There were no emergency plans for infectious diseases and no training or drills about responding to crises, resulting in a poor response . InadequThere were never any drills for the nursing personnel of organizations managed by the Ministry of Health to prepare them for infection crises. There are only occasional mock drills for dealing with a crisis for the nurses and doctors at military hospitals. Well, we hadn't been trained and this affects our handling of this crisis as well as ability to provide effective care.”  “The departments of laboratory, radiology and pharmacy cannot follow with clinical steps. We cannot improve our efficiency.”  “The guidelines about which mask to use in which situation seems to be continually changing. With things constantly changing it makes it difficult to stay on top of things as well as you question the reasons behind some of the changes.”  “Synthesized finding 3: Facing difficulties and challenges, nurses could only partly cope by using mixed means to overcome those, including media, learning, gaining skills, responding together, and organizational assistance.Category 13: Nurses' individual psychological coping styles.To maintain mental health, several nurses took measures, such as reading, writing, music, meditation, cooking, and so on , 66, 74.Music helps me a lot. Uplifting music.” “I will play my favorite online games after work, which can relieve my pressure and no longer think about my work experience.”  “I wrote in a diary every day, recording what I had done and what I had gained, and this made me feel much more comfortable.”  “I ate a lot during the crisis. I think I gained around 10kg. I'm exhausted after work; I eat a lot so I can bulkup more energy. I took vitamins more consistently too. I do exercise as well. I limited my alcohol intake during the crisis. I didn't want my immune system to drop.” “To avoid the impact of negative news, the nurses limited the exposure to media and paid less attention to news about COVID-19 , 53, 67.… I do not watch any news in the evening, I follow them on the Internet. I muted all of the WhatsApp groups, I check them out for about 5 mins when I am available... to see if there is anything involving me... I protect myself like this …” “I tried not to think at first. I think more in the hospital. When I come home, I go to my room and try not to have close contact with family members. I comfort myself saying that these days will pass, only some more days to go, as if it is a temporary period. At first, I was thinking a lot, so my fear, panic and anxiety were very high. Now they decreased, as I am not thinking about it.” “One day, I felt that the working pressure was too high to bear, so I burst into tears hiding in bathroom, and I became relaxed after crying.”  “Category 14: Active learning through various ways.Many nurses learned knowledge and skills about COVID-19 and protective techniques actively from the internet, social media, and team members , 79, 84.Through learning, I acquired medical nursing skill, especially for COVID-19 patients in a short time.”  “I must adjust myself because I cannot be immersed in sadness, I must focus on combating the epidemic, and take efforts to save more lives, win the battle, and help everyone to return to a normal life.”  “The nurses followed precautionary measures , 75, 84,Category 15: Seeking external support.A number of nurses took the initiative to seek external support, such as medical supplies support and psychological counseling , 26, 71.We encourage each other. It doesn't feel like I'm fighting alone, I'm not afraid.”(P595) ”[I was with] 3 of my closest friends… so just having them to be able to turn to and… bounce ideas off of or… even vent to… having some familiarity with one's colleagues also made it easier for nurses to support each other in providing patient care.”(P4) “I was very scared that I might pass the disease on to my family members, but I relied on God and tried to keep those thoughts away from me.”  “Category 16: Organization's coping strategies.Nursing managers played an important role as coordinators and experts during the pandemic , 64, 84.Really, they are good. They helped us. They looked after patients as well as us. They asked what the problems are and what the shortcomings are. They arranged meetings to talk.” “Hiring usually takes place at a very inopportune time and doesn't take into account if we are novice nurses.” “One day, I went up to perform my normal duties and the head nurse called me. She was worried as she couldn't find nurses who could care for COVID-19patientsdue to the lack of available staff members, so she chose me to do it and I was not able to refuse at that time.” “…the huddles at the beginning throughout it with our staff and our nurse director were very good…we could talk to each other, express [concerns],[and] it was in real time as we were going through it. You can bring stuff up, support was given.”(P5) “Category 17: Application of modern technology in caring for patients with COVID-19.When caring for patients with COVID-19, robots were used to deliver foods, medicine, and other stuff to the patients. However, the application of robots in patient care had a negative impact on relationship between patients and nurses, resulting in the nurses' guilt . The nurThat means we do not always collide with the patients. We had a robot. He is the one who sends all the foods to the patient. We only collide directly with the patient when we take blood. That's why we have to go very rarely.”  “For elderly patients [without a phone with video calling capabilities], we give them a Tablet to use so that they can video call their family members.”  “All along the interpreter was used to communicate with this poor wife who was already stressed and overwhelmed with all that was happening. Then with IPad in hand and pressed up to the glass window of the patients' room, the family prayed, and then watched us take him off the ventilator…” “Synthesized finding 4: To better respond to the COVID-19 pandemic, nurses' needs should be paid attention to. Counseling, training, information, resources, and investment are pivotal.Category 18: The need for psychological support.When the nurses involved in rescue work at the very beginning or suffered psychological problems, psychological support provided by psychologists and therapists for these nurses in time was necessary , 75, 84.We don't know how to deal with it … I think it would be easier if there are psychologists who can provide psychological counseling …We do need some kind of support from family members or social groups because we are facing high risks.”  “…We don't know coping strategies... I feel like consulting an expert, so it would be much much better if psychosocial support were to be provided by psychologists, therapists in related fields by making appointments... We really need some sort of support, because we are under a lot of risk.” “I think it would be nice to have counseling for nurses at the very beginning. We had nurses who did not come for the duty.” “Category 19: The need for training and information.The training project prepared the nurses well during the COVID-19 pandemic . Novice I felt the training programme prepared me well for the work in the COVID-19ward.” “…I do not even know how to protect myself; there is no related training. It's so dangerous and I feel scared when I think about this…” “Managers should strengthen the training of emergency rescue content in order to respond to unexpected accidents in the future.” “If there was a clear policy about this condition that we acted based on it, it would be much better, our care is performed based on our previous experiences, I think a series of clear and scientific care and treatment policies should be provided.”  “Category 20: The need for resources management.Due to the shortage of nurses and heavy workloads, the scheduling and human resources were needed to adjust dynamically to meet the requirement of working and keep the strength of the nurses , 72, 84.…What we need most is an effective management team that can arrange personnel and distribute staff appropriately…” “Before the assignment, we were basically not asked about our work experience or anything like that.”  “The management of the material has been a bit chaotic, I have not felt insecure, nor that I had no material. But neither have I seen that there was enough material to provide good care.”  “Category 21: The needs for more investments in nursing.A great many of nurses longed for more investment, financial support, and incentives in nursing , 81, 84.I expect the authorities to support us in this situation. Well, it can be financial or promotion in the work system.”(P87) “You should be rewarded as a nurse for putting an extra effort into this; because it was also a risky job …it's so Florence Nightingale like. We would really like to help, you just feel that you are not rewarded for i…we would like something other than a box of chocolates for the coffee and thanks for the good treatment.” “We were labelled as health heroes. We know we worked. Although labelled, we did not receive our overtime and public holiday payment even.” “Category 22: The needs for the rights to be respected.Several nurses were forced to work on the front line , 80, 81.I had to meet up (in the COVID-19ward) with 24hours warning, then they changed my employment contract again. Actually, I have no choice, I simply can't accept that.” “We want the authorities to always pay attention to us, not when they are in urgent need. We are told that you are at the frontline of combat and you are on the battlefield against the disease. Well, this is our usual job, now it has become a little harder. So always give us importance.”  “For decision-making regarding patient care and unit policies, the nurses believed it was a right for them, but the nurses did not involve in unit decisions . The nurFrontline staff needs to be given more information on management decisions…if they can understand why different decisions are made, they would have fewer grievances and can be more supportive.”  “Category 23: The needs for improved response efficiency of healthcare system.The system responding to the similar crisis needed to be improved . Timely Synthesized finding 5: Despite the hardships, the nurses became stronger and gained gratitude, positivity, mental peace, and confidence.Category 24: Advancing in nursing career.Through involving in rescue work, the professional skills, work experience, and management ability of the nurses improved , 81, 84,I've never been so proud to be a nurse. I feel like this has been an accomplishment.”(P159) “I began having other objectives because there are no perspectives of professional growth for me.”  “I have become much more conscious of my competencies and value as a nurse.” “To be honest, I once thought about quitting my job. But after this event, I feel that my professional identity has been greatly strengthened, and I have a sense of achievement.”  “I think I have to continue to improve myself, and I suddenly have the impulse to study as a specialist nurse and a graduate student.”  “Category 25: Improved relationships and social recognition.Some nurses realized the professional solidarity between colleagues was increased, which made them support one another during the pandemic , 68, 77.I felt that they thanked us from the bottom of their heart. Some patients cried when they discharged from hospital. Some family members kneeled down to express their thanks when they picked the patients up.”  “One patient, when we went to facilitate his functional exercise and talk to him, was very willing to communicate with us and kept thanking us.”  “One patient, when we went to facilitate his functional exercise and talk to him, was very willing to communicate with us and kept thanking us.”  “Category 26: Being more positive toward life.After self-reflection of the nurses, they realized that their will and courage to face life enhanced, and their potential was discovered , 26, 57.After the epidemic, I wanted to try new things which I did not dare to do before, such as skydiving and bungee jumping.”  “Good health was the foundation of everything. I would cherish life more and pay more attention to my health than before.”  “It's nice to be alive. Everything else is unimportant.”  “In this review, a total of 70 qualitative studies were included and five synthesized findings were created to better understand the front-line nurses' experiences and needs during the COVID-19 pandemic. The front-line nurses showed a strong sense of professional responsibility and mission, and their psychological responses were dynamic and varied during the COVID-19 pandemic. The front-line nurses encountered a variety of difficulties and challenges, and they could only partly cope with. Meanwhile, they needed psychological support; training; timely, accurate information; adequate manpower, and material support et al. To better support the front-line nurses, their needs should be noticed and met. Being involved in front-line work during the COVID-19 pandemic, despite the hardships, the nurses' professional ability improved, and they gained a lot.Not all the nurses were adversely affected, but no one was invulnerable. In our study, the front-line nurses had a lot of negative psychological experiences in the early and middle phases of pandemics, such as fear, anxiety, distress, and depression et al. According to the previous study, the prevalence of anxiety symptoms and depression among the nurses during the COVID-19 pandemic was 29 and 22%, respectively . A natioAccording to the pieces of literature, <7% of medical staff were trained in managing patients with COVID-19; 83.8% of them lack confidence in managing suspected cases. Furthermore, <60% of medical staff received training in PPE, and only 43.2% of them knew proper hand hygiene techniques . In lineHealth-care resource availability was associated with patients' mortality . HoweverThe results of this review showed that public education was insufficient, and the nurses had lots of negative social experiences, such as social stigma, which badly affected their work and life. Radhakrishnan et al. found that more than 50% front-line nurses experienced social stigma . Social According to literature, modern technology has been used to combat the COVID-19 pandemic in recent years . In the This meta-synthesis adopted a rigorous systematic search strategy and an article review process to ensure the quality of the research. However, there were some limitations in this study. Although we searched seven databases systematically to identify related articles, it was possible to miss out the potential data from other databases. Only English-language pieces of literature were included in this study; therefore, the findings may not confidently capture the experiences and needs of the front-line nurses in non-English-speaking culture. Despite this, study settings included other cultural groups, such as in China, Japan, Turkey, Italy, Iran, Spain, South Korea, Thailand, and Brazil.This study highlighted the experiences and needs of front-line nurses during the outbreak of COVID-19. Their psychological experiences were dynamic. They also faced various challenges in rescue work and needed multifaceted support. Managers should establish psychological support services for nurses, including offline and online services for them. It is necessary to establish scientific support echelons, ensure the adequacy and availability of nurses, and provide sufficient PPE and facilities. Regular training and drills could improve emergency response capabilities of nurses.Managers should facilitate regular and formal training to enhance nurses' emergency response capabilities. Nurses should constantly learn to improve their knowledge, skills, and resilience. When responding to similar crises, it is necessary to establish scientific support echelons. Nurses' willingness, capacity, experience, and readiness should be considered by nurse managers. Working on the front-line was challenging; nurse managers should provide sufficient supports, including providing adequate PPE and medical equipment, and timely psychological support. Meanwhile, nurse managers should increase investment in nursing and protect nurses' rights and interests. For better work, modern technology can be properly applied.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.XY: study conception and design. SDi, SDe, and JH: data collection. SDi, SDe, ZL, and YZ: data analysis and interpretation. SDi: drafting of the article. XY and QW: critical revision of the article. All authors have read and approved the manuscript.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The aim of the present review was to explore the effect of parental misperceptions of their offspring’s weight status during childhood and early adolescence on weight control strategies and children’s eating behavior. Literature searching was limited to the PubMed database and to the English language from January 2000 to August 2022. Eligible studies had clearly associated parental misperception of offspring’s weight with child eating habits or weight management and eating strategies in childhood to early adolescence. Sixteen studies  were included in the analysis. Weight loss attempts and child’s eating behavior were the main outcomes. Sixteen studies found significant associations. Parental misperceptions of their offspring’s weight status do influence their child’s weight and eating behavior, especially in overweight children. Parents tend to follow potentially harmful methods when they overestimate their children’s weight (food restriction) and when they underestimate their children’s weight (pressure to eat). However, additional longitudinal studies are needed to better understand the impact of parental weight status perception on health behaviors and children’s weight gain over time. The potential need for preventive intervention studies is warranted. Obesity is a major public health problem. Obesity stemming from childhood often projects into adulthood with well-known devastating health consequences ,2. PreveParents often misperceive their offspring’s weight status, especially in early-middle childhood ,8. It isThe 5–7-year-age period is regarded as the beginning of the ‘‘age of reason’’ . ChildreA computer-assisted literature review was performed using the PubMed database. The search was narrowed to articles between 1 January 2000 and 31 August 2022. In this narrative review, used search strings were: “parent*” AND (“perceptions” OR “misperceptions”) AND (“weight” OR “weight status”) AND “child*” AND (“diet*” OR “behavior*” OR “feeding” OR “practices” OR “eating” OR “strategies”). Restricted to humans, children and young adolescents  clearly associated parental misperception of offspring’s weight with child eating habits or weight management and eating strategies, (ii) children or adolescents between 6 and 15 years of age, with no child being over 15 years of age, i.e., entering from early to middle childhood and extended up to young teenage, leaving out middle and late adolescence period. We included studies with children and early adolescents since, during childhood and early adolescence, parents can still effectively influence their children’s eating behavior and lifestyle.From each study, the following relevant data were extracted: first author, year of publication, country, study design type, sample size, age of children, parental perception assessment, diet assessment, BMI reference norms and the key results/conclusions of each study.In this study, we reviewed former relevant published studies to investigate the effect of parental misperceptions of their offspring’s weight status during childhood and early adolescence on weight control strategies and children’s eating behavior. This narrative review showed a total of sixteen studies related to the aforementioned association .N = 5, i.e., 8 European countries (n = 1) including Belgium, Greece, Hungary, Netherlands, Norway, Slovenia, Spain, Switzerland, and the UK (n = 4)], in Asia , in America , in Australia (n = 1) and from the network (n = 1). The sample size varied from 49 individuals [ividuals  to 47,41ividuals , while aividuals  to 6–18 ividuals . Howeverividuals ,16,30,32ividuals ,27,32,33For the assessment of parental perceptions, the following methods were applied: interview with quantitative techniques , interviHowever, different questions were used to assess parental perception of their child’s weight. For example, in the study of Almoosawi et al. (2016), parents’ perception of their child’s weight status was assessed using the question ‘How would you describe your child’s weight at the moment?, while in the study of Robinson & Sutin , the resRegarding the evaluation of dietary habits, the Child Feeding Questionnaire was the most used tool ,24,27,33Percentages of parental weight misperception  ranged from 17%  to the hFour out of the sixteen studies included in the present review explored parental weight misperceptions in association with weight loss attempts of the children  under the term “slimming behavior”). In the other twelve studies, parental misperceptions were explored in association with child eating behavior and parental attitudes towards healthy eating.More specifically, it was revealed that children whose parents perceived them as overweight were more likely to attempt losing weight , and if Regarding healthy eating behavior and parental perceptions, it was revealed that children whose parents misperceived their weight status did not follow the optimal dietary pattern  and thatFinally, two studies revealed that parents who perceived their children as overweight or obese use restriction eating methods, e.g., always watching the quantity and the quality of children’s food consumption or hiding specific foods from their children ,33; whilFour out of the sixteen studies evaluated separately maternal and paternal perceptions and strategies. It was found that mothers were more likely to use pressuring methods to eat if they believe that their child’s weight is below the normal  and moreIt is worth noticing that parents behave differently based on the sex of their child. For example, parents are more likely to wrongly identify a boy’s weight than that of a girl’s ,23, whilAccordingly, parents behave differently based on the age of their children. For example, parents were more likely to underestimate children’s weight status than that of adolescents ,27, evenFinally, in the study that used cross-sectional and longitudinal analyses, it was revealed that more parents misclassify the weight status of their adolescent sons than of their daughters, while 50% vs. 43.9% of the overweight boys and girls who had not been encouraged to diet, respectively, remained overweight compared to the 74.1% and 66.1% of boys and girls who had been encouraged to diet .The present narrative review, summarizing the effect of parental misperceptions of their offspring’s weight status during childhood and early adolescence on weight control strategies and children’s eating behavior, showed that parental weight misperception may influence children’s weight and the strategy each parent will follow to improve eating behaviors, especially in overweight children. It seems that parents who accurately or not perceived that their child was overweight reported restrictive feeding practices and encouraging methods to modify their children’s eating habits. At the same time, parents who underestimated their children’s weight were more likely to follow harmful strategies for their children. Moreover, it seems that European parents were more inconsistent regarding their perception about the actual body status of their children compared to Asian, American or Australian parents. Based on the above-mentioned results, these can be characterized as particularly important for the future course of life and health of children, who will constitute the human resources of a healthy society.The role of the parent Is one of the most important and, unfortunately, there is no instruction manual. No matter how hard parents try, they will also make mistakes raising their child, as their roles are multiple . It is tMoreover, all the before-mentioned results could possibly be explained by the fact that parents’ perceptions of their child’s weight are also shaped by cultural, socioeconomic and psychological factors. Factors such as the child’s gender and age, ethnicity, parent’s weight, increased daily caloric intake of the parent, low income and low educational level affect the ability of parents to correctly estimate their child’s weight . It seemInaccurate perceptions begin very early, in infancy. Pediatricians, nutritionists, and health scientists should help parents improve their understanding of the actual body weight of their children. The parental perceptions of a child’s development and correct eating behavior are the factors that will determine the future weight status of a child. Also, they are the ones that will be a key factor for the family, leading them to modify their eating behavior and change their general way of life . ActuallTo the best of our knowledge, this narrative review paper is one of the first of its kind to summarize the effect of parental misperceptions of their offspring’s weight status on weight control strategies and children’s eating behavior. However, this review has some limitations that need to be addressed. The observational nature and the epidemiological evidence presented from observational studies are more prone to bias and confounding and cannot be used to demonstrate causality. Besides, the heterogeneity of research tools applied to evaluate parental perceptions may be considered as another limitation. Regarding the review process, it was limited to the PubMed database and to the English language. However, as data paucity on the interplay between parental weight misperception in early-middle childhood and child’s healthy behavior is well recognized, it seems unlikely that any further publication would substantially alter our findings.In conclusion, the aggregated evidence corroborates that parental weight misperceptions do influence their child’s weight and eating behavior, especially in overweight children. Meanwhile, parents seem to follow restrictive eating methods when they believe, accurately or not, that their child is overweight or obese, while parents who underestimate their children’s weight are more likely to pressure them to eat, i.e., two strategies potentially harmful for children. However, the association between parental misperceptions and the weight control strategies implemented needs further investigation. Systematic observations and prospective studies may shed further light on the issue and allow the appropriate community interventions. Further studying the effect of parental misperceptions on weight control strategies may provide valuable information for educating families and promoting healthier lifestyles in early adolescence with apparent benefit in adulthood.


Family-based lifestyle interventions (FBLIs) are an important method for treating childhood weight problems. Despite being recognized as an effective intervention method, the optimal structure of these interventions for children’s overweight and obesity has yet to be determined. Our aim was to better understand participants’ (a) implementation of behaviour strategies and long-term outcomes, (b) perceptions regarding the optimal structure of FBLIs, and (c) insights into psychological concepts that may explain the success of these programs.n = 53) and children  three months following their involvement in a 10-week, multi-component, FBLI involving education and activities relating to healthy nutrition, physical activity, and behavior modification. Using an interpretivist approach, a qualitative study design was employed to examine participant experiences.Purposive sampling was used to recruit participants. We conducted focus groups as well as one-to-one interviews with parents (We identified three higher-order categories: (a) participants’ program experiences and perceptions (b) lifestyle changes post-program, and (c) recommendations for optimizing family-based programs. Themes identified within these categories included (a) support and structure & content, (b) diet and physical activity, and (c) in-program recommendations and post-program recommendations. We identified several challenges that can impair lasting behavior change  following involvement in a FBLI. On optimizing these programs, participants emphasized fun, interactive content, interpersonal support, appropriate educational content, and behavior change techniques. Concepts rooted in motivational theory could help address calls for greater theoretical and mechanistic insight in FBLIs. Findings may support research advancement and assist health professionals to more consistently realize the potential of these interventions. Childhood overweight and obesity is recognized as a global public health crisis . In AustBehavioral and lifestyle interventions  aimThere exists a vast literature on frameworks and psychological constructs that may explain varied effects of FBLI programs. For example, in self-efficacy theory, there are four antecedents to an individual’s confidence in their ability to perform a behaviour, namely, performance accomplishments (whether a task is performed successfully), vicarious experiences , verbal persuasion  and physiological and affective states (such as stress or joy) , 38. In In discussing the merits of FBLIs, Berge and Everts  noted thNotwithstanding the positive outcomes for which family-based treatments may be responsible, however, there remain important questions to be addressed in this area. In a systematic review exploring the viewpoints of adolescents (12–17 years) who had attended overweight and obesity interventions, several of the key themes which emerged were: intervention tailored to the individual, active engagement and fun, longer term support, value derived from professional, peer and family support, and an emphasis on enjoyment from physical activity . FurtherIn this study, we sought to understand (aspects of) participant experiences during and following a FBLI for children’s overweight and obesity. In seeking to address the broad issues outlined above, we sought detailed feedback from parents and their children after they had completed a FBLI. More specifically, we sought information regarding participants’ (a) experiences in and perceptions of the program, (b) lifestyle changes following the program, and (c) recommendations for optimizing the effectiveness of programs of this kind. These three broad discussion areas were selected because they either mapped directly onto issues that we sought to better understand , or because they would likely enable us to make inferences about issues that may be considered too esoteric  to discuss directly with community-based participants .Grounded in our desire to capture parents’ and children’s lived experiences within a family-based intervention, we adopted an interpretivist approach to enquiry . The intn = 97) or one-to-one interviews (n = 6 parents). All children were classified, according to body mass index (BMI), as overweight (BMI > 25.0) or obese (BMI > 30.0) at entry into the program, and participants were drawn from the Perth metropolitan area.We aimed to recruit parents and their children who had completed a program and had returned to an extended period of ‘independent’  living so as to enable us to explore long-term effectiveness and lifestyle change/maintenance post-program. We primarily sought to obtain insight from parents and children who had received the full program ‘dose’, as those participants would likely have the richest experience upon which to reflect. For the sake of contrast and in order to capture more balanced data, however, we aimed to supplement these accounts with information from a sub-sample of parents who had withdrawn from the program . A total of 53 parents  and 50 of their children  participated in focus group interviews  and parents (n = 9 sessions) separately to ensure that the perspectives of children were freely explored. Six of the parent participants were those who had left the program early, and these parents were separately recruited (via email) in order to provide perspectives from program non-completers. One-on-one phone interviews were held with these non-completer parents to obtain the richest possible accounts from all of these participants.All program completers were invited to participate in the study. During a scheduled program follow-up assessment that took place three months after the end of a family’s involvement in the 10-week family-based program (see following section for program information), prospective participants  were approached by members of the research team (over 50% of those invited were willing to participate). Focus groups were used to provide an in-depth understanding of participant perception and identify barriers to change that cannot be addressed using quantitative methods  in a timIt is worth noting that some inter-patient and patient-interviewer dynamics likely affected the findings of this current study. For instance, prior to participation in interviews, participants became acquainted through participation in the FBLI program. There is little consensus in the literature on the impact of conducting focus groups with acquaintances. Some researchers , suggesThree members of the research team developed a semi-structured interview guide for parents and children prior to data collection. In line with the aims of this study, the interview guide included open-ended questions developed to explore parent and child (a) experiences within and perceptions of the program, (b) lifestyle changes during and following the program, and (c) recommendations for optimizing the effectiveness of programs of this kind. Probing questions were used to explore answers given by participants, concepts surrounding answers, and to gain further explanation regarding a belief or behavior. At the end of each focus group or phone interview, participants were invited to ask questions. Based on the nature of thematic analysis, there always remains an ability to generate alternate meanings from data, and as a result, data analysis may never truly be considered ‘complete’. Data collection continued, therefore, until members of the research team made an interpretive judgement that the data provided a faithful and detailed representation of participants’ experiences during and following the program . On averwww.betterhealthcompany.org/) provides a childhood overweight and obesity intervention called the Better Health Program  to families across Australia who, over the past 10 years, have shown statistically significant improvements in self-esteem, BMI, healthy eating habits and physical activity upon program completion. The program aims to have children build confidence, improve self-esteem, become fit, and teach parents the skills to ensure their children are healthy. The organization is reputable, well-known, and government funded; its program is based on best-practice programming guidelines and published research evidence . The 10-week multi-component program involves weekly, two-hour parent-and-child sessions—delivered by trained health professionals—focused on the provision of resources, education, and experiential activities relating to healthy nutrition, physical activity, and behaviour modification . The program targets children with overweight and obesity aged 7 to 13 years old, is cost-free for participants, and operates in venues such as leisure and recreational centers, community and school halls, and council facilities across multiple locations in Australia. Participants are recruited through community promotion  and referrals by health professionals. The Better Health Program—in terms of lifestyle modification aspects, behavior change content, expert delivery, and program length—adheres to many of the best-practice recommendations for family-based program content  finds herself in the middle of a group where they all have the same level of activity, so nobody is faster or stronger or better. That really helped her because, as a group, they all helped together through the same activities.” On a separate issue, another parent appreciated the supportive comments from peers, stating, “saying nice things about other [children] in the group, it builds other people up as well. I think that was helpful, and [the children] were quite proud of it, it’s something for them to hold on to”  the significance of practical and interactive components, (b) the inclusion of appropriate educational material, and (c) the importance of program features that support participant enjoyment.With respect to practical and interactive components, parents and children appreciated the ‘hands-on’ elements of program content. This practical approach allowed parents and children to develop their understanding (and competence) regarding, for example, nutrition-related skills. Specific strategies will vary program-by-program, but one example of this interactive approach in the present program was the use of food label reading sessions, and a ‘live’ visit to a supermarket. Discussing this component, one parent commented, “the best thing we did was when they took us to the supermarket and they actually showed us how to look for the labels… like, telling us ‘this is good, this is not good, this has too much fat, this one has a little bit of sugar’, it just gives us details on what to take away.” Children also appreciated these practical methods for delivering educational content. One child commented, “I liked it when we went to the shop and learned about the labels. We got to learn about the labels and what’s good for you, what’s bad for you, and what the best brands are.” Similarly, reflecting on ways in which program content could be improved, another child noted he would have appreciated “if we got to learn things in different ways, like doing activities, instead of sitting and… trying to listen.”As well as describing the importance of practical program elements, participants also expressed a desire for educational material—which was central to program content—that was considered ‘new’ or ‘fresh’. For example, the program afforded parents and children with the opportunity to learn new healthy recipes; one parent noted that “[the] program’s been really helpful in terms of recipe ideas and giving information about reading labels and all those kinds of things I didn’t know before.” Similarly, another parent commented, “A lot of the stuff… was all new for the kids, and the information was very accurate. They kind of gave you websites that you can look for, go and search for recipes, community activities and things like that.” It was noteworthy that children expressed the same sentiment. One child commented, “I learned that when you have lots of muscle, fat won’t be able to grow that much. And also, instead of using sugar, you can use natural sweeteners or healthy fruits. And instead of having white bread, you could have whole-meal bread. I found out that wheat is much better.” Whilst discussing educational material, parents expressed concerns when information was not considered to be ‘new’ or ‘fresh’. One parent, for instance, noted that “I think the program itself is good, but I don't think it was suited to my son. You know, they gave a lot of good tips and things, but it was nothing that wasn't already common knowledge.” A parent who did not complete the program added, “it’s all good to say ‘you need to stay away from junk food’, but we all know that already. It was based a lot on things that we already know… we stopped going because everything that we were learning was stuff that everybody knows.”Finally, participants emphasized the importance of program elements that support participant enjoyment. Many parents and children reported that they enjoyed the physical activity within the program sessions. One parent summarized, “the exercise, that’s the fun part. Because they’re all the same, they helped each other, and they had real fun, they loved it. The kids will go off with the instructors and get bright red, sweaty, and they absolutely loved it, and they would stay behind”. This enjoyment appeared to be derived from children being able to access a variety of different forms of physical activity, and ‘having a say’ (or some degree of autonomy) over their activity involvement and choices. Participation in different team or cooperative activities was perceived as enjoyable and as an opportunity to learn and develop competence in new areas. One child noted, “I liked the sports. We got together and worked as a team. And we got to run around and be free, have fun, and learn new stuff. Bouncing! And running! I liked getting to do the different exercises.” The same effect was described in instances when children felt that there was a lack of variety or autonomy. One child commented, for example, “I didn’t like having to do fitness, it didn’t really help me. We were just standing in circles for the whole thing, we didn’t run or anything. I thought we’d be racing and that stuff.” One parent echoed this sentiment, noting, “[my boy] kind of felt like it was a bit, like he had no choice with that side of it, that’s how he felt, that's what he said to me” , participants spoke broadly about two key health behaviors. Specifically, they described successes and challenges relating first to children’s diet, and second to children’s physical activity levels, which were grouped into two themes. In doing so, participants also described some of the reasons underlying those successes and challenges. In the material that follows  had successfully adhered to, or sustained, dietary changes brought about during the program. These ‘successes’ reflected an ongoing awareness—that had been provided through participation in the program—regarding (a) healthier choices, recipes and food substitutions, and (b) nutrition resources  and simple ‘tips’ or skills  that were considered valuable and sustainable.Speaking generally about making healthier dietary choices, one parent noticed, “we’re now eating more fruits and vegetables. We don’t have food goals, but we’re just eating more of the healthier stuff now.” Similarly, one child mentioned, “we make these cupcakes now, and we didn’t put any sugar on them at all. We do it healthier, the healthier version.” Another child highlighted that his family was still making healthier substitutions that had been introduced during the program, “now we use wholegrain bread all the time. And also wholegrain spaghetti, and wholegrain crackers”  of physical activity. First, parents highlighted that the withdrawal of the structure provided by the program  had made it difficult for them to continue to support their child’s physical activity. On this issue, one parent commented, “it’s hard for me—there’s not enough time. Sometimes, we [the parents] don’t have the energy. Sometimes, we have the time, but we get more tired than the children, they have energy, but it’s just us that doesn’t.” Another parent explained, “The program’s just really good, it’s just the challenge of having, of how to go on on your own, because it’s very goal oriented, that’s been so good, it is more of how you keep them motivated to carry on.” A different parent reinforced the same issue, “The exercise part for the kids is missing after you finish, so we had to fill the time, even if he does other things, it’s not the same, because if you’ve got something interesting, they get more into it I find. I think just not having the fixed times, that we knew that Thursdays four to six, that’s what we’re going to do.”In reflecting on the benefits of being with similar others during the program , some parents noted that integration into ‘regular’ community activity post-program was difficult. One parent explained that her child felt ostracized when she tried to participate in community-based sport following the program, “the people organising the activities don’t use your kids in games because they’re “fat” or they’re “slow”, and it’s adults saying that to kids.” Another parent shared, “when [my son] was doing the exercises, he was actually so confident and relaxed because everyone else was the same… it’s the interaction with other kids. It’s just different after [the program] when they go out and to do the sports on their own” , or those focused on the period following the program . Below, we detail key issues highlighted in these two themes  following the program, some parents suggested that longer programs (including a dedicated ‘transition’ phase at the end) may be beneficial. One parent commented, “I think it would be nice if programs were spread out, instead of having it in just one school term.” On the issue of a gradual transition out of the program and into self-regulation, another commented, “it would be nice to have a bit more continuity instead of just doing that one program and finishing.” One parent suggested that a transition phase could involve shorter sessions, “You could, you know, make those later sessions just a quick blast of activity. We’ve got what we need for information, but that could be a way of keeping things active for longer.”In terms of intervention content, it was apparent that children expressed a desire for prioritizing time toward (enjoyable) physical activity during the sessions. One child mentioned, “less talking, more playing. We normally do an hour of talking and a bit of sport, and then we’re coming back, and then we have to leave.” Similarly, another commented, “I want more games, I want to run more. If not, we do more mind things instead of active things.”Finally, some children raised noteworthy recommendations about sensitivity to grouping considerations. Although the majority of children observed likeness with others in terms of weight and health issues, age differences appeared to be a barrier to participation in some instances. One child mentioned, “I don’t know, maybe the age groups that they take in at one time should be smaller, because for me to come in was awkward, because I’m 13 and all of you guys are like 10.” Another child commented, “I kind of wished like the age groups were exactly the same for everyone. You won’t get a lot of teenagers wanting to join unless their parents force them into it.”Parents provided valuable recommendations for post-program strategies that could improve the maintenance of healthy dietary and physical activity behaviors learned during family-based programs of this kind. The overarching recommendation reflected the importance of maintaining connections—with the program and those with whom the families had completed the program.For example, parents endorsed the possibility of having formal ‘post-program support’ through occasional contact with the children. One parent explained, “to have someone like that [from the program] calling, you know, contacting you, asking how you’ve been, what you’ve been doing, what your goals are for the next month, I think that would just reinforce the message, and it wouldn’t take a lot of time.” Other parents felt that a continued connection between program and parent would help ensure children were able to maintain their newly-learned healthy behaviours. One parent said, “it’d be a good back-up, like a review or something. Maybe we should make it every 2 or 3 weeks, just to keep us motivated.”In addition to formal connections with the program, parents also indicated the benefits of facilitating continued connections with one another. Parents suggested that social media platforms could be used to create a lasting sense of community, allowing them to connect with similar others and organize social and physical activities. One parent summarized, “I think creating a Facebook group would be fantastic. You can connect with everybody together, you and the kids can meet somewhere, they can play in the park or walk around.” Another stated, “we started a thing online through Facebook, we sort of just join our own personal group to keep helping each other, and you know, we can add whatever we want to, and sort of check in on each other to see how we’re going, and that has helped.”Finally, one parent suggested utilizing gamification principles in this respect, “Like, a five-day challenge, you can do it on Facebook or Messenger. It comes through, post up what you had for breakfast, get everyone involved. It’s going along the nutrition lines, you’ve got your five days a week included, and another’s posting up all the meals you had in a day, and adults can get into that sort of thing, I think it’s a great idea to actually get people on track” . There Family-based programs of this kind are developed with the aim of modifying lifestyle behaviors during and following the intervention; two particularly prominent behaviors in this respect are physical activity and diet . Based Some of the barriers to lasting dietary and physical activity change (post-program) identified in our results such as cost, time, and competing priorities as barriers to physical activity and lifestyle change are well documented and understood . HoweveFrom a practical perspective, as well as being mindful of support strategies that are commonly recommended in this area , addressing specific stigma-related physical activity challenges might help programmers translate improvements in physical activity attitudes into sustained physical activity participation. In terms of methods for doing so, participants spoke about the benefits of end-of-program transition periods, and strategies aimed at ‘maintaining connections’ with one another (and with program staff) following the completion of a family-based program. The benefits of these continued connections  may not only provide opportunities and social support for physical activity , they maIt is often recommended that family-based programs accommodate themes of nutrition, physical activity, and lifestyle modification . WithSeveral of the issues identified by participants mapped onto elements of motivation theory, and in particular, self-determination theory . It was An additional element of self-determination theory with relevance to these findings is the notion of basic psychological needs . It was Aside from relatedness issues, we also obtained feedback relating to the importance of autonomy and competence development , and regarding the importance of variety, which has also been shown to predict autonomous motivation . It is pThere are many factors—such as socioeconomic issues To mitigate weight-related stigma impacting long-term change, families emphasized end-of-program transition periods and strategies to maintain connections with both program staff and participants. On optimizing the program design, participants highlighted a desire for autonomy in program activities, tailored, interactive and novel content, and their similarity to other participants. In line with self-determination theory, participants’ desire for autonomy, competence and relatedness suggested they were driven by autonomous motivation, which has the potential to bolster long-term outcomes. Other barriers to lasting behavioural change post-program included time and financial constraints and competing priorities. The focal program in this study is empirically grounded, accommodates many best-practice recommendations, and consists of elements common across programs of this kind. That being the case, it is reasonable to expect that the evidence reported in this investigation may be informative for other programs and researchers . It woul


Technologies for self-care can drive participatory health and promote independence of older adults. One self-care activity is regularly measuring and registering personal health indicators (self-reporting). Older adults may benefit from this practice, as they are more likely to have chronic health issues and have specific self-monitoring needs. However, self-reporting technologies are usually not designed specifically for them. Pain is usually measured using patient reports compiled during medical appointments, although this process may be affected by memory bias and under reporting of fluctuating pain. To address these issues, we introduced a simple tangible interface to self-report pain levels and conducted a three-hour evaluation with 24 older adults. The goal of this study was to identify whether specific activities, activity levels or pain levels trigger older adults to self-report their pain level, besides to understand how older adults would use such a device. Within the limited time frame of the experiment, the majority of our participants chose to report pain when they felt it most, not reporting lower levels of pain. No evidence was found to suggest a relationship between the reporting of pain and the activity (or activity level). Several design insights intended to improve the design of technologies are provided. Howeverressure) .e.g., due to the “peak-end phenomenon”, in which patients typically only recall their worst or most recent levels of pain  as well as to include users in their development  have be of life . Howeverelopment .e.g., the use of a touchscreen can prove particularly challenging for older adults , which allows users to self-report pain levels, and asked older adults to try it for a short period of time (3 h). The research questions guiding this research are the following ones: (1) What event triggers older adults who experience chronic pain and have low digital skills to report their pain? (2) What is older adults’ perception of a tangible device for reporting pain?This study aims to provide understanding about how older adults use a simple tangible interface to self-report pain. Specifically, we focus on the usability of such a device, as well as the moment in which the older adult reports pain, to determine if activities or pain levels trigger self-reporting. Understanding what guides people to make decisions about pain is essential to understanding the process of pain reporting . Therefous study , called TeRa prototype and its evaluation. ‘Results’ presents the results, while ‘Discussion’ presents the discussion, including limitations of this work. Finally, ‘Conclusions’ describes our conclusions and possible avenues of future work.The rest of the article is organized as follows. ‘Materials and Methods’ describes the TeRa, a simple tangible device for users to record their pain levels. Then, we describe how the device was used to understand which activities or events may trigger participants to register their pain levels. For this, we decided to monitor contextual information using a context model for adults with pain , which requires patients to assign a number from 0 to 10 to their pain . The NRS is the gold standard for pain reporting eporting . For theeporting , we deveeporting  . Eleven participants lived in a retirement home and 13 in their own home; 16 were receiving varying degrees of treatment for pain  during the time of the study; while the remaining participants were receiving no type of treatment during the time of the study, despite experiencing pain (The inclusion criteria for participants were the following: (1) they had to be 60 years old or older, (2) without cognitive problems and (3) experiencing chronic pain. Our final sample of participants included 24 older adults , between the ages of 60 and 87 , who had participated in previous studies at the university and who met the inclusion criteria. If they agreed to participate in this study, after their participation we asked them to recommend contacts who fit the research criteria and who could potentially participate as well. Second, we recruited participants from nursing homes. To do so, we contacted nursing homes near the university campus and asked whether they were interested in participating. If they expressed interest, we sent them information about the study, To collect the information from the participants, several instruments were used. Each instrument is described below. 1.Evaluations of the technology:  •System usability scale. The system usability scale (SUS) is used to evaluate the usability of a product or system . The questionnaire has four dimensions: pragmatic quality, hedonic quality-identity (HQ-I), hedonic quality-stimulation(HQ-S) and attraction . BPI is a questionnaire that consists of nine elements, aimed to assess pain levels. It includes questions about pain during the day, pain intensity, pain treatment and pain interference . GADS is a questionnaire that can be used to assess the emotional state of a person. It consists of two subscales: one for anxiety and one for depression . Each participant received oral and written information about the aim of the research, and written consent to the overall study was subsequently provided. Participants were informed that their involvement was voluntary, that anonymity would be guaranteed, and that they could withdraw from the study at any time.The evaluation was conducted over three months, before the COVID-19 pandemic . Each exe.g., name, gender, and age (10 to 15 min).First, researchers explained the goal of the study and participants were asked to sign the consent form (10 to 15 min). Then we applied the DIGCOMP, GADS and BPI questionnaires and we captured demographic data, TeRa device works by using an example scenario. This example involved a person who experienced pain and used a device to self-report pain for a predetermined period of time. In their subsequent medical appointment, the physician was able to see the pain scores reported by the patient (10 to 15 min).Following this, a researcher explained how the TeRa device and asked to carry out their normal routine . Finally, we asked participants to answer questions about their experience through a semi-structured interview  were analyzed by using the Chi-square test of independence to determine whether the variables were related or not, with a 95% reliability. The data of five participants was not recorded on the wristband for unknown reasons, therefore this information was not analyzed for these participants. The qualitative (interview) data was analyzed through thematic analysis , which wWhat event triggers older adults who experience chronic pain and have low digital skills to report their pain? and What is older adults’ perception of a tangible device for reporting pain?). Section 3.4 (TeRa usage during the experiment) provides information about how TeRa was used by older adults. Participant quotes, taken directly from the interviews and translated from Spanish to English, are provided to illustrate the discussed concepts.The results are organized in four sections. Section 3.1 contains the general data. Sections 3.2 and 3.3 aim to answer each of the research questions  to report their pain levels. For example, P15 stated,The number of steps and the heart rate during the experiment were obtained from the participants’ wristbands. For each participant, this data, as well as the level of self-reported pain, were analyzed to determine whether there is a relationship between the level of pain felt by the participant and the number of steps or heart rate. This analysis was performed using the chi-square test of independence. No correlation was found between the variables, therefore, they are independent.We reviewed whether participants living with anxiety and/or depression  had higher pain that caused interference in their daily lives , and altWhen pain is felt”, “When no pain is felt”, and “With an objective”. These are described next.The interviews did provide interesting insights as to when participants reported their pain. Participants felt that they were able to report pain adequately and correctly using the NRS and that their doctors could use this information to better understand their pain levels. Three sub-themes emerged to explain when users reported pain: “i.e., when they felt no pain, they did not report a score of zero.The majority of participants reported pain only when they experienced the sensation of pain. For example, certain individuals felt pain while moving or changing position and chose to report their pain levels during these moments. Participants confirmed in interviews that they reported pain when moving after having been sitting in one position for a long period of time or when moving abruptly. It should be noted that they did not report pain when the sensation of pain was absent, “Well, when I moved, for example, in the case of my arm that hurts, I felt a lot of pain when moving forcefully, that’s why I reported the pain” (P16).Other participants self-reported pain during the three-hour period, but without having moved or changed position. For example, one participant with arm ligament problems had received physiotherapy treatment during that week and, as a result of decreased pain in the affected area, was reporting lower levels of pain. Similarly, participant P14 stated clearly that when she felt comfortable (no pain), she did not report pain.“If I touched it gently... my arm would suddenly hurt a little, which is why I reported it, even though it was only a small pain” (P17).“I reported when I was in pain, only when I was in pain. I didn’t report feeling pain when I felt good” (P14).i.e., when they were in pain and then when they were no longer in pain. Participant 24 exemplifies this fluctuation:Very few participants claimed to have reported decreasing pain levels, due to having rested or changed activity. Similarly, few participants reported a fluctuation in pain, “When I walk a lot or when I’m tense, I feel a small pain in the body, in my upper arm, between a three and a four, and suddenly 0 out of the blue... I reported it when I felt it and when I felt nothing I reported 0” (P24).Some participants, despite not feeling pain during the three hours in which the experiment took place, reported pain . Participants who did not feel pain used different techniques to report, for example, some reported periodically, while others did so when they thought they should report. The reporting was seen as a task to be completed.“I think it’s important to understand your own pain levels. I reported every so often to try to see if during the passage of time I had been pain free, and during the whole period I felt no pain” (P18).Participants also reported pain with a specific objective in mind, such as to show the collected information to another person or to themselves.“To be able to see the pain intensity in one’s actions, step by step” (P4).TeRa had a SUS score of 87.61. none or low and with low educational levels (none or primary) had SUS scores over ninety. However, there was a difference in the outcome of SUS score with respect to older adults living in their homes (94.6) and those who live in a retirement home (79.3).TeRa user experience, it was found that this device is within the “desired” product quadrant, having obtained a high pragmatic quality (PQ = 1.76) and a high hedonic quality (HQ = 1.57). This means the device is easy to use and helps users to self-report pain, as well as to feel motivated and stimulated.By analyzing the results obtained from the AttrakDiff questionnaire, which measures “desired” quadrant , was 1.93. The hedonic quality stimulation score (HQ-S) was lower (1.22).Likewise, trust levels were 0.37 for PQ and 0.29 from HQ, which means that although responses were a little bit diverse, they were always within the rant See . The attTeRa, only one participant (who experienced low levels of pain) said that they would not use the device again. In addition, another participant said they were unsure whether they would use it in the future because measuring pain on a scale was a new concept for them. However, several participants stated that self-reporting pain with the device every day would be the best alternative, “to know how my pain is... I would use it a few times a day” (P23).Regarding how often they would use TeRa could be used in the future. Then, we comment on the actual use observed during the experiment.This section first provides feedback from the participants about how Some of the participants mentioned that being able to self-report pain could provide them with new information that could help them understand more about their own pain. For example, having data about one’s own levels of pain could enable participants to correlate their pain with the specific activities they have undertaken, as well as allow them to get to know themselves better, understand how their pain evolves, and which parts of the body are most affected.“It’s useful to be able to see the intensity of the pain one feels day-to-day, or to see the intensity of the activities one usually carries out, as a statistic” (P4: 63).TeRa would help them feel like they are being listened to by the medical professionals.Certain participants raised the possibility of receiving feedback regarding the information they reported during the experiment, which indicates a desire to become more active in managing their chronic pain. Furthermore, they feel that being in possession of a device such as “I am aware of being in pain... I would like to have some feedback when my time with the device is over” (P16).TeRa, as mentioned previously, and offered them a waist pouch in which to carry the device during the experiment. However, 11 participants decided not to use the waist pouch. Instead, we identified two other locations that participants used to store TeRa  achieved 94% compliance  studies can vary widely according to method and study setting . Previou., seven , 3–20 , so it is important to study other interaction approaches for this group of older adults, who have needs and limitations that may be somewhat different to more independent older adults.The usability evaluation and user experience of r adults . Moreover adults ; in our e.g., movement disorders . Therefore, the strategies used by previous studies in which pain levels are requested periodically or at random intervals are probably best. These strategies could take into consideration the personal preferences of each user, e.g., for those who feel that a certain activity affects their pain, this activity could be detected and trigger a request for pain reporting, and for those who would like to understand trends in their pain, it should request pain reporting at the same time everyday. 2.Feedback and Visualization: Devices such as TeRa should provide a report, or visualization, of the information input by the users. This would allow older adults to understand their data and feel they have an active role with respect to their own health care. This information should also be able to be shared with health professionals or family members. This finding was also evidenced in  3.Portability and weight: Pain self-report devices must be small and lights, so users can carry them anytime, anywhere; and also should be discreet, to allow users to report pain privately. 4.Clothing considerations: TeRa was placed in different locations during the experiment, with eight of the male participants choosing to insert it in their shirt pockets and ten of the female participants electing to carry it in a waist pouch. This implies that clothing plays a role in the placement of the device, since the clothes that were worn by men had pockets (the shirt), while the women’s clothing was more limited in this regard. This type of consideration regarding clothing should be taken into account when using tangible devices that need to be transported during the carrying out of daily tasks.TeRa was a brief intervention lasting three hours. In HCI studies, time is a factor that determines whether evaluations are made with users or not, due to the complexity they present , so it is not possible to conclude that tangible devices are better than other types of devices, even with participants with low digital skills. Another limitation is the number of participants in the study, since with 24 people it is not possible to generalize the results to a broader population. Likewise, a limitation of the study that must be taken into account when analyzing the results is the fact that when the participants did not report pain, it could be for a number of reasons, e.g., they did not have pain, they forgot to report the pain, or they were in too much pain to report it.Although participants had low digital skills, we did not compare TeRa device was found to have good usability and a positive user experience. Older adults, even those with low digital skills, were able to use the device successfully. The location in which the tangible device is transported may vary depending on the user.Participants self-reported their pain when they were feeling pain, and very few people reported that their pain was decreasing or that they had no pain. The TeRa, to create a version of the device that is more appropriate for older users who want to register and report pain levels. Then, we plan to validate the new version of TeRa by comparing it with other types of non-tangible interfaces, in order to identify if there are significant differences. The idea is to study the adoption of the device over time through qualitative and quantitative analysis, i.e., monitor compliance with pain reporting as well as uncover participants’ reasons for using or not using the device as expected. We also plan to study how to leverage the device to improve the relationship between users and healthcare professionals. Finally, it would be valuable to allow users to explicitly include with their report, what triggered them to report their pain. However, future studies should propose how to do so in a way that is unobtrusive and does not interrupt users or inconvenience them.In terms of future work, the next step in our research is to incorporate these design insights into 10.7717/peerj.13716/supp-1Supplemental Information 1Click here for additional data file.