Pro-diversity beliefs hold that greater diversity leads to better results in academia, business, politics and a variety of other contexts. This paper explores the possibility that pro-diversity beliefs can generate unfair expectations that marginalized people produce distinctive bonuses, a phenomenon we refer to as the “diverse person’s burden”. We suggest that a normic conception of diversity, according to which non-diversity entails social privilege, together with empirical research on psychological entitlement suggests an explanation of how the diverse person’s burden can arise in many social settings. We also suggest structural and institutional remedies to address the diverse person’s burden, as well as an individual virtue we label positional awareness. Pro-diversity beliefs, according to which diversity is beneficial and likely to produce better results in academia, business, politics, and elsewhere, might seem entirely beneficial and even morally laudatory. After all, positive attitudes toward inclusiveness and diversity are obviously better than overt discrimination and exclusion of out-groups. Furthermore, some empirical research has found that diverse groups tend to perform better when their members hold pro-diversity beliefs . Fehr . Fehr  and Bere3). Fehr  discuss 3). Fehr  argues tOur approach to the diverse person’s burden rests on a distinction between two concepts of diversity. The first understands diversity as variety within a group while the second emphasizes the inclusion of people who are subject to discrimination and social marginalization. The first diversity concept is labeled “mere diversity” by Harding , p. 35 aThe second understanding of diversity we discuss is labeled “normic diversity” by Steel et al., . Normic Non-diversity in a normic sense entails social privilege. In this paper, we claim that privilege is crucial to generating the diverse person’s burden because of its tendency to promote psychological entitlement, a persistent sense of oneself as especially deserving . In addition, Ahmed’s discussion echoes many of the themes raised by Fehr, Davis, and Berenstain. Ahmed notes that diversity officers at institutions of higher education tend to be female and/or racialized minorities, and recalls her own experience of being recruited to join a “race equality team” in which the only other faculty member was also a person of color . She notes that creation of diversity offices or other similar initiatives in response to legal or administrative requirements are often not accompanied by interest within the institution in taking substantive action . Moreover, Ahmed reports that experience of resistance to diversity promotion, often described as “a brick wall” or “institutional inertia,” was common among her sample of interviewees . Ahmed develops the concept of “non-performative” speech acts to characterize officially expressed commitments to diversity that do not involve any specific action and which may even help to conceal ongoing discrimination and other inequalities . For example, she describes how official diversity commitments can lead to push back when concerns about racism are raised: since the institution is committed to diversity, concerns about racism within its ranks are a public relations problem . Consequently, those who draw attention to racism risk becoming the target of a counteroffensive that seeks to restore the positive image. As Ahmed puts it, “one of the best ways you can deflect attention from racism is to hear racism as an accusation” .The social dynamics described above are attested to in work describing the experiences of people for whom promoting diversity and inclusion within organizations is a profession Ahmed, . In her White Fragility, by DiAngelo , while diverse groups are produced by randomly selecting from agents who pass a threshold of competency  developed by Campbell and colleagues . This scFor the present purposes, it is important to consider how psychological entitlement relates to privilege. A number of studies find that socioeconomic privilege tends to be associated with greater psychological entitlement Piff, . Given sWe suggest that psychological entitlement is connected to the diverse person’s burden because of its propensity to foster beliefs that inequalities are not unfair. That is, beliefs that one’s privilege is to some significant extent unearned and linked to social injustices are obviously dissonant with the view of oneself as specially entitled to benefits. Thus, psychologically entitled people would be motivated to find explanations of why any inequalities that favor them are not unfair  that was produced by the Measuring Morality survey.A study by Côté et al.,  suggestsIn sum, Côté et al.’s work suggests that educating privileged individuals about inequalities might have the unintended consequence of increasing their sense of entitlement and decreasing their inclination to be generous. That coincides with the discussion of active ignorance from the previous section. Spurious explanations of how inequalities are fair may arise as an active response to awareness of inequalities, rather than from simply being uninformed. And these are precisely the sorts of beliefs that, according to our proposal, drive the diverse person’s burden.In this section, we consider what might be done about the diverse person’s burden in light of our proposed analysis of it. We explore the implications of our proposal on this issue from structural, institutional, and individual lenses, in that order. By structural, we refer to the extent of historical and current inequalities in wealth and access to opportunities within a society and the social, economic, legal, and political causes of those inequalities. By institutional, we refer to the internal structure and habitual workings of particular organizations, such as corporations, universities, hospitals, or government agencies. At the individual level, we are concerned with individual persons operating within broader social-structural and institutional contexts.Our proposal suggests that greater social and material inequality within a society accentuates the diverse person’s burden. As noted in the previous section, socioeconomic advantage tends to be associated with heightened psychological entitlement Piff, . MoreoveAs a result, our argument suggests that reducing social inequalities in a society would also have the long run effect of blunting the diverse person’s burden. Structural measures that promote social equality include such things as progressive income tax, taxes on inherited wealth, prosecution of tax evasion among the wealthy, universal access to quality healthcare and education, and rigorous prevention of racial and other forms of discrimination in the legal system, housing, and employment , advocating for proper recognition of these works as well as taking on a fair share of service work.We suggest two caveats regarding the virtue of positional awareness. The first advises against moral smugness. It is easy to find examples of absurd narratives promoted to justify social inequalities, such as characterizations of European colonialism “as a civilizing mission” Piketty, , p. 270.The second caveat is to avoid seeking self-exemptions. Not every privileged person is an embodiment of the “mythical norm” of financially secure, cis-gendered, heterosexual, able bodied, white male. People obviously can be socially privileged in some aspects of their social position but not in others, for example, a low-income white man, a homosexual white woman, or a wealthy black man. And practically everyone has suffered tribulations in one form or another. However, a key aspect of practicing the virtue of positional awareness is not treating one’s hardships as a get out of jail free card. For example, a gay white man may have suffered discrimination relating to his sexual orientation, while still having enjoyed social privileges associated with being a white male. As such, he can practice the virtue of positional awareness. Of course, some are privileged more systematically and along more dimensions than others, and the virtue of positional awareness is, consequently, especially important for those fortunate sons. However, just as almost everyone has suffered misfortunes, most have benefited from some events and aspects of society over which they had little control. The virtue of positional awareness entails a focus on the latter rather than the former.The virtue of positional awareness can be contrasted with Fricker’s , 2010 prAs should be apparent from Sect. Dotson (2012) points out that efforts to avoid one type of injustice sometimes inadvertently inflict another. We have advanced the analogous claim that pro-diversity beliefs can sometimes have the negative effect of generating unfair expectations for marginalized people, a phenomenon that we refer to as the “diverse person’s burden”. We suggest that the concept of normic diversity is helpful for understanding the diverse person’s burden because it links non-diversity to socioeconomic privilege, which research suggests is associated with psychological entitlement. We suggest that psychological entitlement motivates privileged individuals to believe that inequalities that benefit them are fair, and that such beliefs can in turn can lead to the diverse person’s burden. For example, the belief that racial homogeneity in an organization is due to meritocracy prompts expectations that racially marginalized individuals should demonstrate some distinctive bonus to justify their inclusion. We consider structural and institutional measures that may be helpful for addressing the diverse person’s burden, and we propose an individual virtue of positional awareness that involves making efforts to understand ways in which one is advantaged.


Driving simulators are an increasingly important tool to develop vehicle functionalities and to study driver or passenger responses. A major hindrance to the use and validity of such studies is Simulator Sickness (SS). Several studies have suggested a positive relation between improvements in simulator fidelity and the likelihood of sickness. We hypothesized that this relation only holds true for static (fixed-base) simulators, and that increased fidelity in fact reduces simulator sickness in dynamic (moving-base) simulators. We performed a meta-analysis investigating the relation between sickness and fidelity in static and dynamic systems. A literature search yielded a total of 41 simulator studies that varied aspects of mechanical and/or visual fidelity and assessed SS for the same driving conditions and the same or equivalent participant groups. Evaluation of a model synthesizing the findings of these studies indicates that SS decreases with visual fidelity, and suggests that this effect may be negated for static simulators. The results of the modeling efforts thereby provide some support for the hypothesis that increased fidelity can reduce SS in dynamic simulators. Based on the evaluation of the literature we also note particular shortcomings and gaps in available research. Finally, we make recommendations for specific experiments that may fill these gaps and allow definitive conclusions on the role of simulator fidelity in SS. Simulator Sickness (SSDriving simulators are an increasingly important tool to develop (automated) vehicle functionalities, for driver training, entertainment, and to test human factors responses , may occur when sensations of motion as generated by the visual, vestibular and somatic sensory systems, differ from what is expected based on previous experience. As intuitive examples, consider cases where visual and inertial sensations of motion mismatch; for instance when riding in a static (fixed-base) driving simulator, or similarly, when driving in a dynamic (moving-base) simulator with a limited motion envelope. Here, patterns of visual and vestibular afferent signals do not match patterns that have become familiar through experience.The most prominent theory on the origin of motion sickness explains its occurrence as resulting from a conflict between actual and expected neural inputs of motion based on previous experience (Reason and Brand Simulated Car Sickness (SCS), which is any motion sickness that results from simulator motion exactly as it would result from vehicle motion during actual driving, and Simulator-Induced Sickness (SIS), which results from false or missing motion cues. These can either be discrepancies between the actual simulator motion and expectations of typical vehicle motion based on previous experience, or discrepancies between motion cues provided by means of virtual imagery and inertial motion cues, again with previous experience as referent condition.SS, then, can be subdivided into fidelity, which exactly replicates real-world visual, inertial, tactile, and auditory referent stimuli within the simulator environment, and which induces a complete sense of immersion, referring to the state and extent of the mental involvement in a scenario  physical motion, resulting in increased SIS when low SCS would be expected  increasing visual fidelity in a static simulator increases SS, whereas (2) increasing visual fidelity in a dynamic simulator will reduce SS.We evaluate these hypotheses by performing a meta-analysis of studies that compare motion sickness for a given scenario between at least two experimental conditions wherein some technological aspect of fidelity is varied, and that were performed either on a static or dynamic simulator. To test the hypotheses, we evaluate whether the direction of any relation between fidelity and motion sickness is different between static and dynamic simulators. Specifically, we expect this relation to be positive in the former case, and negative in the latter.The literature was searched using Scopus and, given its particular relevance to the present topic, the proceedings of the Driving Simulation Conference.For the Scopus search, the search terms were derived from the research questions:The terms “simulator sickness”, “motion sickness”, “cyber sickness”, “car-sickness”, “sea-sickness”, “air-sickness”, and “kinetosis” were used to represent the dependent variable.visual-audio fidelity and motion fidelity as defined by Liu et al. (As independent variable(s) we consider the general term “fidelity”, and key features of different aspects of u et al.  ; for modality we included: “monitor”, “screen”, “projection”/“projection system”, “HMD”; for the availability of stereoscopic cues: “2D”, “3D”, “monoscopic”, “stereoscopic”; for scene content: “realism”, “graphics”, “scenario”; and finally, we included “resolution”.Motion fidelity is the correspondence between mechanical/inertial accelerations experienced in the simulator and in the real vehicle for a given trajectory. We discriminate on a high level by comparing static to dynamic simulators, but for motion simulators we also consider the simulator “degrees-of-freedom” (DoF) and “motion cueing” algorithm, because these relate to the hardware and software capabilities of a motion base.((“motion sickness” OR “simulator sickness” OR “cyber sickness” OR “cybersickness” OR “car sickness” OR “air sickness” OR “seasickness” OR “kinetosis”) AND )The search was last performed June 27, 2022, and yielded 1282 results. To narrow down these results, the term “simulator” was included, resulting in 558 results; We also evaluated a search including the additional term “driving”, yielding 151 results.Terms for the dependent and independent variables were bracketed, separated by the term“OR”; with an“AND” between the bracketed strings for the dependent variables and the independent variables, such that the search string was:In addition to the Scopus search, we searched the proceedings of the Driving Simulation Conference (DSC) using the search terms “sickness” and “kinetosis”.written in English,at most 20 years old,peer-reviewed,empirical work using human participants,in a paradigm that involved vehicle motion,reporting sickness metrics,comparing at least two experimental conditions with varying aspects of fidelity for the same scenario.Studies also had to provide sufficient detail on the methodology for the dimensions of visual and motion fidelity under study to be characterized or quantified, and SS data had to be sufficiently detailed to derive at least one overall sickness metric with a known scale per experimental condition. The latter requirements were judged after reading of each study.The titles produced by the searches were screened, and for titles that provided an approximate match with the criteria the abstracts were read. The primary eligibility criteria for inclusion were that studies were: For studies found suitable, data were extracted either from relevant tables or graphs, or was provided by the authors upon our request. Where authors were unresponsive, studies were excluded from the analyses. In total, suitable data was obtained from 41 studies.All studies that were screened are listed in the spreadsheet document that is available as supplementary material, along with any data obtained and used for subsequent analyses.the nature  and FoV  of a motion base, andthe physical realism of a simulator (ranging between sitting at a desk to being seated in a vehicular cabin),with each measure being given 1–5 points. Because the ranges are equal, each measure has equal weight to the total rating, which can take on values between 3 and 15. The rating system allows placement of a simulator along a fidelity continuum. On the lower end would be the lowest fidelity simulator, existing of for example a single computer screen and a seat. At the opposite end would be high-fidelity simulators, consisting of a motion base, vehicle cabin and large FoV projection screens surrounding the cabin.A number of fidelity rating systems have been proposed previously. As an example, we consider the system proposed by Wynne et al. . In the contribute to visual fidelity, it is not clear how variations of individual characteristics affect aspects of fidelity; how continua may be binned; or how different dimensions should be weighted to reproduce the experience of fidelity. To deal with these issues, we first separately consider Visual fidelity; Mechanical fidelity, referring to the realism of mechanical/inertial motion; and a number of peripheral factors affecting either fidelity or SS  rating system(s). The primary issue is that these systems necessarily rely on a number of more-or-less arbitrary choices; given the definition of simulation fidelity, ratings of particular modalities should capture the extent to which some technological aspect accurately reproduces its real-world counterpart. Whereas the FoV and the number of screens, or the presence or absence of a motion base and its DoF arguably In addition to monitors and projection systems, visualizations may also be produced by an out-the-window view, or by using head mounted displays. Although an out-the-window view by definition provides the highest visual fidelity achievable, the ordering of the other systems in terms of their contribution to an experience of fidelity is not known, and this ordering may also be affected by specifics of the particular system. For example, on the one hand, Head-Mounted Displays (HMDs) might offer the highest degree of immersion out of the existing visualization technologies, but on the other hand, HMDs introduce detrimental latencies  and issues related to the lenses, which do not apply in the same way to other technologies.The binning of the FoV proposed by Wynne et al.  is arbitOther factors that may affect visual fidelity reflect the quality of the equipment in relation to human vision. Specifically, whereas humans have 3D vision thanks to biocular stereoscopy, typical monitors and projection systems render only a single visual virtual environment visible to both eyes, which is a 2D stimulus; furthermore, the maximum visual acuity of the human eye is approximately 128 pixels per degree . Indivistatic and dynamic simulators, and evaluate whether there is any apparent relation between SS and the DoF of a simulator motion base.The quality of simulated mechanical motion ultimately may be expressed by the extent to which presented mechanical accelerations match a trajectory of target vehicle accelerations. However, studies typically do not report sufficient detail on the cueing that was used nor on the generated accelerations to estimate such correspondence. Moreover, as there is an infinite number of ways for a mechanical motion trajectory to differ from a target trajectory, it is not apparent how such correspondence should be quantified. Therefore, we will contrast We will distinguish simulators according to their physical layout using a subset of the categories used by Wynne et al. , namely Various methods exist to quantify motion sickness. These can be subdivided into physiological and subjective methods. Although physiological methods can be considered objective, there are issues with their reliability and specificity  and Disorientation. The scale features 16 Likert-scale items, each with integer scores ranging between 0 and 3. Scores can be calculated for the factors by summing the scores on subsets of seven items that load on these factors, and weighting the results by coefficients of 9.54, 7.58, or 13.92, respectively. A total score can be calculated by adding the unweighted factor scores, and multiplying by 3.74. Thus, the total score can range between 0 and 235.62  have used the Simulator Sickness Questionnaire  to quans et al. ; 1/41), s et al. ; 1/41); s et al. ; 3/41), s et al. ; 5/41). s et al. , there as et al. . We normSickness scores were retrieved either from mean and standard deviation (SD) or standard error of the mean (SEM) values reported in text or tables, or by reading out values from figures; using a vector drawing program to derive precise measurements.From those studies that used the SSQ and that reported both the mean and standard deviation  the central FoV Stereoscopy Thirty-three studies used (biocular) non-stereoscopic visualizations in 79 experimental conditions  simulators, dynamic (moving-base) simulators, and on-road conditions in real vehicles. Static simulators were used in 36 studies with a total of 94 experimental conditions, and average SS of 0.096      . These effects are at minimum a random intercept, and may include any study-dependent effects. For instance, the part between brackets could be a copy of preceding part of the equation following Ideally, the relation between multiple aspects of fidelity and SS would be assessed without making assumptions on the weight of any independent variable. One possible model for such an analysis, in Wilkinson notation Wilkinson and Rogers , is:1\doSimilarly, to reliably estimate effects of the continuous independent variables, they should all be observed. This is complicated by the fact that not all studies provide information on the continuous predictors we wish to include: FoV, PPD and FPS. To deal with this, we calculate a visual fidelity score that combines the observed continuous predictors into one. We assume that fidelity increases with higher FoV, PPD and FPS. For FoV, the maximum value possibe is u for the unweighted model, and a subscript w for the weighted model. For both versions of the model, fixed effect coefficients were similar. For the unweighted model, we found a negative significant effect for the fidelity score , these variables may be confounding factors in analyses of either of them in isolation. In an attempt to disambiguate the role of stereoscopic 3D cues and HMDs versus monitors and projection screens, we fitted the following model:reduces with increased fidelity. Moreover, trends appear to support our hypothesis that this view may need to be further nuanced, and that the role of fidelity is different depending on whether a simulator features a static or dynamic base. However, even after synthesis of the data from many studies, the strength of the evidence was found to be limited, as the significance of findings depended on how data from different scales was combined and on the specific parametrization of the model . In the following, we first discuss the observations made in the exploratory analysis, followed by an evaluation of availability of data and the hypotheses. Finally, we make recommendations for future research.In the work presented here, we set out to provide a quantitative synthesis of effects of simulator characteristics on SS. The literature was searched for studies that varied aspects of visual fidelity for simulators with static or dynamic motion bases, and a sample of 41 studies was obtained from which data could be extracted. The analyses that were performed on this data allowed us to evaluate whether the available evidence supports the notion that high-fidelity visualizations cause more SS. In general, the data shows the opposite, namely that SS not simultaneously taking into account other variables.To assess how simulator fidelity affect SS, we distinguished between dimensions of visual fidelity, mechanical fidelity, and a number of peripheral factors. For each of these dimensions, a selection of aspects was made that allow placement of simulators/studies along these dimensions. In the exploratory analysis, we assessed how SS varies with each of these factors, In relation to visual fidelity, we found that HMDs produced more SS than alternative visualization modalities, and that visual stimuli presented in stereoscopic 3D were more sickening than non-3D stimuli. There was also evidence that more PPD lead to less sickness. FoV and FPS, by themselves, did not appear to affect the level of SS that was observed in studies.A comparison between static and dynamic simulators to assess the role of mechanical fidelity per se also did not show any fundamental differences in the level of SS that would be attained in a study, and this result does not appear to change when considering the DoF featured by a simulator motion base. As the availability of more DoF may allow for closer approximation of a target trajectory, this evaluation thus does not provide support for the notion that “no motion is better than bad motion”  of a simulator; whether participants had an active or passive role; the duration of exposure; or the average age of the participant sample.Apart from the observed effects of some aspects of visual fidelity, which will be discussed in more detail below, the absence of general effects of other factors is not necessarily surprising. This is because researchers typically aim to control the level of sickness in studies; either because it is considered a nuisance in the study of other dependent variables, or to achieve a certain average target level of sickness, on top of which differential aspects of independent variables may be identified. To achieve a target level of sickness, researchers may tune the intensity of their motion paradigm and exclude from further analysis participants who either do not show any sickness or exceed a threshold level of sickness. In other words, some factors that may be expected to affect SS, such as exposure duration, may not show effects in a meta-analysis due to covariation of other variables.The aspects considered here were chosen based on earlier work , then conflict can actually be increased.Despite the consistency of these findings with conflict theory, it must be noted that, this effect was not significant in the weighted version of the model. A visualization of the data vs. the model fits suggests that in order to disambiguate the interactive effects of simulator base, data should be collected for either very low or very high visual fidelities see Fig. . Here, tIt is worthwhile noting that the observed differential effects of type of simulator base were robust to exclusion of the available data points for relatively high fidelity visualizations in dynamic simulators. These observations (approximate fidelity score of 0.6 in Fig. it is common practice to exclude data from participants who aborted experiments from analyses. Information on the number of participants who aborted experiments along with their reasons for doing so and the level of sickness at the time of abortion could be useful to evaluate whether findings on SS are affected by censorship of such data;the calculation of sickness metrics was found to differ from original definitions in various studies. Although in some cases variations of calculations were intentional, for instance to achieve a better resolution for particular sickness symptoms, in other cases the variations appear to have been mistakes. This typically does not appear to invalidate results, as the calculations were performed consistently. In order to avoid confusion, it is recommended to report the exact equations used in the calculation of reported metrics.information on specific characteristics of equipment can usually be obtained from datasheets that are available from the OEM. Hence, by reporting the brand and model for each piece of equipment that is used in an experiment, other researchers may be able to retrieve information that may be irrelevant in an original study, but that may become relevant in future evaluations of studies with different research questions;Finally, we recommend to make experimental data along with any anonymized idiosyncratic demographic variables available to the scientific community. Making data available on the level of individual participants or observations allows other researchers to extract the maximum amount of information. Means and standard deviations are summaries of data that do not convey the number of observations nor how data are distributed. Consequently, any synthesis of individual data will be more powerful than a synthesis of summarized data. Various public repositories exist, and journals regularly offer options to include data in the form as online supplementary material to articles. A global registry of research data repositories is for example made available by the ‘re3data.org’ initiative (Pampel et al. Overall, the present analyses indicate that higher fidelity simulators provoke less sickness. The comparisons between static and dynamic bases furthermore hint that a nuance may be required, namely that this conclusion could be primarily true for dynamic motion simulators, but not so much for static simulators. This finding is consistent with the sensory conflict theory of motion sickness. Apart from the considerations presented in the preceding discussion, observations made during the process of this analysis invite a number of recommendations for future research. These recommendations are not limited to research on the role of fidelity, but may generalize to research on motion sickness in general:


We consider lesions inducing acquired cholesteatomas as any lesion that has the potential to induce the development of cholesteotoma in the middle ear. Several studies have assessed cholesteatomas regarding their possible causes, their evolution and their histological characteristics and treatments. Several classifications have been made regarding their location.However, in all the published studies, little is said about the characteristics of their primordial lesions. Cholesteatomas are classified descriptively and when they are already structured: skin migrations through perforations (rarer) and regions of tympanic membrane affected by negative pressure, or retraction pockets without objectively characterizing them regarding the degree of development or prognosis (considering the dynamics of the process). It is necessary to adequately describe an initial lesion, so that it can be easily perceived and recalled, as the conduct of care, the follow-up, the surgical urgency, the prognosis that depend on it.We know that words sometimes do not adequately represent what we are trying to define. This is not rare when one wants to explain a clinical finding, describe a surgery, or even explain and publish a study. We often are not able to describe what we are really seeing in others. Aiming to allow an easier communication, we often use analogies in anatomy and pathology to construct the desired image. Thus, why not use these resources to make us better understand, and to make everyone capable of adequately visualizing, while using the same standard, what we want to depict in the description of tympanic lesions?To adequately classify lesions inducing acquired cholesteatomas of the middle ear (negative pressure and retraction pockets), we have used a classification based on well-known domestic utensils, thus requiring no memorization skills. This process aimed to facilitate the use of a guide, especially for students, including the evolution, treatment and prognosis in each case, for their appropriate management. Obviously, treatment choices will vary according to each otolaryngology department guideline.To consolidate our experience, a small questionnaire was applied to individuals attending our Digital Otology Outpatient Clinic. The project was submitted to the Institution's Ethics Board (2346725) for its approval, after obtaining free and informed consent form from the participants.Congenital cholesteatomas and secondary cholesteatomas due to skin migration through a pre-existing perforation, rare in our sample, were not evaluated, neither the residual and recurrent cholesteatomas, both post-surgical types.This classification with a didactic guidance was presented to six otorhinolaryngologists with different degrees of experience, namely, a professor, a fellow, two third-year residents and two second-year residents. They were shown 41 scanned otoscopic images, which they had to classify according to the proposed morphological characteristics. The standard for comparison was defined by the author .Figure 1Small, shallow and empty – Normal and frequent anatomical finding in the “pars flaccida” region of the membrane, close to the short apophysis of the malleus. Some individuals may have a predisposition for “pars flaccida” cholesteatoma. It is usually bilateral and may appear on the tense side, resembling a small neotympanum area.Treatment – Expectant, but it should be followed clinically, if it occurs in a patient with Eustachian tube dysfunction, when it can come under the influence of negative pressure and progress to a cholesteatoma, especially if this has already occurred in the contralateral ear.Deeper than the saucer, it does not retain skin or secretion, and can be the evolution of the saucer type in the “pars flaccida” or occur in the “pars tensa” as an initial area under the influence of negative pressure of a small neotympanum.Treatment – It should not be a condition of concern if it can be reversed by Valsava maneuver. Otherwise, may be submitted to surgery . In such cases, a reinforcement is made in the affected membrane zone, using fascia or perichondrium to prevent its evolution to a cholesteatoma.With a wide “mouth” and empty, it can be found in the “pars flaccida”, as the saucer enlargement or in the “pars tensa”, as an initial area under the influence of negative pressure of a large neotympanum.Treatment – The plate in the “pars flaccida” is the evolution of the saucer and may become a reason of concern due to the possible involvement of the ossicular chain. In the “pars tensa” it is usually reversed by the Politzer or Valsalva maneuver. Otherwise, it should be surgically detached, and reinforced with fascia, perichondrium or even cartilage, to maintain the tympanic membrane semirigid structure. If the treatment does not seem feasible due to the possible rupture in the detachment, it should be treated expectantly, as it does not always develop into a cholesteatoma.With a “wide” mouth, deeper, but still empty (without skin cells retention), it is the evolution of a plate or cup into the attico-antral region. It may be located in the “pars flaccida” (rarer) or be the partial retraction of the membrane “pars tensa”.Treatment – Difficult surgical treatment due to the risk of skin rupture and entrapment, which will result in an iatrogenic cholesteatoma. This procedure may be attempted if the lesion is not attached to the ossicular chain, which would usually be partially eroded.Total retraction of the tympanic membrane, atelectasis or adhesive membrane. It begins with the retraction of the atrophic membrane, which later touches the incus and can erode the latter or adhere to the promontory.Treatment – Depending on the stage, it can be controlled with tympanotomy with insertion of a ventilation tube, Valsalva or Politzer maneuvers or by strengthening the tympanic membrane with fascia, perichondrium or cartilage. It tends to suffer the influence of a negative pressure into the attic and antrum region, constituting a “pars tensa” cholesteatoma.With a small “mouth” in relation to its “belly”, which is larger, it retains desquamated skin, and usually becomes infected, no longer characterized by a retraction pocket, but actually a cholesteatoma. It can be the evolution of the saucer/cup type in the “pars flaccida” region or retraction in the “pars tensa”. The size of its “belly”, whether deeper or wider, can often be determined only through imaging (CT) or the surgical procedure. It tends to migrate to the attico-antral region and can occupy much of the mastoid process.Treatment – Surgical. Depending on the size and location, surgery is performed through a canal wall down mastoidectomy  or canal wall up mastoidectomy (tympanomastoidectomy). Whenever possible, the second method should be used in order to preserve the middle ear anatomy and function; but a canal wall up mastoidectomy can be more problematic due to frequent recurrences.It shows a large amount of skin migration and infection, and it is not possible to determine the real origin.Treatment – Surgical, usually through radical or canal wall down mastoidectomy.shallow bucket in the anterior epitympanum region. That is, the retraction of a neotympanum, near the area of the Eustachian tube, of which the bottom shows no skin retention or infection. Or, bowl with jug formation under the malleus handle, characterized by membrane atelectasis with a retraction area located in the attic region, with desquamation and secretion, characterizing a cholesteatoma. Or, saucer in the “pars flaccida”, tending toward a cup shape, indicating some negative pressure retraction with the tendency to become an attic cholesteatoma.This classification can be further described according to the lesion location and characteristics. For instance: For each shape (41) presented, the participants classified the lesions according to their morphology, following the proposed classification. Evaluator 1 was a professor, number 2 was a fellow, numbers 3 and 4 were third-year residents (R3) and numbers 5 and 6 were second-year residents (R2). Therefore, we obtained the results regarding the correct/wrong response regarding the aspect of the lesion from the six assessed participants, in comparison with the standard established by the author (in percentage):Thus, we observed a significantly high percentage of correct responses from all participants, even among the least experienced.We believe that this classification of conditions that can induce acquired cholesteatomas and the comments on their evolution and management can clarify the concepts of their dynamics and progression, especially for students. It may also be helpful for describing adequately these clinical conditions and findings to another doctor in a medical file or chart for future reevaluations, and most importantly, to understand the characteristics of the initial lesions, which, if not adequately managed, can lead to serious complications and expensive treatment.This classification and comments do not aim to teach otology, they are just didactic suggestions that have been successfully used with great acceptance in our department.The author declares no conflicts of interest.


Evidence of nurse presenteeism has mainly focused on quantifying its prevalence and consequences on productivity, quality of care, and patient safety. Few data exist on nurses’ perceptions of their presenteeism and its related causes. We explored concepts of presenteeism and its contributing factors with frontline nurses and nurse managers in different healthcare settings in Portugal and Switzerland. Our qualitative study design involved 8 online focus groups involving 55 participants. The transcribed data was explored using thematic analysis. Three main reasons for presenteeism were identified: unfamiliar terminology; the paradoxical effect of `being present’ but absent; and presenteeism as a survival strategy. Six contributing factors were also recognized: (a) institutional disinterest toward employees; (b) paradigm shift: the tension between person-centered and task-centered care; (c) sudden changes in care practices due to the COVID-19 pandemic; (d) a lack of shared work perspectives with hierarchical superiors; (e) the financial burden of being absent from work; and (f) misfit of human responses. This study generates valuable, in-depth knowledge about the concepts and causes of presenteeism, and significant suggestions for the broader audience of nurse managers and leaders seeking to improve the quality of care. North ANurse presenteeism has long been of international concern, with impacts on nurse staffing levels, patient care, and hospital costs ,12,13. NSickness (attending work when sick) and job stress (when work stress affects performance) have both been linked to nurse presenteeism . PresentThe global health crisis caused by the COVID-19 pandemic has fostered a greater interest in and a need to understand nurse presenteeism ,26. AccoTo the best of our knowledge, there has been little research on individuals’ conceptions of presenteeism based on their lived experiences. We thus chose a qualitative methodology to explore and understand nurse presenteeism, as it is hard to explain this phenomenon using simple external factors alone. Moreover, little is known about the contextual situations, processes, or motivations of nurses who provide care while they are sick . FurtherOver the last 10 years, there has been a significant migration of nurses from southern European countries toward western European ones, notably from Portugal to Switzerland . The preThis study’s main purpose, therefore, was to explore the factors associated with presenteeism among frontline nurses and nurse managers in acute, primary, and long-term healthcare settings in Portugal and Switzerland. The study’s research questions were: (a) How do nurses perceive the concept of presenteeism? and (b) What do nurses perceive to be the causes of presenteeism? This study is part of a larger international project to study the link between presenteeism in the nursing workforce and its impact on the quality and safety of patient care . We conducted a qualitative descriptive study involving online focus groups (FGs) and designed with regard to Krueger and Casey’s  methodolThe FGs involved 55 participants and took place over 5 months (from March 2021 to July 2021). The Portuguese research team conducted four online FGs in acute care hospital settings: two with frontline nurses active in acute care wards  and two with nurse managers . The Swiss research team conducted four online FGs: two in long-term residential care facilities and two in community healthcare settings, all with frontline nurses and nurse managers . Participants were recruited using a purposive sampling technique. The inclusion criteria were: (a) working in a public or private healthcare setting with at least 1 month’s experience in their current workplace ; (b) working at least 20% of a full-time equivalent position; and (c) having a bachelor’s, master’s, or a PhD degree. It was important for us, knowing the clinical reality and organizational constraints, to impose the inclusion criteria of participants having had at least 1 month’s experience in their current workplace. This would give them the time to integrate and to be able to express themselves about the workload and organizational culture and procedures. Participants also had to be able to connect to the internet using a suitable device. Prior to the FGs, the lead local researcher contacted the participants by email or telephone. As presenteeism affects not only presentees but also those who work with them, we did not exclude nurses who had never worked while feeling unwell or unable to.We sought a balanced number of nurses in each FG to ensure relative homogeneity but enough variety to allow for differing viewpoints. To acquire different data on nurse experiences of presenteeism, no restrictions were placed on their gender, age, or seniority. This study’s rationale and interest were explained to participants upon invitation to engage in the FG.We conducted eight FGs (four in each country) with frontline nurses and nurse managers, gathering a broad range of opinions, attitudes, and experiences from diverse sociocultural contexts. Each 1.5- to 2-h FG was facilitated by 2 researchers with significant relevant knowledge of the national and local setting. The first, an experienced research nurse, moderated the meeting, explained its aims, and encouraged the exchange of ideas. Meanwhile, the second observed the atmosphere, interactions, and conversation flow, and recorded field notes. Real-time data of the interactions between participants and the researchers was gathered using videoconferencing technology ,38.Each of the eight FGs started with participants completing a data sheet with questions about their age, sex, work function, years of experience as a nurse, and their current work area. The researchers then presented a situationally and culturally adapted vignette about presenteeism . Indeed,The two most important factors in cross-national FG research are that questions address the same topics in each country and that all the participants understand the questions in exactly the same way.At the beginning of each FG, participants were ensured of full confidentiality of the results and asked whether they agreed to either audio or video recording of the sessions. Participants were also informed about the professional backgrounds of the moderator and observer, the rationale for their interest in the issue, and that FG data would be analyzed and submitted for publication. All research participants gave their permission to be part of the study and were asked to provide written informed consent. Volunteers received no compensation for their participation. All study data were kept in a padlocked drawer, and digital data (such as audio recordings and transcripts) were kept on a password-protected desktop computer.The research team used Braun and Clarke’s six-step guide for thematic analysis to analyze the transcribed interview data . Thematic analysis is a useful tool for assessing diverse participant views, showing commonalities and contrasts, and uncovering unexpected findings. This method is also useful for processing data in a well-structured manner, resulting in a clear, well-organized final report . Data an®. Codes were adjusted to fit two pre-existing frameworks containing aspects of interest, specifically those provided by Rainbow and Steeg  for a manager. Sometimes presenteeism is essential. Yes, yes, we also replace [each other], we fill the gaps when there are absences, we go, we work. No, but it’s, there you go, we all do overtime (...)”. (FG4-CH-nurse managers)Respondents mentioned a wide range of events and reasons for presenteeism, which were grouped into six contributing factors: (a) institutional disinterest toward employees; (b) paradigm shift: the tension between person-centered and task-centered care; (c) sudden changes in care practices due to the COVID-19 pandemic; (d) lack of shared work perspectives with hierarchical superiors; (e) financial burden of being absent from work; and (f) misfit of human responses. (a)Institutional disinterest toward employeesParticipants stated that professional overload made it difficult for nurses to care for others and posed a danger to workers themselves. This scenario can create a vicious cycle, whereby healthy nurses become sick or are injured in the workplace yet are then expected to maintain their existing workloads in that condition. The lack of a supportive environment may cause job dissatisfaction and reduce employee trust in the organization. On this point, participants stated: “The boss forgets that we are human too!” (FG2-PT-frontline nurses); “The concept of presenteeism is related to professionals’ excessive workloads and the lack of responses to the professionals’ needs”. (FG1-PT-frontline nurses)Some nurse managers adopted a “sandwich” metaphor because, as middle-level managers, they support upper management by implementing organizational policies and decisions, and they support their subordinates, particularly when it comes to policies relating to the delivery of care: “I feel sandwiched because I have to obey those above me and provide results, but I can also understand what… the bottom of the sandwich is suffering and that they have difficulties and needs, and sometimes I don’t have the tools to do all that…” (FG4-PT–nurse managers)Nurses also pointed out that they sometimes felt abandoned by managers and leaders. Nurses, it appeared, overwhelmingly requested better assistance to do their tasks more efficiently. They frequently expressed concerns about a lack of organized or appropriate help, and they desired improved management support mechanisms: “I relate it to institutional disinvestment in the wealth represented by human resources, in how to keep people motivated”; “What matters is having X staff working that day. Their condition doesn’t matter; the context they’re in doesn’t matter; whether they are properly emotionally or technically prepared, it doesn’t matter…” (FG1-PT-frontline nurses)Support is a cornerstone of management practice, and it is critical for employees to feel engaged in an organization. However, some participants discussed the lack of support from specialized  services: “Yes, there is a lack of answers... The few answers that exist are difficult to access [specialized services]. There is some stigma for any colleagues who seek them out. They exist, but they are not well used!”; “There is a lack of answers from institutions”. (FG1-PT-frontline nurses)(b)Paradigm shift: the tension between person-centered and task-centered careNurses may feel as though no critical thinking is expected of them and, at times, that they are merely service providers. An individual who delivers services does not need to think, does not have the capacity to change, and is obligated to merely execute orders: “I think the biggest factor related to this is that we, as employees, stopped being people and became numbers. What matters is having X staff working that day”. (FG1–PT-frontline nurses)Several responsibilities in the nursing job, and other duties unrelated to patient care, might divert a nurse’s energy. They can also increase workload stress, harm a nurse’s capacity to deliver person-centered care, and promote task-focused work practices: “The constant demand that has been happening... we are targeted, whether in terms of changing care and our demands, in terms of records, of what a nurse is supposed to do... attention to the needs of the patient and family members get called into question... and this wears professionals out”. (FG3-PT-nurse managers)Many institutional initiatives are not directly related to patient care or safety because of shortages in human resources, and as a result, participants expressed feelings of being overwhelmed: “But when we can’t show up, budgets get cut, and staffing is reduced. In the end, we become understaffed. Because the budget is not defined, let’s say. Unfortunately, this is also a reality. And so, that’s what creates all this pressure, I would say”. (FG6-CH-frontline nurses)Nurses appeared unable to control and regulate their workloads, torn between the care they would like to deliver and the care they were required to provide: “When there is no one else to replace me, I cannot be absent, because if I am absent, my patients will not have access to care”. (FG1-PT-frontline nurses)(c)Sudden changes in care practices due to the COVID-19 pandemicThe pandemic situation posed significant difficulties for nurses. Despite caring for patients with COVID-19 on a regular basis, many seemed lost in the jumble of shifting information, as if they were in the dark about what to do and where to receive help: “Everything was always changing, and it seemed that there was something different each day, and it was very difficult at first”. (FG2-PT-frontline nurses); “[There was] a lot of reorganization. Many sites started having 12-h shifts instead of the usual eight”. (FG1-PT-frontline nurses); “(…) the issue of unexpected mobility to go and reinforce the services in most need”. (FG4-PT-nurse managers)“They are doing the best they can” (FG1-PT-frontline nurses). Others, however, felt frustrated: “They go to work, they are not prepared, they do not have time to get prepared, and of course, the first feeling is frustration”. (FG1-PT-frontline nurses)Amidst the chaotic scenario, some participants were sympathetic to their management and acknowledged that: (d)Lack of shared work perspectives with hierarchical superiorsA lack of leadership may result in a breakdown in communication between nurses and management. Participants highlighted their management’s unwise support of organizational practices that compelled employees to be present at work: “Sometimes, the head nurses don’t help a person who comes into work despite having trouble doing so, because the managers pressure them to maintain the number of professionals present and consequently [staffing] ratios”. (FG2-PT-frontline nurses)They also stated their absence of trust and confidence in nurse managers—a previously identified barrier between nurses and management—as something preventing those managers from fully supporting, recognizing, sharing, and connecting with nurses: “So, sometimes, people find it hard to confide in us, because we’re managers, when in fact we’re just like them. But it is a fact that we’re managers and we’re [hierarchically] superior. It raises barriers”. (FG5-CH-nurse managers)(e)Financial burden of being absent from workPresenteeism has been linked to personal and work-related issues. Participants clearly perceived and experienced significant financial consequences when absent from work, although the extent of the financial impact differed. Nurses’ dedication to their daily lives and issues involving their families had a constant influence on their presence at work, reflecting fears of losing income and facing further financial strain.The sense of financial hardship started with the need to keep working because they were the family breadwinner: “The monetary part counts for a lot because a person who is used to [living on] a basic budget of one thousand euros, with family expenses, cannot afford to stay at home for a week to rest and recover—only if it’s really a life-or-death situation”. (FG2-PT-frontline nurses); “There’s also a lot of presenteeism linked to the financial side”. FG6-CH-frontline nurses)Moreover, if nurses take sick leave, they cannot even do part-time work: “There are people who cannot go to work because this is impactful from a financial point of view. Many nurses work part-time (…) and if they don’t work, if they are on sick leave, then they can’t work part-time either, and the impact is even greater and, therefore, this is also important”. (FG3-PT-nurse managers)(f)Misfit of human responsesDue to the stressful nature of their work, nurses developed different ways of dealing with the challenges of presenteeism imposed by their work on a daily basis. Individual actions that are viewed as misfits for suitable work relationships and a healthy organizational atmosphere were included in this theme. If nurses are to stay up to date, motivated, dedicated, and empowered, they need to work in an atmosphere that fosters ongoing professional growth. Some participants underlined the need to align nurses’ individual characteristics with particular clinical specialties, because a lack of nurse engagement results in less resilient individuals, with less energy  for coping with their work’s demands, as the following quotes illustrate: “Forcing them to work in a place where the work is not what they like to do—it blows people up”; “Our way of being is a very important factor in how we react to a given situation”; “The internal variables [intrinsic to the person], such as motivation, interest, perhaps a certain resilience, that optimistic outlook that things will go well, these can be important factors that, when not present, lead to phenomena of this nature”. (FG4-PT-nurse managers) “I think it’s individual to each person and depends on the organizational culture, uh… I think it’s very personal”. (FG6-CH-frontline nurses)Participants were aware of some warning signs and symptoms of presenteeism; however, it is the normalization of this behavior that determines its presence in the workplace. They described having physical and mental problems, including fatigue, fluctuating moods, and mental stress: “(...) even if I’m physically tired, psychologically tired, or even depressed and I don’t feel able to come to work, that’s not quantifiable, it’s not taken seriously”. (FG6-CH-frontline nurse); “(...) do we have a good reason to miss work? Yes, we do! As long as it is fatigue or a depressive mood, it will always be justifiable. We are all tired!” (FG7-CH-frontline nurses)Although family support typically enhances work performance, commitment, and efforts to accept one’s job’s demands, a lack of this resource may affect the need for nurses′ presence at work. Support from colleagues may provide a stronger buffer against work’s strain than other sources of support  by increasing nurses’ sense of belonging and commitment. In this regard, participants said: “Often, people who are not very well, especially in terms of mental health, come to work to talk with their colleagues, to get a kind of moral support they wouldn’t necessarily get in their private life. I’ve often come across this with colleagues who, despite their inability—I mean—to be available for their work, came in because there was support from their colleagues. They could talk about their problems, etc., which they couldn’t do at home. So, I have the impression that there is also a lack of personal resources in their private lives and perhaps of someone in their private lives who’ll say, ‘No, you’re in no state to go to work.’ That’s it. (…) They come to work at all costs, in the end, to get help too”. (FG5-CH-nurse managers)Traditionally, the strongest justifications for absenteeism are the delays and deductions in pay and sometimes the total forfeiture of wages. Several participating nurses expressed concern about the effects of absenteeism, preferring “being presentee” even in bad conditions: “There is pressure (...) we know that if we are absent for more than a month, we will be fired. There was a political dynamic in my old job, where they instilled fear. So, often, employees have this fear of, ‘I have to work, I can’t afford to stop working (…), to stop getting a salary’, so they come to work... I even have stories of colleagues who came to work and vomited on the floor, and all because they knew they risked being [fired]”. (FG8-CH-nurse managers)presenteeism seemed to be new to several participants. Others defined the term as “going to work when unwell” but were unaware this was a well-known construct. This lack of awareness of the phenomenon did not mean they were not rapidly able to comprehend it. Some individuals appeared to favor doing everything they could to attend work when unwell, whereas others did not. Our findings corroborated a recent study [Presenteeism is viewed as a growing organizational problem . In ordent study  showing nt study ,43. As ant study . They shnt study . Neverthnt study ,17,44. USome of the reasons given for presenteeism, such as a lack of knowledge, constraints on absenteeism, job resources, job demands, peer support, and health status, were found to be consistent with previous studies ,45. In aResearch shows that presenteeism has negative work consequences. It can lead to higher rates of short- and long-term absenteeism, lower productivity, and poorer health outcomes . HoweverIn addition, and depending on the social security system, presenteeism may also alleviate the economic privations resulting from not working . This isAlthough presenteeism’s positive effects as a stabilizing component of team performance should be recognized, precautions should be put in place to avoid an insidious long-term deterioration in the health of substantial segments of the workforce . This isOur findings revealed that nurses go to work despite being physically or psychologically ill due to a variety of organizational and personal variables. Labor and organizational aspects such as the pressure of high workloads, a lack of support from supervisors or colleagues, and even the workplace environment may increase presenteeism. These findings support earlier studies on presenteeism in which some authors claimed that healthcare institutions encouraged this behavior ,58. IndiFrom the perspective of hospitals or healthcare facilities, there seems to be a culture—particularly prevalent in Europe—of staff being expected to be present or seen . In thisOur study underlined that a lack of support from hierarchical superiors and institutions’ disinterest in their staff were relevant factors contributing to presenteeism. A previous meta-analysis showed negative associations between presenteeism and co-worker support, interpersonal relationships, and supervisory support . DespiteHealthcare facilities with significant corporate cultural barriers strengthen professional norms against taking sick leave, which might unintentionally encourage presenteeism . This evInterestingly, financial needs acted as a contributing factor to presenteeism among frontline nurses. Previous research found that nurses with significant personal financial needs were at a higher risk of presenteeism . This faIn our findings, misfitting responses were a relevant factor of nurse presenteeism. Misfit is typically assumed as an extreme of the fit spectrum, implying discomfort or incompatibility. Scholars have argued that more attention should be devoted to the misfit situation to better understand how people deal with it ,65. MisfSeveral participants attempted to address the underlying causes of their perceived person–environment misfit. They worked to re-establish a sense of fit by altering either the surroundings or themselves. As a result, even if they appeared to accept their misfit, they were still actively engaged in efforts to limit its effects and modify either themselves or their environment. According to a study by Pit and Hansen , presentDespite the particularities of Portugal and Switzerland’s cultures and working environments, nurses’ perceptions of the concept and causes of presenteeism were quite similar. According to Maaravi et al. , nationaThe diversity of individuals who participated in the FG discussions is one of the study’s strengths. There was a mixture of different types of nurses from various clinical settings and with different perceptions of the phenomenon under study. Another strength was that our research was conducted in two different cultural settings. We used a similar semi-structured interview guide for both countries’ FGs, covering the same basic structure and topics; however, we also considered national contexts and cultural specificities to clarify or slightly reformulate some questions. Interviews were conducted in participants’ native languages (Portuguese and French). Moderators used a constructivist approach when asking questions and let participants steer the conversation based on their personal experiences.This study also had some potential methodological limitations. First, our approach to participant recruitment might have been susceptible to selection bias . For example, presentees focused more on their own conduct and non-presentees focused more on a fictitious decision-making process; however, we cannot rule out the possibility that the decision processes changed between the two groups . This shSecond, the study’s cross-sectional design might be viewed as a limitation. We thus recommend the development of multisite, longitudinal research in a variety of work settings. Third, new factors linked to workers’ health  might be added to future studies to examine their possible links and negative repercussions for nurses. This might require employing a larger sample size. Lastly, this study was conducted at the onset of the COVID-19 pandemic. Thus, the novelty and associated uncertainty of the entire COVID-19 situation may have influenced the results. The development of consistent methods to prevent and minimize presenteeism among nurses will benefit from a comprehensive understanding of the phenomenon’s contributing factors. According to Hemp , raisingManagers should be aware of and trained to recognize the early warning signs of common physical, emotional, and mental health issues in the workplace, so that they can act as soon as possible and communicate supportively with employees who are having health problems. Healthcare facilities should conduct regular evaluations of their workers’ well-being to reveal their true health status and implement worksite wellness programs to help health professionals improve their physical and mental health. Effective interventions, such as occupational health strategies and counselling, might help nurses improve the professional quality of their care and boost their occupational health in terms of physical activity, stress reduction, sleep hygiene, work–life balance, and the physical demands of their job . MoreoveA better understanding of presenteeism among the nurses in both countries could be facilitated by the development of strategies to combat it presented in nursing students’ curricula. Assertiveness training, the promotion of self-esteem, resilience skills, and ergonomic training should be applied via simulation-based training programs that help students transfer their learning outcomes to clinical practice. This might also improve self-confidence and team performance. Closer collaboration between higher education establishments and institutional clinical settings has been advocated to improve the translation of learning results from simulation to clinical practice .This qualitative study generated valuable, in-depth knowledge about the concepts and causes of presenteeism and instructive input on the subject for a broad audience of nurse managers and healthcare leaders. According to our thematic analysis, numerous elements go towards explaining presenteeism. They are closely connected with institutions placing demands on their staff to attend work, personal restrictions and commitments that staff place on themselves, and organizational environments. There are a variety of reasons why nurses report for work despite their inability to work effectively or efficiently. When it came to presenteeism, we found evidence that staff members’ individual perspectives about how to deal with their health and sickness generally played a pivotal role. In addition, presenteeism was influenced by organizational issues, such as a lack of any replacements when an employee was off sick or a professional nursing culture where taking sick leave was seen as a weakness. Finally, contextual variables, such as a lack of sufficient legal protection against dismissal due to illness, were key drivers of presenteeism and reflected cultural variations between the countries. These characteristics must be considered when devising interventions to prevent presenteeism, increase the quality and safety of patient care, promote staff well-being, and to maximize overall healthcare performance. To turn presenteeism into a positive historical experience, the nurses who strive to provide their patients with optimal care must proactively take care of themselves and their colleagues in the same attentive manner.


Adolescents and young adults (AYAs) represent a unique population with distinct psycho-social risks and care needs. About 10% of AYAs live with chronic pain (CP) and transition to adult pain care between 16 and 25 years of age. These transitions in care happen simultaneously with other bio-psycho-social changes and require flexible multi-disciplinary support models. As it stands, transitional pain care appears suboptimal, fragmented, and opportunistic in Quebec (Canada). The objective of this Brief Report is, therefore, to present our study findings and propose a multi-disciplinary transitional framework vision applicable to AYAs living with CP. Data were collected using a sequential-consensual qualitative design with a longitudinal participatory component. The consecutive stages of this work included an exploratory stage, semi-structured interviews with primary care providers, and inter-disciplinary deliberative stakeholder consultation groups. The deductive inductive thematic approach and the three-level Health Care Transition Research Consortium's theoretical framework were used to analyze the data. A representative group of stakeholders discussed findings from the first two steps, made fifteen actionable recommendations and formulated their vision of a transitional pain care model that can be further adapted in other settings. The study results present important insights into various psycho-social factors associated with transitional pain care for AYAs. An estimated 9–12% of Canadians aged 12 to 44 years live with chronic pain (CP) condition  resultinCP is known to influence the neuro- and social development of children and youths , 11, whoThe last stage of transition and integration to adult services is almost a decade long (16–25 years of age) and happens simultaneously with transitions in vocational training and employment, social and family responsibilities, rendering AYAs prone to multiple stressors and poor clinical outcomes , extensiThe Canadian Association of Pediatric Health Centers (CAPHC) guideline  recommenPediatric care ends when adolescents are discharged at the age of 18, which makes the small number of existing transitional programs unipolar and narrowly focused on the preparation for the transfer to adult services. As our understanding of the PCPs' role in transitions, including training requirements, is developing , the scoThe objective of this Brief Report is, therefore, to present our study findings of the psycho-social factors relevant to the transitional pain care for AYAs and propose a multi-disciplinary transitional framework vision pertinent to the pain field and applicable to this important population segment.stage 1, an exploratory stage that informed further steps, followed by stage 2, semi-structured interviews with twelve PCPs, and concluded with stage 3, three inter-disciplinary deliberative stakeholder consultations groups. Three AYAs patient-partners were involved longitudinally in the entirety of the project, directing its development, validating study findings, and helping with the understanding of the findings' significance.Data were collected using a sequential-consensual qualitative design  with a lindividual, service, and healthcare system levels. A detailed description of methodology and findings are provided elsewhere ) transitional framework was adopted. The deductively coded data were categorized into the corresponding framework domains. The inductive analysis allowed for the emergence of the new codes. The reviewers iteratively identified and discussed emerging themes and drew conclusions.We performed an iterative deductive inductive thematic analysis of the transcribed bilingual data collected in stages 2 and 3 using QRS International's NVivo11 software  . The thrindividual (patient) level, all participants agreed that the integration of adult services and building youths' capacity for self-management should be the focus. At the service level, the improvement in the inter-disciplinary care coordination and communications were noted in all three stages. Overall, our findings indicate that the most important barriers to overcome were identified at the system level. Even individual and service variables were frequently discussed as a function of the system level barrier and facilitators. Due to a high degree of fragmentation of the medical care provision, the need for more robust and structured transitional care was recognized by all participants. Unexpectedly, the initial concern about mental health and addiction, discussed in the exploratory and interview with PCPs stages, was not included in the final set of recommendations. Below, we summarize each level in more detail as matched to chosen CAPHC guideline recommendations and by applying HCTRC theoretical framework variables as appropriate for our setting.Data from stages 1 and 2 were used to inform stage 3. We present a summary of the main findings from stages 2 and 3 supported by the quotes from participants. At the an orientation session [with] their parents where the whole process can be explained, and we're (pain service team) up front setting expectations about what this service is about…kind of concrete protocols or concrete steps that could be implemented at the system level to facilitate that transition” . Transitional planning was strongly supported by the PCPs who felt that AYAs live through very complex times when “…nothing is settled. It's shifting sands in every way, within their personal life, their professional life, their studies, their love life, their whatever, their family relations… So, … they're much more vulnerable to screwing up” (Dr. Office). Another PCP emphasized how AYA's planning capacity could still be in development, “I think it has to do with how their brains work, and they're more impulsive, and they're more in their present. So, if it's not in the front of their awareness, they, other things are more important, and that's what they focus on” (Dr. Diego). These sentiments were echoed by the stage 3 group participants, who saw transition planning as multi-faceted and continued with the adult provider teams.Individual transition planning was discussed by the clinicians and AHP groups. Their views converged stating that due to the pediatric and adult care models differences, AYAs' would benefit from a patient peer support network to undergo “… it's even more important sometimes in this group of people who do have chronic pain, who miss a lot of schools, who miss a lot of working opportunities, to give them the flexibility to have later evenings, or early mornings, that we promote that they don't miss school or don't miss work” (Paris). AYAs insisted that the timely supporting documentation plays a crucial role in validating their limitations and obtaining disability-related accommodations “so that I can keep up with the other students and sometimes just to get those kinds of letters and stuff can take months… if I have midterms, if I have finals in university, I need them right now… getting documents, simple documents and such becomes really, really tough.” (July).Clinicians and patient groups agreed on the need for accommodations of the AYAs' vocational and working schedules, recommended a telephone helpline (clinicians), and implementation of “drop-in hours” similar to walk-in clinics (patients). Clinicians emphasized that “safe, caring and effective transitions.” One of the most discussed solutions was a shared electronic online platform accessible to patients and healthcare providers that “…would house information… [be] patient friendly… [with] a visual component that might be more interactive” . Such technology could be multi-functional and serve for the confidential information exchange, as an administrative tool. There might be a patient portal offering virtual orientation sessions, the ability to contact the team, and assisting with a standardized transition process by providing “…a web-based referral form that obtains the essential information needed by the pain treatment clinic” . Such a platform was also seen as a safe space for case discussions and knowledge exchange with “…the hub experts of the pain clinic and then physicians, it's not limited to physicians, but allied healthcare professionals in the community” . Here, the participants mentioned the technological advantages of an ECHO .The agreement on the involvement of PCPs was unanimous and participants felt that the benefits are mutual. Thus, AHP desired ongoing assistance from the PCPs, and clinicians pictured PCPs as a longitudinal “like a resource person that people can call at all times…” . Patients hoped that the pivot nurse could absorb some of the physician's responsibilities, “tell[-ing] you “You know what? Come into the hospital, I'm going to squeeze you in right away”…the root of the problem, is the fact that there is no person in the middle… and [there] has to be someone else in the middle, not the patient.” . The pivot nurse was seen as a patient advocate to “communicate between primary care providers and… pain specialists”  and liaise with other professionals, “be the go-between” team member. . This would be “…paramount because … unless you have that advocate or unless you can really advocate for yourself, not everyone has that makeup to really put themselves out there…” (February).A pivot nurse position was another idea supported by all participants and discussed extensively in all stages. This role was seen as quite extensive and would include monitoring patient's attachment to primary care services and appointment attendance, ensuring the smoothness of ongoing communication between patients and involved healthcare professionals, informing and educating the patient, and be the first line of contact, “it speaks perhaps with the philosophy of family physicians vs. other physicians, where they're kind of cats vs. dogs. Where I think it's hard to herd cats. It's not a hierarchical structure as it would be in a hospital setting…So that you have to be careful with it.” (Titan).Discussing professional collaborations, participants realized there might be some fundamental differences in how primary and specialty adult services are set up, which might be confusing for the AYAs, affecting their expectations from the services and different care providers. As one of the AHP group participants put it, “…the details there are grosso modo, they are just sort of ticked off” . PCPs, on the other hand, described their confusion about pain services saying that “there should be a site or something that gives us the adequate [information on the services]- because it doesn't go through the CRDS [central online depository], so you have to know where you're sending them.” (Dr. Lily). One of the AYAs interviewed in the first phase exclaimed “My family doctor? No, she had no idea how to help me and where to send me.” Another patient recommended implementing “a standardized transition system…Maybe a task force of different… doctors … who lay out their… 10 steps that need to happen when a patient aged 17 goes through for the next 12 months until they are kicked out [of pediatric services] and they start at the [adult] hospital.” (February).All stakeholders agreed that there is a need for a consistent approach to transitional pain care pan-provincially. The tertiary care providers qualified most referral information as incomplete with “[as she] saw a medical practitioner talking to July [AYA patient], who thought he had a 50-year-old, or a 40-year-old in front of him… [and supporter] was shut down because of the fact that she's obviously over 14.” (May). An experienced educator AHP gave examples on his work with family medicine trainees evaluating AYAs who are “different from older adults, who require different interviewing and management techniques…” (Titan). A patient echoed these sentiments by emphasizing that gaps in training might be also associated with the perceived stigma: “I just noticed that a lot of … doctors seem to be more kind of against like, “Oh, there's nothing wrong with you” or… they try but maybe they don't have the knowledge that they need…” (March). The stigma of CP in a young patient was discussed by PCPs as something pervasive and omnipresent, one of the PCPs explained “…[e]verybody will open the door for an old person with a cane or a walker, right, but a young person, everybody looks at them, and it's almost like they have leprosy. It's like there's something wrong with them, what did they do, you know” (Dr. Lily). Another PCPs stated, “I've been told that chronic pain is just as common in children and young people as it is in adults. I was very surprised by that information…” (Dr. Diego).Training for healthcare workers was another extensively discussed variable. For example, a patient supporter described her attempt to intervene “A more detailed description of quotes and CAPHC-matched recommendations is found here .We conducted a three-stage qualitative study on transitional pain services for AYAs in the McGill Healthcare Network and involved a diverse group of informants. The stakeholders discussed a complex interplay among the inter-disciplinary care provision, longitudinal primary care support, stigma, and other psycho-social determinants. The deliberative stakeholder consultation groups reviewed the findings of the first two steps, the transitional CAPHC guideline  and formulated a set of 15 actionable recommendations . The HCTindividual patient, service, and healthcare system levels. Interestingly, the focus of most discussions was on strategies with a direct impact on the AYA function within the system: building youth's capacity to navigate the system, orientation to adult pain services, development of a pivot nurse position to have a “go-to person,” PCPs' involvement in a role of an AYAs' ally when integrating into the new system, multidirectional communication strategies, standardization and predictability of the transition processes across the province, and implementation of the e-platform. This focus on the system's shortcomings likely stems from the AYAs' need for a more unambiguous and predictable environment that would limit “shifting sands” and allow for better function and coping.The main findings evolved around AYAs' pain experiences at three different levels, via e-consults, telephone helpline, receiving preliminary information on incoming AYA patients) were supported only by one enthusiastic group .Most but not all participants chose the development of a patient peer network, training in adolescent medicine for care providers, strategies on accommodations of individual AYA's needs, overlap in care, pre-transfer between specialists and PCPs/pediatric and adult providers, age-friendly clinic designs, and training in communication strategies for the clerical staff as important local initiatives that would strengthen transitional care. Resource-heavy recommendations  underscored today fast-paced and highly competitive environment outside of the clinical setting that puts AYAs in a significant disadvantage socially but also medically. Patient supporters and PCPs admitted that AYAs are having difficulty planning, acting “in a reactive way” when the crisis has already arrived. Greig and Tellier described AYAs as those “…who are still in the process of acquiring autonomy, have marked similarities with adolescents and differ from older individuals who have attained full independence” . FurtherSensitizing care providers to the existence of pain in AYAs and providing training in pain management were among the most discussed topics. To be able to recognize CP in AYAs, and properly assess and manage it, a curricula improvement for all healthcare professionals is urgently needed , 57. ThiMultidisciplinary treatments are preferred but remain poorly accessible, and symptoms deteriorate while patients are waiting for clinic appointments , 59. CouThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by St Mary's Hospital Ethics Review Board. McGill University. The patients/participants provided their written informed consent to participate in this study.IK developed the original study idea, led the project, and wrote a draft of the manuscript. GB, MP, YS, LT, MC, and IV participated in all study steps, idea development, meetings, discussions, and conceptualization of the study findings, were involved in writing or proof-read the manuscript. All authors contributed to the article and approved the submitted version.La Lettre d'entente no 250 (recherche en médecine de famille) salary support.The study received support from the Réseau de connaissances en services et soins de santé intégrés de première ligne du Québec (Réseau-1 Québec), grant # 29053. Louise and Alan Edwards Clinical Research on Pain fellowship support. 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.