Quality is a multidimensional issue involving various features that depend on service performance and personal assessment. Clarifying the concept of quality is essential in order to further facilitate the understanding and improvement of quality in healthcare. The purpose of this study was to investigate how clinical nurses, providing care to adult medical patients, perceive and define the concept of quality nursing care. A descriptive qualitative research design was applied. A purposive sampling strategy was used to recruit nurses from the clinical sector of a general public hospital in Athens, Greece. Ten female nurses from the medical sector participated the study. Data collection was conducted through in-depth, semi-structured interviews. Conventional content analysis was used to analyze the verbatim data. Four categories were revealed from the data analysis, namely: (a) “Quality care is holistic care”, (b) “Good care is an interpersonal issue”, (c) “Leadership is crucial”, and (d) “Best care is our responsibility”. Quality care was defined as holistic care, addressing all patient needs with competency and aiming for the best patient outcomes. It was associated with communication, teamwork, good leadership, and personal commitment. By developing an in-depth and mutual understanding about what quality means, nurse leaders and practitioners may collaborate in finding common paths to support quality interventions and enhance quality nursing care in clinical practice. Τhe concept of quality of care has been a topic of debate among the members of the scientific community for many years, as it has been associated with various dimensions of healthcare, such as interpersonal and technical aspects of care, patient outcomes, structure, processes, and the setting of quality standards ,2,3. FurSome of the most influential efforts on quality of healthcare include those of Donabedian , who desDespite the fact that many scientists have been working intensively to formulate a commonly accepted definition of quality care, this concept remains unclear, as quality means different things among patients, healthcare providers, and organizations . MoreoveIn terms of clinical context, attributes such as effectiveness, efficiency, patient safety, best patient outcomes, and effective, continuous interaction and communication between the patient and the nursing staff, seem to be the common denominators that contribute significantly to a high quality of nursing care . Ryan etAs contemporary healthcare systems focus on the patient for achieving a high quality of services, factors such as personalized care, nurses’ responsiveness to patient requests, an effective patient –nurse ratio, adequate information, and accessibility were valued as important dimensions of quality care and patient satisfaction ,11. In aQuality models such as the one mentioned above, have being widely used to frame research on quality of care and, as such, nursing care had to be adjusted to the novel interventions, advanced practices, and technologies raised by these challenging efforts. Accordingly, clinical nursing has been reshaped to a highly demanding sector that requires excellent nursing knowledge and the skills for achieving the best outcomes and high quality of care . Within A review of the literature showed that the concept of quality nursing care has not been adequately investigated and only a few studies have examined the meaning of quality care from the nurses’ viewpoint ,14,15. IThe purpose of the study was to investigate how nurses, working in clinical settings and providing care to adult medical patients, perceive and define the concept of quality nursing care.A qualitative descriptive research design was applied using a conventional content analysis approach.Qualitative research designs are particularly useful when little is known about a phenomenon and when the researchers seek to answer questions about the participants’ views, perspectives and experiences. These designs help to identify key concepts and constructs and to gain in-depth understanding of the phenomenon under study within its real social context . More spAs such, a, qualitative descriptive design was considered the most suitable for gaining in depth knowledge and understanding on how nurses perceive and define the concept of quality care.A purposive sampling strategy was used to recruit nurses from the clinical sector of a general public hospital in Athens, Greece, having a 476-bed capacity. Quality policy is supported within the hospital by the Department of Quality Control, Research, and Education. The department’s role is to highlight, promote, and monitor the implementation of the quality policies as defined by the hospital management and assist the administrators to continuously improve the quality of healthcare services by making appropriate recommendations. In this context, cooperation with nursing staff has been developed in a range of quality activities, such as monitoring of clinical errors and management of nosocomial infections. A short introductory training on quality of care is provided to the newly employed nursing personnel.Registered nurses having at least two years of working experience in the medical sector were included in the study. This working experience was considered essential for the study participants to thoroughly discuss their views and perceptions about the quality of the care provided in their working environment.Recruitment of study participants took place within the hospital by a member of the research team who advertised the study through informal meetings and personal contacts with the nurse managers and the staff nurses who were employed in the medical sector. At the time the survey was conducted only female nurses responded to the invitation to participate in the study. This is likely to happen not only because the number of female nurses is higher than the male ones but also because of the onset of the pandemic that limited the ability of the nurses’ participation in the study. Finally, 10 female nurses working in the medical clinics participated in the study. They all held a bachelor’s degree in nursing, while nine of them were M.Sc. graduates. Participants’ ages ranged from 30 to 47 years, and their length of employment in the clinical sector was between 2 and 22 years . None ofEthical approval was gained from the scientific board of the hospital before data collection (Ref. No. 15/9-7-2019). An informed consent form was signed before conducting each interview. Relevant information on participant anonymity and confidentiality was provided. Τhe voluntary nature of the study and a participant’s right to withdraw from the study at any time without any consequences were discussed. Before each interview, permission was granted by the participants for tape recording. Personal data were protected throughout the study, and code numbers were given to participants for preserving anonymity. Interview extracts were used in order to illustrate the presentation of the findings, without including any identifying information.Data collection was conducted through in-depth, semi-structured interviews. This kind of interviews is useful when detailed information about a person’s views is required. Semi-structed interviews allow the study participants to provide wealth of information by answering spontaneously on complex matters . Data coThe interview guide included one open-ended question that invited nurse participants to describe what quality of care means for them. Additional questions were used, whenever necessary, to further explore the participants’ views concerning (a) features of good care, and (b) factors affecting the provision of quality care. Each interview lasted approximately 20 to 30 min. In total, 10 interviews were conducted. Data saturation occurred at this point of data collection, since the interviewer recognized that data were repeated in prior interviews and no new information was revealed. At this point it is important to note that emphasis was also placed by the researchers upon the concept of ‘information power’, which actually determines the sample size by the amount of information the sample provides rather than the number of the participants. ‘Information power’ is important in descriptive qualitative research, where small sample sizes are common, as a manner of ensuring that adequate information has been attained . A tape organizational aspects), reflecting an explicit concept or meaning. Codes involving relative concepts were then grouped under higher-order headings , leading to generation of categories and subcategories. At the third stage, the analysis process and the findings were reported through the formed categories and sub-categories.A conventional content analysis was used to analyze the verbatim data. In conventional content analysis, coding categories are derived directly from the data, and it is also known as inductive category development . Data anFor ensuring the trustworthiness of the analysis process the development of categories and subcategories was examined independently by a second analyst, a member of the authoring team, and a consensus was reached regarding the presentation of the final categories and sub-categories ,26.Member check is considered as one of the most important techniques used by the qualitative researchers to enhance a study’s credibility . This waTen female university-graduate nurses participated in the present study. They were all employed in the medical sector, with a minimum overall working experience of seven years. None of them had received any formal training on quality of care. The demographic characteristics of the study participants are presented in Study participants were asked to define what quality of nursing care means. They defined quality as a holistic approach to patient care, involving issues of communication, best patient outcome, competency, knowledge, satisfaction, and meeting the patient’s needs. The concept of quality was also related with managerial issues and personal engagement. In this respect, four categories were revealed from the data analysis, namely: (a) “Quality care is holistic care”, (b) “Good care is an interpersonal issue”, (c) “Leadership is crucial”, and (d) “Best care is our responsibility”. Nine subcategories were also formulated and were assimilated, respectively, into each appropriate category .“Quality care is holistic care”: this was the main message that the participants conveyed when asked how they define quality of care. Treating the patients as a whole and meeting their needs in a holistic way were highlighted by the participants as major issues, with regard to quality of care.Quality care is holistic care. It means to be able to meet all the patients’ needs, not only to take care of his medication…”“(p6)They further emphasized on the significance of addressing the patient’s needs through understanding, trust, and competency, which were regarded as key features of quality and holistic care.Quality care is caring for a patient as a whole with interest and understanding, meeting all his needs …”“(p9)To meet the needs of the patient, psychological or physical and to build a trusting relationship with him …”“(p8)Well-educated, skilful and knowledgeable nurse practitioners appeared to be a necessity for providing meaningful care.Quality is to have the practical skills to provide meaningful care… and at the same time to have the theoretical knowledge needed…”“(p2)Nurses mentioned empathy and safety as integrated concepts of quality care.Excellent nursing care is the theoretical and practical knowledge we get from our studies combined with empathy…”“(p4)… to apply nursing interventions based on our knowledge… to be informed and keep the patient safe…”“(p3)Being capable to identify and solve the patient’s problem(s) was considered as an indicator of providing a high quality of care and promoting patient recovery.I like to be able to solve the patient’s problems… and when you see the patient to get better and you know that you helped in it, you know that you have done a good job”“(p7)Contributing to a patient’s recovery and achieving best patient outcomes were mentioned as imperative features of quality nursing care.… when I know that I am doing the right thing for the patient, in the right way at the right time… when I help the patient to recover… this means good care for me”“(p4)Nurses described these as significant aspects of personal and professional fulfillment, leading to quality care, satisfaction, and self-actualization.Care is an act leading to an outcome… you care for the sick person, you try to make him feel better… and when he is cured, this is the greatest satisfaction for every nurse”“(p5)Nurses and patient satisfaction were referred to as essential parts of a quality-care definition. Quality care appeared to be interrelated to professional and personal satisfaction for both the nurse and the patient.Quality care is when everybody is happy. Both the nurse and the patient. For doing the right thing in the right way for the patient.”“(p1)Furthermore, coordinated care and preserving patient privacy appeared to be important issues that determine quality of care and patient satisfaction.… to have a coordinated care, to have a satisfied patient, to maintain privacy and rest, to ensure his family is next to him…”“(p6)Nurse participants were also referred to issues that constitute quality of care. Effective communication, recognition of their work from patients and other professionals, and cooperation with colleagues during work shifts, impact positively on the provision of optimal nursing care and enhanced nurses’ job satisfaction.Good care is an interpersonal issue, it means having good relationships, having a nice conversation learning from people from different cultures and educational backgrounds… things that fill in your day nicely…”“(p1)To communicate with the patient and have recognition for my work, to get a thank you at the end of the day… this is quality at work”“(p10)Elimination of fragmented care through team coordination and effective teamwork was an additional asset for the provision of quality care. Meaningful communication among healthcare team members appeared to be a prerequisite for providing holistic and meaningful care.… quality care should be well coordinated… to have meaningful communication with doctors… so to be able to provide holistic and meaningful care…”“(p6)… to have a colleague by my side, that we can work together nicely and effectively…”“(p7)On the contrary, lack of effective communication with other healthcare professionals, heavy workload, and inadequate time for patient care were referred to as obstructing factors that impede optimal interaction and quality care.… miscommunication with other professionals, shift schedules and unclear job description… these have a negative impact on care”“(p10)I do not have enough time to deal with my patient as I should… this makes me unhappy and affects the quality of my work”“(p4)A trusting leadership was referred to as a crucial organizational feature for introducing quality transformation at an organizational level. However, nurses stressed that this does not occur automatically but is a long-term process.Leadership is crucial… They (the managers) need to support us, to recognize that we have the theoretical knowledge to provide excellent nursing care to our patients. To trust that we can change old practices to new ones. This will not happen overnight… it needs time… this may create conflicts… so it is the manager’s responsibility to decide when and how will do the change…”“(p4)Supportive leadership, staff recruitment, and effective resource allocation from top management are actions that may enhance quality nursing care.The shortage of staff and equipment, could be resolved at a managerial level. Supportive management decisions, will really help us a lot to do our work in a better way and to provide good care…”“(p5)Professional development and provision of training for the nursing staff appeared to have a distinguished role in the provision of quality care.The staff needs to be trained to be able to cope with critical situations to have the knowledge and the skill. This would help to deliver better quality of care”“(p10)According to the participants, working conditions have an impact on quality of care and job satisfaction. The nurses claimed that despite the fact that they love their job, poor working conditions impede the provision of quality care and cause physical and emotional exhaustion.I like to be with the patient… I like nursing, I have been practicing it for so many years… but I do not like the working conditions… it all gets so difficult… and providing good care is difficult too”“(p9)… we are all tired due to staff-shortage… we are sort of resources… and because of this we are emotionally and physically exhausted. I am so disappointed with working conditions…”“(p2)Staff recruitment and adequate ward facilities appeared to be critical factors for improving nurses’ work and providing effective and quality care.To have more nurses in each shift, to improve the nurse/patient ratio… to have more facilities in the ward, a better shift schedule… not to get so tired, this is vital for good patient care…”“(p1)unbreakable chain” among the members of the interdisciplinary team, were considered as a personal responsibility for providing good care.Personal engagement and a positive professional attitude were mentioned by the nurses as ways to cope with difficult situations and maintain good care. For the participants, issues of team work and strong collaboration, like an “I’m tired of it, but okay, I’ll not let it to get me down… I’m trying for the best… we all try to do our best… it’s our responsibility to provide the best care to the patient”“(p7)… it’s our personal duty to build a strong, solid cooperation between all these people . To be an unbreakable chain, so nothing could harm our good work, our care…”“(p1)Being aware of the multidimensional nature of the nursing science, consciousness of what nursing care actually is and being responsible for the care provided to the patient were reported by the participants as personal qualities that significantly impact on quality of care.We need to realize what our job is about. It is a matter of character… unfortunately not everyone can understand what our job involves and how we can do things in the right way… that we should work according to protocols, to have audits, to be responsible for the care provided to the patients and for the work doing in the clinic. It is important each of us to realize that our practice, reflects to patient condition, to patients’ life, to care provided”“(p3)On the other hand, participants stressed that personal engagement is undermined by the difficulties they face on a daily basis in their clinical environment, as these inevitably impact the provision of quality care to a patient. Overcoming these obstacles is often done at a personal cost that negatively affects the life of nurses. The study participants suggested that organizational support for overcoming these impediments and for providing quality services is essential.Of course, if the patient-nurse ratio was better, then maybe I could have some more quality time for myself within my 8 h shift, and some more quality time to devote to my patient… but this does not happen… somedays we do not have the time for a break… it is a personal cost… we provide the best nursing care at a personal cost… few things can be done if we think of the conditions within the Greek reality, but I believe that with support from the top management and with personal commitment, the care can be improved”.“(p4)The aim of the present study was to investigate how clinical nurses, providing care to adult medical patients, perceive and define the concept of quality nursing care.The study findings revealed that quality of care was defined as holistic care. Nurses’ perceptions demonstrated that the holistic nature of quality care encompasses notions of skilfulness education and expertise. Furthermore, addressing the patient’s needs and building trusting relationships were associated with delivering quality nursing care. These findings confirm those of previous studies, in which quality care was described by nurses as a relationship-based care, while addressing the patient’s needs, was strongly associated to the provision of quality of care in clinical practice ,11.Our participants highlighted that being a competent and knowledgeable nurse practitioner appeared to be a necessary condition for providing meaningful care and achieve the best patient outcomes. In addition, our results showed that empathic nursing care, based on evidence and scientific knowledge, may lead to patient safety and satisfaction. Similar research evidence underscored that a nurse’s competence and expertise are essential to maintaining quality care and achieving optimal patient outcomes in clinical settings ,30.In particular, Rahmah et al.  demonstrIn addition, issues such as the significance of a well-organized care, the maintenance of patient well-being, privacy protection, and patient and staff satisfaction were underscored in our study. These features were regarded in relevant studies as critical for high quality of care, as they may reduce nurse-burnout levels and improve professional performance and clinical practice ,34,35.Interpersonal issues, such as meaningful relationships, effective communication and collaboration, work recognition from patients and colleagues, and teamwork, appear to positively impact on the provision of quality care.Similar issues were highlighted in the study of Ryan et al. , in whicRelevant research evidence reports the importance of supportive inter-professional relationships and collaborative teamwork in patient outcomes, by highlighting that recovery and discharge decisions are affected by inadequate communication among healthcare professionals ,33. ThisSupportive leadership was closely associated by the participants to quality care and improvement. In the same vein, a positive working environment was valued as enhancing the provision of quality nursing care. These findings confirm those of previous studies, which demonstrate that the supportive role and the positive attitudes of ward managers were highly appreciated by nurses, as elements that facilitate nursing practice and improve quality of care in the clinical sector . Asif etQuality of care in the present study was associated with respectable management, recognition, professional development, and staff recruitment. These findings are supported by relevant studies, stating that leaders should encourage and reward quality nursing care, while authentic leadership should create and sustain empowering work environments that reduce burnout, increase nurse job satisfaction, and improve patient-care quality ,40.Being responsible of the care provided to the patient was reported by the nurses who participated in the present study as a personal obligation that significantly impacts the quality of care. Quality care was associated with nurses’ personal engagement and positive professional attitudes. Personal qualities such as awareness, commitment, responsibility, and consciousness appeared to impact on the quality of care. The relevant literature reported that nurses with high levels of professional commitment strive to promote integral care, and well-committed nurses are needed for providing safe and effective healthcare ,42. AccoAdditionally, the study participants mentioned the difficulties encountered in their clinical environment, which negatively affect their personal lives and patient care. They further referred to the crucial role of personal commitment and organizational support in overcoming these problems. Previous research evidence indicates that good organizational resources and effective management are important predictors of nurses’ professional commitment and overall staff empowerment ,44. Accoquality of care is holistic care” is that quality is shaped not only through typical evaluation, which is often conducted in an impersonal way, but through human understanding, personal insight, and empathy.The message conveyed through our study and the formed definition of “It is important to note at this point that the nurses in the present study, although they defined quality care as holistic care, failed to openly demonstrate an in-depth understanding of the notion of holistic care as described in the relevant literature . The emoIn our case, although a lack of nurses’ conscious knowledge on the notion of holistic care was indicated, the participants appeared to intuitively communicate these concepts in patient care. By referring to issues of empathy, self-responsibility, self-awareness, and understanding the patient’s needs, we realize that a humanistic approach to care is demonstrated and that the need to further educate nurses on holistic care and quality seems imperative, for consciously implementing quality and holistic care in clinical practice.quality care as holistic care may reinforce the already formed perceptions that knowledge, ability, interdisciplinary communication, and personal commitment are important dimensions of the definition of quality of care. In particular, the nurses’ perceptions of what quality of care means seem to move beyond the Donabedian’s triad of structure, process, and outcomes, by valuing personal engagement and professional commitment as major issues that constitute the concept of quality of care. The definition of quality and its relevant components, as evolved through the nurses’ eyes, highlights the inextricable link between quality and the essential dimensions of nursing, as described by Fawcett [Furthermore, defining  Fawcett . It furtThe study sample consists solely of female nurses working in the clinical sector. A sample involving male nurses too, might provide additional views on the concept of quality of care. In addition, the study participants were all employed in the medical sector of one public hospital, located in Athens. For this reason, transferability of the results is limited, and applicability of the study evidence in other contexts and situations may be restricted. A future study with a sample from different clinical areas, in both public and private healthcare sectors, and from broader geographical areas would enhance the scientific knowledge in the field under investigation. Finally, during the data-collection phase, the first wave of the COVID-19 pandemic was occurring, which resulted in a prolonged lockdown in Greece. Major and immediate changes were introduced in healthcare systems globally that severely affected nursing practice. To this end, the results of the present study should be viewed, while taking into consideration these decisive changes.Quality of care is a complex and multidimensional concept. Few studies have focused on clarifying this concept. The findings of the present study have significant implications for both clinical practitioners and nurse leaders. The knowledge evolved from this study can be used by clinical nurses to further evaluate and improve their practice. The study findings provide significant information for reframing nursing education and care, enhancing patient safety, and achieving best patient outcomes. Sharing a common understanding of what quality of care means can assist nurse leaders to develop supportive strategies for promoting nurses’ professional development, satisfaction, and empowerment. Furthermore, at an organizational level, the evidence raised from this study may contribute to creating positive working environments and supporting teamwork and commitment. Shared actions based on quality expertise can further inform clinical practice, nursing education, and competence.The concept of quality of care was defined by nurses as holistic patient care, which encompasses the issues of meeting the patient’s needs, nurses’ competency and empathy, best patient outcomes, and satisfaction. Additional features, such as effective communication among healthcare professionals and patients, teamwork, and good working conditions, are inextricably linked to the concept of quality of care and the quality level of provided health services. Personal and professional commitment and supportive leadership were considered to be factors that facilitate the provision of quality care in the clinical setting. Future research will contribute to gaining further understanding and knowledge on the concept of quality and its related factors.


Background: Experiences of discrimination are prevalent among minority populations, although often empirical evidence does not provide depth into the source and types of discrimination, such as racial/ethnic, gender-based, age, etc. The goal of this study was to assess the unique patterns, types, and sources of discrimination experiences that college students face and explore the role these experiences play in their mental health. Methods: An explanatory sequential mixed-methods study was utilized. Quantitative assessment of college students from a Hispanic and minority-serving institution was conducted to evaluate experiences of discrimination and its association to physical health and mental health , as well as food insecurity, a marker for poverty. Next, qualitative data were thematically analyzed to further provide an in depth understanding on the sources of such experiences, types of discriminations, as well as the impact on mental health. Results: Results of the quantitative assessment highlight that discrimination was prevalent among the population with a higher everyday discrimination score significantly associated with serious psychological distress, low mental health status, low physical health status, and being food insecure. Further, most of the participants reported that they felt discriminated due to their appearance, with race/ethnicity and skin color as next most commonly cited reasons. Qualitative assessment further demonstrates distinct types of discrimination experiences from a variety of sources. Within a family, colorism and having an American accent while speaking a native language was a predominant source, while among peers, having a non-American accent was a primary source of discrimination experiences. Such experiences based on elitism, gender, and age (being younger) from the workplace were prevalent among the target population. Finally, feelings of isolation, not belonging, as well as negative impact on self-efficacy and self-worth were noted. Conclusion: Experiences of discrimination are prevalent among college students, including from within family and peers. To improve mental health outcomes of such a population, campus-based measures are needed to promote resiliency and social support, as well as community-based initiatives to promote workplace training to create inclusive environments for younger generations entering the workforce. College students face a disproportionate share of health disparities, including poor sleep health ,2,3,4, rAnother key emergent area of disparity noted among college students is that of discrimination. The American Psychological Association notes that discrimination is an “unfair or prejudicial treatment” of population based on shared characteristics, such as race, gender, age, sexual orientation, etc. . AlthougThis study used an explanatory sequential mixed-methods approach, with quantitative assessment followed by that of qualitative. In this approach, qualitative data are utilized to explain, interpret, and provide further clarification of the quantitative results . CombiniIn this study, during the first phase, quantitative analysis of an annual student health assessment was conducted. Students, aged 18 years or older, were recruited from general education courses to ensure inclusion of a variety of majors and extra credit was provided as incentives. The annual survey collects data on various health and behavioral outcomes, including alcohol and tobacco use, sleep health, mental health, experiences of discrimination, and sociodemographic characteristics. In this study, we selected participants who identified as racial/ethnic minorities (chosen from a list provided). In the U.S., ethnicity is primarily defined as Hispanic/non-Hispanic, while racial groups may include (but not limited to) one or more of the following: African American, Asian American, White, etc. All participants who were currently enrolled, were at least 18 years of age, whose classes shared the survey, and who provided written consent were selected in the study. We did not collect any parental or family data. However, a majority of the participants at the institution are first-generation college students on financial aid. We further evaluated experiences of discrimination, assessed through the Everyday Discrimination scale , as wellt-tests) with alpha = 0.05 were used to assess whether mean discrimination differed by serious psychological distress status, mental health status, physical health status, and sociodemographic characteristics.All quantitative data were analyzed in SPSS version 28 . First, descriptive statistics were conducted to assess the mean discrimination score, as well as prevalence of psychological distress, low mental health status, and low physical health status. Next, bivariate analyses  the researchers refrained from one-on-one interviews and instead opted for a focus group to allow a more relaxed peer-based discussion.As a result of reaching theoretical saturation, we included responses from a total of 18 students. Semi-structured interviews in a focus group format were conducted. Such open-ended questions included whether students experience discrimination of any sort during their daily life, and if they have, detail the types of experiences and sources, as well as how that impacts their mental health. For participants who did not directly experience any discrimination, they were asked to describe what they have seen others experience instead. All responses were electronically recorded and transcribed verbatim, followed by de-identification of data per ethical board approval guidelines. Such qualitative responses were then thematically analyzed to identify emergent themes in a five-step process . First, In our quantitative phase, a total of 308 participants were evaluated. As shown in p < 0.01) and those with low mental health status versus those with excellent/good mental health status . Likewise, such mean discrimination score was significantly higher among those with serious psychological distress, versus those without . Further, participants who were food insecure reported a significantly higher mean discrimination score, when compared to their food secure counterparts .We then compared everyday discrimination score by stressors  to evaluate the potential compounding role. Results show that mean everyday discrimination score was significantly higher among those with low physical health status, as compared to those with excellent/good physical health status , primarily based on younger age, as well as gender stereotypes were the most prominent theme among study participants.When assessing specific sources and types of discrimination, further theme of “… it sucks to know that someone is undermining a lot of the trainings that I went through and the experience that I got.”“I think it’s because we are millennials. I’m guessing that’s what it is…that we’re not as competent compared to someone from another generation.”“I wish I could be seen as a professional and not just as seen as …too young to teach them…”“Just being a woman when it comes to like… heavy lifting, I kind of see guys tend to not like, pick me because I’m small. For example, I work at the gym, so it’s like lifting treads and all that it’s like let’s send the boys to do it.”elitism, and based on educational attainment, discipline, as well as income. Participants noted that employees with higher rank often belittled others who did not hold a similar position or higher degrees. Responses show that choices in academic fields have also been discriminated against. Such experiences of discrimination that participants experienced further led them to quit their jobs and the associated stressors.Another common theme related to workplace discrimination was related to “I work with a lot of doctors, nurses… they [have] higher education. I feel like sometimes I’m looked down upon.”“Oh, well what are you doing? And I’m like oh, I’m doing public health and they’re like oh, well that’s not interesting.”“…people with money they see all the other people a lot lower.”colorism from within the family, where several participants noted that family members (including themselves) who were of darker complexion were often mistreated by others in the family of lighter complexion.Furthermore, another emergent theme was that of acculturative stress, when the process of adapting to the norms of U.S. resulted in a negative impact on both domestic and international students. For example, most Hispanic/Latino and Black/African American participants noted experiences of “My Mexican side of the family will be like…You guys are black [referring to skin color and not race] anyways…I’ve kind of felt different in a sense… we’ve always been like kind of kicked to the curb.”“I have two little cousins and they’re both the same age and one is like blond light-colored eyes and the other one is like darker, you know just a little bit tanner and he [grandfather] like willingly shows like he prefers like the lighter one.”language-based discrimination occurred, where those not speaking a traditional language fluently often resulted in being called names or felt isolated. For instance, several participants described situations where having an American accent when speaking their family’s native tongue often resulted in being targeted and felt lack of belonging.Furthermore, participants also noted that within family, “They just started arguing with me like, okay, they were real… they’re like [I was] trying to be white or something.”“…you don’t belong… when I try to speak Spanish… so that always kind of made me feel like a sense of loss of identity.”being an immigrant, and primarily due to having a foreign accent while speaking English or ethnic-specific stereotypes, which, in turn, participants noted left them with feelings of isolation or unwanted negative attention.Although experiences of discrimination on campus and/or classrooms were not widely reported, among those who did, such experiences were based on “Foreign exchange students sometimes they get looked down upon… when they’re speaking.”“I notice sometimes when I talk to people, they like to point out my accent.”“Sometimes I feel a little different in class…because my English no good, no one wants to work with me.”“One time during class we were choosing groups and I heard people say that [redacted ethnic identity] are lazy and only cheat.”Nearly all participants noted that the various forms of discrimination, especially related to work, negatively impacted their mental health. Many noted that such experiences, especially at work, made them question their own skills, abilities, worth, as well as added stressors with long-term feelings of hurt, isolation, and self-blaming.“I can’t do my job without having [the discrimination experiences] in the back of my mind.”“…now I go to therapy because I talk about all of the stuff that I go through [at work].”“When I go home… I relink what whatever happened… replay everything in my head.”“It’s more like a frustration kind of thing… but it also makes me feel like maybe I’m not approaching them the right way… what am I doing that’s wrong?”“Well, honestly I do get self-conscious about my accent, and I think about it all the time now.”The purpose of our study was to assess experiences of discrimination, how that may influence mental health, as well as delineate the various types and sources of discriminations that such a population face. The results of our explanatory sequential mixed-methods study demonstrate that: experiences of discrimination were prevalent among college students with disproportionate shares among those who were food insecure, highlighting the most vulnerable. This is further clarified in qualitative analysis that highlights socioeconomic status-based discrimination, where participants’ education level and degree type at workplace was cited. Additional workplace-related discrimination included experiences based on younger age and gender identity. Furthermore, experiences of discrimination came from within the family based on colorism and having an American accent and from peers based on having a non-American accent, especially among immigrants. The expectation of discrimination, especially among Black/African Americans was also common. Cumulatively, various levels of discrimination  and types  demonstrate the complexity of the stressors college students experience that can negatively impact mental and physical health of the target population.The literature notes that mothers (of young children) who experienced racial/ethnic discrimination were also more likely to report household food insecurity and poorer mental and physical health status , with siFurthermore, our results highlight that a substantial ongoing theme of workplace discrimination based on both younger age, as well as woman/girl gender identity. Such results have significant implications for long-term professional development of college students. For instance, while historical legislation on ageism has focused on discrimination against those aged 40 years or older  and reseFurthermore, a unique theme noted in our study was family as a source of discrimination, especially based on colorism and having an American accent when speaking the family’s native language. Colorism results in advantages and privileges for those lighter skin, when compared to those of darker skin within racial/ethnic minorities . StudiesIn addition, our results provide insight into the role of accents and the catch-22 that racial/ethnic minority college students face. For instance, while having an American accent while speaking a native language within one’s family was related to experiences of discrimination, isolation, and sense of not-belonging, having a non-American accent, on the other hand, was a source of accent-based discrimination among peers. Although limited, the literature notes the prevalence of accent-based discrimination among international students and the negative burden of mental health ,50, as wFinally, a concerning pattern noted in our qualitative assessment was the expectation of racism, especially for Black/African American college students. Herein lies opportunities for institutes of higher education to be active in their diversity, equity, and inclusivity initiatives through integration of culturally responsive and social justice pedagogy ,55, in tThe results of the study should be interpreted in the context of its limitations and strengths. Although our study utilized a mixed-methods approach, the cross-sectional nature limits our ability to assess the long-term impact of experiences of discrimination among college-students. Additional dimensions of discrimination were not assessed in the quantitative assessment, especially those stemming from acculturative stress for immigrants, sexual orientation, or others. Nevertheless, our qualitative assessment provided means to lower this bias by providing additional content on experiences of socio-economic and linguistic discriminations experienced by the target population.Cumulatively, our study highlights that college students experience a plethora of discrimination from family, peers, as well as during opportunities of professional development. Optimizing mental health outcomes and overall well-being of the population requires both public health and legislative initiatives that promote the creation of an inclusive environment and resilience building.Experiences of discrimination are prevalent in the U.S., especially among vulnerable populations. Most of studies related to discrimination, however, focus on racial/ethnic and sometimes gender-based experiences. In our study, we aimed to evaluate both the unique types and sources of discrimination among college students as they often face a plethora of different environments during this transition period. Our results are consistent with the literature in highlighting that discrimination is prevalent among college students. However, such findings further note that such experiences are significantly related to their health outcomes, including mental health and perceived self-worth. In particular, the results note that experiences of discrimination may benefit from assessing social class in America, acculturation-related patterns, as well as whether expecting such stressors can lead to maladaptive coping mechanisms. Workplace training as well as campus-based initiatives are needed to promote inclusive environment for college students.


Open Access funding enabled and organized by Projekt DEAL.The article “Preoperative quality of life as prediction for severe postoperative complications in gynecological cancer surgery: results of a prospective study” written by Jalid Sehouli, Kathrin Heise, Rolf Richter, Hannah Woopen, Louise Anders and Melisa Guelhan Inci was originally published electronically on the publisher’s internet portal on October 29, 2020 without open access. With the author(s)’ decision to opt for Open Choice the copyright of the article changed to © The Author(s) 2020 and the article is forthwith distributed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third-party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The original article has been updated.


The purpose of this paper is to re-examine the relationship between grammars and processing systems in light of the various forms of experimental research  that has been conducted in the last fifteen years or so. First, the notion of ‘processing strategy’ or ‘heuristics processing’ is considered followed by a discussion of structures of great morphosyntactic complexity that parsing systems seem to tackle by simply respecting complex grammatical laws, instead of by resorting to shortcuts. Then, grammatical illusions and what these can teach us about the processing of grammar are considered. It is argued that illusions allow us to discern a few explanatory principles that may redefine the way we see parser–grammar relations. Among these is the idea that how long illusions last in the online-to-offline transition depends in part on their ‘templatability’, that is, the ease with which they become gestaltic templates. Another key idea is that some apparent illusions are in fact nothing more than grammar contemplated at work as in slow motion. Linguists who take the notion of psychological adequacy seriously are usually not satisfied with what Jackendoff defines as “methodological convenience”  p. 652)2]). SeenDerivational Theory of Complexity episode has played too big a role in negatively defining the relationships between linguistics and psycholinguistics and, even if we were to endorse the cynical view that the DTC was a complete failure (but see  have, as the editor mentioned, ever received a pay raise.The first indication that NPI illusions are not the monolithic phenomenon that early work seemed to suggest is that, as Parker and Phillips have shown, they can be “switched off by increasing the amount of time from when the potential licensor is processed until the NPI is encountered”  (p. 323)illusions of ungrammaticality. De Dios used structures such as Examples (25)–(27) [25.never received acknowledgement…The authors [that the critics recommended] have 26.no critics recommended] have never received acknowledgement…The authors [that 27.No authors [that the critics recommended] have never received acknowledgement…Since NPIs display a great deal of cross-linguistic variation (I thank a reviewer for this reminder), it is as well to consider evidence from other languages. In a recent study by Yanilmaz and Drury with Turkish NPIs , ERPs sh25)–(27) :25.The a…for a best-selling novel.no and never appearing in different clauses. Example (27) has double negation, but both no and never appear in the same main clause now. De Dios conducted three experiments  and obtained a cline of results. In the three experiments, the double negation condition, Example (27), exhibited the worst grammaticality judgements and the slowest recovery from disruption. The multiple negation condition, Example (26), exhibited greater acceptability ratings and faster recovery from disruption. Finally, the single negation condition, Example (25), was the fastest to process and judge. As compared with the Xiang et al. study  local match (X X X cabinets are X X X) easily but not so from No authors that the critics recommended have never received acknowledgment for …. I suggest this is because we fall for a heuristic in the latter but not in the former. In the former, we simply use ‘mini grammar’ locally , until time for deploying ‘maxi grammar’ becomes available . “One representation is favored at one moment and then disfavored just a couple of hundred milliseconds later. But these representations are different steps in the workings of a single parsing mechanism, not the results of separate systems” [No…. ever] or [more … than] are probably worth templating for the very good reason that more often than not the appearance of ever is indeed preceded by the appearance of a c-commanding negative element, and the appearance of the first set of a comparison is more often than not accompanied by the appearance of the second set after it  these, though sloppy, are still ‘good enough’, given the complexity that must be parsed.In addition to systems” ,98,99. Ia.Various instances of research aimed at showing the worth of heuristics ;b.Various instances of research aimed at showing the worth of blind obedience of grammatical rules ;c.Various instances of illusions .In summary, first, a brief review of the following has been presented:templatability potential, evidence for strategic shortcuts (heuristics) may be expected to correlate more with the easily templatable domains, and evidence for dogged observance of complex grammatical constraints may be expected more for less template-driven forms, such as islands. If these ideas are correct, then the classic discussion of whether algorithmic grammar antecedes strategies or strategies antecede algorithmic grammar may revolve around constructing specific profiles. Note that, in a system such as the one that is being sketched here, a (yet-to-be-determined) portion of what heuristics are supposed to cover is covered instead by grammar at different snapshots of time , that i


The Chronicles of Narnia, nature plays a prominent role in driving good’s triumph over evil, and while Lewis’s environmental activism in writing Narnia has gained critical attention, the connection between his penchant for nature and his educational philosophy has not yet been accordingly considered. Stemming from his early studies of Wordsworth’s Prelude, Lewis illustrates the crucial correlation between children spending time in nature and developing imagination. Lewis replaces English school systems and educational philosophy with natural images ranging from the transformation of pupil desks into rose bushes in Prince Caspian to Aslan’s emergence from the forest and subsequent abolition of Experiment House in The Silver Chair, connecting nature’s role in children’s moral development to their formal education. Lewis’s concerns expressed in Narnia draw renewed relevance with the prominence of technology and standardized testing in today’s classrooms. As Richard Louv argues in Last Child in the Woods, twenty-first century children are experiencing an alienation from nature that is causing physical and spiritual damage. This paper will explore Lewis’s educational philosophy as evidenced within the natural settings of The Chronicles of Narnia, its ramifications in a twenty-first century context and the real-world results of incorporating nature-based education into classrooms for all ages.Throughout  Surprised by Joy, (1955) and his educational treatise The Abolition of Man. (1943) He most strongly develops this philosophy, though, across his children’s books The Chronicles of Narnia, as characters like Edmund Pevensie and Eustace Scrubb grow into better citizens in a way that directly correlates with the amount of time they spend outdoors. Throughout Narnia, Lewis replaces broken education systems with natural imagery, expressly arguing for the necessity of nature in “good” education systems. This marks Lewis as a progressive educational philosopher who would anticipate Richard Louv’s arguments nearly sixty years before nature-deficit disorder was named.Nature-Deficit Disorder is a prominent issue among twenty-first century children who consistently trade time spent outdoors for time spent on screens. Even education systems are shortening recess time in exchange for seat time in hopes of producing better test scores. A 2016 study conducted by Great Britain’s National Trust found that twenty-first century children spend less than half the amount of time outdoors that their parents did at their age , Vitamin N: The Essential Guide to a Nature-Rich Life (2016) and Our Wild Calling: How Connecting with Animals Can Transform Our Lives—and Save Theirs (2019).In his landmark book illness” , p. 36. , Louv remembers how “Americans around my age, baby boomers or older, enjoyed a kind of free, natural play that seems, in the era of kid pagers, instant messaging, and Nintendo, like a quaint artifact” . Nature is necessary for proper moral and behavioral development, and the educational upheaval caused by Covid-19 may be the opportunity educators and theorists need to reimagine how nature is incorporated into the educational experience.Louv’s theories drew renewed relevance during the COVID-19 crisis, when parents began to notice negative behavioral changes in their children during stay-at-home orders. As Meg St-Esprit McKivigan reported in a June 2020 Chronicles of Narnia, but he is not the first British children’s writer to do so. One can trace this idea back to William Wordsworth’s poetry, which served as an important body of inspiration for Lewis. Other children’s writers throughout British history, noted the necessity of nature to a child’s “proper” upbringing. Tom Brown often turned to pony rides in the valley for solace from his hellish boarding school environment in Tom Brown’s Schooldays, and time spent outdoors in the garden directly correlates with healing and emotional growth in Frances Hodgson Burnett’s The Secret Garden, to name a few. It is only Lewis, though, who physically replaces schools like Experiment House in The Silver Chair with explicitly natural imagery, making nature’s connection to healthy child development even more urgent in the Narniad. This essay will explore both the development and ramifications of this idea. I will first evaluate relevant current scholarship regarding Lewis and nature before tracing Lewis’s love for nature back through his readings of Wordsworth’s Prelude and how it influenced his own imaginative and spiritual development in his childhood as he describes it in Surprised by Joy. I will then track how he develops these ideas both in his poetry and in The Abolition of Man before exploring how he more explicitly develops his theory of nature-based education through The Chronicles of Narnia. Finally, I will turn to real-word examples of educators implementing nature-based education programs in their schools in a variety of ways, from field trips to reading nature-rich books in class in spaces where direct access to nature may not be readily available. In undertaking this project, I will uncover the progressive educational theorist that C.S. Lewis was and seek to understand whether reading books like Narnia can truly help alleviate symptoms of nature-deficit disorder, in hopes of providing yet another strategy to help today’s children healthily cope with the ramifications of both the COVID-19 pandemic and living in a society where more and more time is spent indoors.Lewis strongly connects healthy moral development to a healthy connection to nature throughout the Narnia. Early in The Lion, the Witch, and the Wardrobe (LWW), Professor Kirk famously exclaims “I wonder what they do teach them in these schools” Notably, Etcherling assumes that Lewis is drawing from the English countryside to describe Narnian landscapes, when in reality, his childhood spent living on a large estate in Belfast, Ireland ignited his initial love for nature. The fact that Etcherling takes issue with Lewis’s depiction of the Calormenes in Narnia is understandable, especially when reading The Chronicles of Narnia through a twenty-first century lens. However, these are not the only villains in Narnia to abuse nature, demonstrating that to deem Lewis’s environmental stewardship as unequivocally tied to his imperialistic views ignores his larger argument that the exploitation of nature is evil and damaging in general, no matter the perpetrator.Despite the natural imagery in his works and even the nature reserve named for him near his property in Oxford, Clare Etcherling argues that century” , p. 96. The Magician’s Nephew (MN), Uncle Andrew and Jadis (who later becomes the White Witch) view the magic fertility of Narnia’s land much like this “gadget”—it is something they can abuse for their own gain. In Narnia and the Fields of Arbol: The Environmental Vision of C.S. Lewis, Dickerson and O’Hara write that “Jadis and Uncle Andrew are so accustomed to abusing creation, and so used to the abundance of things, that they cannot appreciate the scene of creation”  are the two long poems to wh. [sic] I most often return” . To Wordsworth, learning fostered by both nature and imagination is essential for proper human development—this is what prevents children from developing what we today may call nature-deficit disorder. It is only when young Wordsworth is at home, away from the sterile education system, that this process can take place.Etcherling’s analysis of Lewis’s environmental attitude also overlooks his relationship with William Wordsworth’s poetry. Lewis’s appreciation for the poet and how he shapes his view of nature’s role in education is well established in t” Gill, , p. 66, t” Gill, , p. 66. Surprised by Joy. While his parents “cared for no poetry at all” . Lewis was also a voracious reader as a child, and just as Wordsworth links reading Arabian Nights to sitting outside by the stream in Prelude, Lewis connects reading to nature, claiming that he “had the same certainty of finding a book that was new to me as a man who walks into a field has of finding a new blade of grass” (p. 10). Lewis then shares three of his own imaginative episodes that he claims defined his life, allowing him to develop a sense of wonder about nature that he believes is essential for proper imaginative development. He writes, “the reader who finds these three episodes of no interest need read this book no further, for in a sense the central story of my life is about nothing else” (p. 19), further emphasizing their importance in both his personal and educational philosophy. The first episode is the “memory of a memory” of his brother’s toy garden, and the second is a glimpse that came through reading The Tale of Squirrel Nutkin, which he sayspossess Autumn?) but to reawake it. (p. 18)…troubled me with what I can only describe as the Idea of Autumn. It sounds fantastic to say that one can be enamoured of a season, but that is something like what happened; and as before, the experience was one of intense desire. And one went back to the book, not to gratify the desire  and desire “with almost sickening intensity something never to be described… and then, as in the other examples, found myself at the very same moment already falling out of that desire and wishing I was back in it” (p. 18). This desire echoes Wordsworth’s “visionary gleam” that he famously describes in “Ode: Intimations of Immortality from Recollections of Early Childhood,” and Lewis indeed calls this desire a “visionary gleam” (p. 291) in the final pages of Surprised by Joy. For both writers, nature, imagination, and reading work together to produce this visionary gleam, or the sense of wonder that Lewis attaches to nature in Narnia. It is also the same sense of wonder for which Louv advocates in Last Child in the Woods. This imaginative wonder is, as all three writers argue, essential to a child’s proper education, transforming young learners into good citizens that help move society forward.Lewis expresses similar views in his own autobiographical work, ” Lewis, , p. 4, hNarnia and The Abolition of Man. Imagination is necessary to enjoy Narnia fully, as Lewis notes in the dedication of LWW. He tells Lucy Barfield that at the time of the book’s publication, she is too old for fairy tales, but that “some day you will be old enough to start reading fairy tales again”  leads his siblings to begin their Narnian adventure with a sense of great pleasure. However, Edmund’s selfish and jealous attitude is in need of acute transformation, and through Aslan’s rescue and ultimate sacrifice, Edmund’s heart changes for the better as the long Narnian winter melts.From Professor Kirk’s first exclamation of “Why don’t they teach logic in these schools?” Lewis, , p. 48 iLWW, the Pevensie children grow up in Narnia and exit the Wardrobe as changed people, but it is in Prince Caspian (PC) where Lewis truly marks their time in Narnia as a rejection of their formal education, demonstrating that it is not only the “bad” children (like Edmund once was) that need to be re-educated in nature, but also the generally good children like Peter and Lucy. In PC, all four Pevensies are drawn into Narnia just before catching the train to go to back school after the summer holidays, explicitly interrupting their British formal educational experience. Once they arrive in Narnia, they spend time traveling through the woods (which the ruling Telmarines are too afraid to enter) to meet the rebels at Aslan’s Howe. In Planet Narnia, Michael Ward notes that in PC, Peter and Edmund do “not simply harden, [but] become knightly” . Peter’s mature response to the news and the understanding he develops demonstrates that his and Susan’s re-education is complete—they are now charged to permanently leave Narnia and live as good citizens in our world. While it seems Peter was more successful at this than Susan, who eventually stops believing in Narnia, it is clear from this episode that the children of our world’s time in Narnia has a specific purpose, and once that purpose has been fulfilled, their visits come to an end. This idea, too, models what Lewis designates as the true benefit of reading fairy tales as children in “On Three Ways of Writing for Children”—such reading “stirs and troubles him (to his life-long enrichment) with the dim sense of something beyond his reach and, far from dulling or emptying the actual world, gives it a new dimension of depth” (Surprised By Joy p. 291) that Lewis believes is essential to proper moral development.In y” Ward, , p. 89, ” Lewis, , p. 164 f depth” , p. 57. f depth” , p. 57. PC, though, Lewis explicitly ties this new moral development to a replacement of their previous education in our world, as Susan and Lucy romp through Narnia with Aslan to physically tear down and replace the Telmarine English-style school system. Since the children left Narnia, the Telmarines (who originate in our world) have invaded and taken over, converting Narnia into something very similar to England: they have built bridges over the rivers (imprisoning the river spirits), pushed the “old Narnians”  into hiding, and set up English-style schools for human children to attend. As Aslan, Susan and Lucy, and a host of “old Narnians” run through Narnia to free her from Telmarine rule, they come upon a girls' school, “where a lot of Narnian girls, with their hair done very tight and ugly tight collars round their necks and thick tickly stockings on their legs were having a history lesson” Aslan quite literally replaces the Telmarine institution of education with nature, indicating that it is among green grass and rosebushes where children can truly be educated. All the girls in the school flee except for Gwendolyn, who is freed from her uncomfortable school clothes and allowed to join the romp. As Aslan’s party travels through the town of Beruna, more symbols of this dry “education” system are converted into natural imagery: a boy being whipped finds that his oppressor has been turned into a tree, and a flock of unruly, piggish schoolboys is turned into actual pigs. As to not limit the availability of a natural, true education to only imaginative children, Aslan also frees a teacher from her duties at the boys' school just as he freed Gwendolyn, because she too saw him through the window and had enough imaginative power to understand the true nature of the “divine revelers” (p. 188). The education system in Beruna has been entirely replaced with natural imagery, and Gwendolyn and the schoolmistress are now free to learn imaginatively as they follow Aslan in his run through the green environment of Narnia.This type of education directly corresponds with the system Lewis criticizes in ” Lewis, , p. 187 The Voyage of the Dawn Treader (VDT), they arrive prepared to experience all of nature’s joys, even as the magic picture transports them directly into the Narnian ocean rather than dry land. Despite being cold and wet, Lucy feels “quite sure they were in for a lovely time”  after Caspian rescues him from the sea. At the beginning of VDT, Eustace is a perfect product of his English school system—a “victim of his education”  and has contempt for more “primitive” (p. 35) ships like the Dawn Treader that leave passengers exposed to the elements. Lewis’s view of modern technology was generally negative—to him, technology “refers to the increasing separation of humanity from nature brought on…by the application of the scientific method to all aspects of human life” . His experience on a boat devoid of technology, at the mercy of the natural sea and wind, has prepared him to be transformed by Aslan by cultivating the imagination necessary to learn from this experience. Eustace then apologizes to his companions and develops a new appreciation for both them and the environment they continue to explore. By the end of the chronicle, people “back in our own world soon started saying how Eustace had improved, and how ‘you’d never know him for the same boy’” (p. 223), demonstrating just how drastically his Narnian re-education has transformed him for the better.In ” Lewis, , p. 98 tVDT, Aslan uses him and Jill to dismantle another example of Lewis’s contemporary schools in The Silver Chair (SC), Experiment House, which is an example of what “progressive” schools were like during Lewis’s time . Just as he destroyed the English-style Narnian school in Prince Caspian, Aslan destroys the negative parts of Experiment House through nature and imagination. After this task is complete, “things changed for the better at Experiment House, and it became quite a good school” (p. 221). To Lewis, children cannot be properly educated without developing an appreciation for nature, and his disbandment of his “traditional” contemporary education systems marks him as a progressive, pro-environmental educator.After Eustace’s transformation in me Ford, , p. 363.MN. In this chronicle, Aslan clearly puts man in charge of creatures and nature in Narnia, instructing Frank the Cabby and his wife, Nellie, to “rule and name all these creatures, and do justice among them, and protect them from their enemies when enemies arise” While Louv concedes that many people would feel uncomfortable with sharing their morning commute with wildlife, he reminds readers that “a de-natured urban or suburban environment is not good for children or the land” (p. 249). Louv is not arguing that urban planners need to destroy bridges like Aslan does in PC, but in order to save children from the damaging effects of nature-deficit disorder, urban and suburban citizens must become comfortable with a more symbiotic relationship with their natural surroundings.Just as his time on the graders” , p. 206.in the present study, the frequency of vicarious experiences of nature, as well as that of direct experiences, was positively associated with children’s affective attitudes toward local biodiversity. This result suggests that, in circumstances where a given amount of natural environment cannot immediately be preserved within the home ranges of children, vicarious experiences could, to some extent, be used as a subsidiary tool in attracting their interest in and care for biodiversity. (Soga et al., It is important to note that this study was conducted in the heavily urban environment of Tokyo, proving that even children who grow up surrounded by concrete instead of forests can develop a positive and productive view of nature. Additionally, the children in this study did not associate nature with “fear and apocalypse” (Louv, Squirrel Nutkin, developing the sense of imaginative wonder that Louv prescribes as necessary for a healthy childhood. Reading books like Narnia, which are so full of natural imagery and respect thereof, can also lead to the development of an appreciation of nature, not in the dry, scientific way that schools often teach, but in a manner that allows children to exert their imagination and avoid the symptoms of nature-deficit disorder.While nothing can replace time spent directly in nature, new research suggests that vicarious experiences—such as encountering nature through reading—can help alleviate symptoms of nature-deficit disorder as well. Stephen R. Kellert, the Tweedy Ordway Professor Emeritus of Social Ecology at Yale , p. 135,e” Louv, , p. 134 Narnia is of course not the only children’s series that can provide children with vicarious natural experiences, but it provides ample examples of children transformed by green, imaginative learning that irrigates the deserts of their minds and replaces the dry, sterile education they have received thus far. Louv, Lewis, and Wordsworth all provide a progressive window to what good, nature-infused education can be, and if twenty-first century educators can implement the ideals they prescribe, the next generation of students will not only be better behaved, more well-rounded, and healthier overall, but they will also be better environmental stewards ready to fully address our global climate crisis.This idea that both direct and vicarious experiences with nature are necessary to a proper education has greater implications than even ensuring healthy child development. Louv writes that “reducing that deficit—healing the broken bond between our young and nature—is in our self-interest, not only because aesthetics or justice demands it…the health of the earth is at stake as well” , p. 6. W


Child to parent violence is a significant concern that has been researched over the last sixty years. However, little is known about the help-seeking pathways of parents experiencing child to parent violence (CPV). Barriers and enablers to disclosing CPV have been explored, and responses to address CPV have been nominally researched. The mapping of a disclosure to a choice of where to get help has not occurred. This study seeks to map help-seeking pathways of mothers and considers these pathways in regards to the relations within families and sociomaterial conditions.n = 11) who experience CPV, and practitioners (n = 19) who work with families experiencing CPV.This narrative inquiry utilizes response-based practice and Barad’s concept ‘intra-action’ to examine interviews with mothers (Five help-seeking pathways of mothers are found in this study. Three themes evident across the pathways are explored including: (1) help-seeking within pre-existing relationships; (2) mothers’ feelings of fear, shame and judgement entangled with help-seeking; and (3) conditions which enable and hinder help-seeking from family.This study finds sociomaterial conditions such as single motherhood and judgement limit help-seeking possibilities. Further, this study finds help-seeking occurs within pre-existing relationships along with the entanglement of CPV with other issues such as intimate partner violence (IPV) and homelessness. This study demonstrates the benefits of employing a response-based approach alongside ‘intra-action’ within a research and practice context. A child’s violence towards their parent (CPV) is a complex phenomenon. CPV, also known as adolescent family violence, has various definitions ranging from a specific act, to patterns of behaviors, and more often refers to physical violence  recognizing a problem; (2) making a decision to seek help; and (3) deciding from who/where to seek assistance  how does the intra-action within family and sociomaterial conditions influence help-seeking? This paper begins by exploring the theoretical framework and methods for the study. The findings are then outlined, followed by the discussion which incorporates limitations and implications for research, education and policy.Help-seeking pathways for CPV has been minimally researched. The research thus far tends to sit in two strands. One strand explores barriers to help-seeking, while the second strand examines the usefulness of responses. A research gap sits between these two to understand help-seeking pathways, such as exploring how a parent ends up at a mental health service for CPV. To the authors’ knowledge there are no studies which map the journey a parent undertakes for seeking help nor studies which consider the influence of sociomaterial conditions or relations within families. Sociomateriality connects the human to the material, that is the objects and contexts, positioning these as co-emerging with agency forming and re-forming in this connection Hultin, . This stThis research is situated within an emancipationist paradigm Lather,  and drawResponse-based practice is an approach utilized in professions such as social work and sits in the theoretical frame of this research. Response-based practice is a way of viewing violence, whereby resistance is seen as always-already present. This study posits help-seeking is one act of resistance. Response-based practice alters the binaries of victim and perpetrator through elucidating the sociomaterial conditions  in which the social interaction occurs  child was under the age of 18 at the time of using violence and (2) parent’s self-defined the violence as CPV, and their definition was explored in the interview. The criteria for practitioners was experience working with CPV. This experience may have been working with parents, children or both. Mothers were offered the choice of pseudonym for the research, and all practitioners were assigned a pseudonym. The location of the interview as well as day and time was selected by the participants  and practitioners (n = 19) from across rural (n = 14) and metropolitan (n = 16) areas of Australia were interviewed. Practitioners identified as female (n = 15) and male (n = 4). Although parents were invited, all parent participants identified as mothers and thus the pathways are explored as pathways of mothers. Fields of practice represented by practitioners include homelessness, family and children, mental health, private practice, and women’s services. Practitioners’ professional backgrounds include social work, psychology, family counselling and community work. Children using violence were identified by their mothers as male (n = 8) and female (n = 6) with an age range of eight to eighteen. Eight of the mothers identified as having experienced IPV from a previous partner. Of these participants, eight practitioners participated across two co-analysis discussions .Mothers actions of a child.Pathway five is an entangled pathway of help-seeking. The help-seeking for CPV is not separate from help-seeking for other issues. Sometimes parents seek help for other issues such as IPV or homelessness, and the issue of CPV arises after trust and rapport is established with the practitioner. Other contexts in which the issue of CPV may arise, in this pathway, are issues of school refusal, mental health issues or as Karen, a practitioner, indicates “I just couldn’t comprehend doing the same with my son”. This entanglement with a mother’s experience of IPV was also explored in the co-analysis discussions, where Richard, a practitioner, explains,“Yeah, some of the hardest things to bear witness to is the crying mother, who says, ‘Here it goes again. I put up with all this crap from their dad, and now my son is doing it’ and that’s that intergenerational cycle and the helplessness and hopelessness that they’re expressing is pretty touching, pretty heavy”.In this pathway, the violence of the child is often bound up with the mothers’ experience of IPV from a male partner. Kathryn describes wanting to respond differently to her son’s violence than she did to the violence from her partner and this is why she sought help, , “and actually Erica [practitioner] was there and she had a talk to Gabrielle and ended up sending her out, all nice and calm, that really helped.”This pathway is the only pathway which includes practitioners identifying CPV. Practitioners may witness violence occurring such as during appointments. Leanne, a mother, discusses violent (en)actions by her daughter while residing in a refuge and the way in which the practitioner witnessed and intervened“So pretty much every child does, at some point, attend a school. And certainly in my experience, it’s often where violent behaviors are first seen or starting to be seen which is then fed back to the family, and that could prompt for parents to then start asking these questions of seeking help somewhere”.There were mixed findings in the role schools play in identifying CPV. Some practitioners felt schools were missing from this pathway, as Richard, a practitioner, discusses,“I think a lot of the time these are behaviors that just happen in the home and that school would have a totally different behaviors”. No mothers report school being a pathway for help with CPV.However, other practitioners such as Rachael feel CPV is only within the home This pathway includes only formal supports. Families may continue to work with services already engaged with for other presenting issues, or in some cases were referred to new services to respond to the issue of CPV.In this section, the themes across the five help-seeking pathways are explored. These themes illustrate sociomaterial conditions which emerge with and in help-seeking for CPV.“I rang Susan from [a family and youth service] and ‘cause I…I know her”. All help-seeking was sought from people with whom family member(s) had previous experience with or a current relationship. Laura, a mother, when travelling pathway two seeking a diagnosis to explain her son’s violence, elucidates the value of the pre-existing relationship to justify why she chose her GP,“So I've always – my doctor is awesome. He has a really good connection with Matthew. He's been his doctor since he was born. He does say to me if Matthew ever needs to come for a chat, just to touch base ‘cause he's more than welcome, just to make an appointment, come and have just a general chat about things. But he sees his behavior sometimes, he knows how difficult it is for me at times. So he's a very supportive doctor, which is nice.”Intrinsic to all help-seeking pathways in this study, is a pre-existing relationship with the person. Amy, a mother states “So, I always find that by the time clients get to me, it’s pretty intense and it’s pretty bad. Like they’ve been everywhere else, and by the time they find myself or other clinicians, it’s completely and utterly out of control… So they’ve usually been putting up with this for a long period of time”.Practitioners identify a concept of late help-seeking. April, a practitioner states,This quote is representative of practitioners who feel families attend their service after the violence is entrenched. The finding of help-seeking occurring within pre-existing relationships supports this idea of late help-seeking. Firstly, mothers discussed the internal options they personally used themselves, in an attempt to address the violence prior to engaging external supports. As such, while it may seem help is sought late, in fact they have been actively seeking to address the issue themselves. Secondly, parents may have sought help from other supports within their pre-existing relationships. These relationships may have connected or alerted them to the practitioners whom participated in the research, resulting in these practitioners feeling the help is sought late.“the amount of psychologists and services that come up is overwhelming, that there’s too many numbers and they don’t know where to go or which one’s the right one”. April, a practitioner in a rural area, discusses,… this is such a context of being in a rural-remote area, that either they don't think the service exists or the specialists to help them untangle this is so busy that it's such a long wait, that by the time they get to us, it's quite difficult. No one would ever find me in a small rural-remote town by Google, because our anonymity…”“Barriers for seeking help outside of pre-existing relationships are also found in this research. The use of technology to search for services limits possibilities of help-seeking for CPV. Practitioners indicate parents may not know which keywords to use when searching online for services. Rachael, a practitioner in mental health, explains another issue with searching online, This quote is symptomatic of the complexities practitioners highlight of using online searching to find services for CPV. Mothers do not report using technology to locate services, and instead relying on their pre-existing relationships for most services in the pathways.“…please don’t report this. Please don’t write this in your clinical notes”. Here, the fear is a concern for consequences for the child using violence and limits the mother’s capacity to talk about the violence she is experiencing. This feeling of fear is also reported by practitioners. Karen, a practitioner, explains some fears mothers have indicated to her such as, “I don’t want them getting in trouble, or ‘they’d think I’m a dog if I dob them in’ and ‘the families gonna be angry with me’. Rachael, a practitioner in mental health, also said fear of ramifications include what would happen if mothers were to disclose “…often [mum] is nervous about telling anybody about it because doesn’t know what’s gonna happen”. Rachael elaborates, discussing the feelings of fear and shame indicating all families she has worked with experiences this feeling,“I don’t think I’ve met a single family where there isn’t fear and shame involved, when there’s child to parent violence involved… There’s usually a heavy level of defensiveness initially, and sometimes outright aggression that other services are suggesting there’s a problem. But underneath that and when you get to know them, there’s a lot of tears and a lot of fear and a lot of shame and that does act as a barrier to help-seeking and they’re often really afraid of what will happen to them as a parent and what will happen to their child”.Mothers’ feelings of fear and shame are entwined with their decision to disclose their child’s violence. Louise, a mother, states when she disclosed CPV to a practitioner she asked, “I think as a single mum, I feel like people are gonna judge me and say well his behavior’s based on you, which is probably stupid to think that, but that’s how I see it”. This quote is representative of judgement mothers feel, and limits the possibility of seeking help. Fear and judgement are intensified in rural areas, as Louise, a mother, explains “they had…no rigorous privacy policies for a small town and safety” limiting the options available for help-seeking. Tanya, a practitioner working in a small community, similarly discusses this concern in the co-analysis discussion,“When there is violent behavior and everything there’s almost a secretive element that I see, so a very big part of ‘why is my child acting this way’, but it wouldn’t be always going to a psychologist or pediatrician, it would be only really talking to friends and family because of the stigma associated to it”.Mothers perceive they will and had experienced judgement when disclosing CPV, limiting ability to disclose the violence. This concern is exacerbated by the sociomaterial condition of being a single mother. Laura, a mother, explains Here, the sociomaterial condition of rural areas and small communities co-produce limits to help-seeking for CPV. The supports in a persons’ network is limited by this small community. The material elements, such as formal supports, of the sociomaterial context limit the means through which mothers can seek assistance for CPV.I feel like if I spoke to my mum and dad about it, which I wouldn’t anyway, they just wouldn’t deal with it”. Other mothers spoke about potential issues this would create in their parents’ relationship with their child, as Linda explains, “I don’t tell my mum anything because she then takes it out on Morgan”. Karen, a practitioner, spoke about a challenge parents may experience when disclosing the violence to other family members, “But I have found quite often that family members can be – kind of reinforce the status quo with the family dynamics. So, sometimes they’ll undermine the mother by blaming the mother as well, like a grandparent”. Here the perception and experience of a negative social response from the family of mothers, is entangled with help-seeking. This social response limits the options to consider and is implicated in the experience of seeking help.Considerations for choosing to disclose CPV to other family members such as parents and siblings of the mother were discussed in interviews with mothers. Mothers, such as Kathryn, identify feeling their parents won’t understand their issues or know how to respond, ““She’s a godsend my mum. I’d be lost without her. And we [siblings] all look out for each other, that’s just the way we were brought up”. The sociomaterial conditions of family in this example, the feeling of closeness together, co-produces the possibility of help-seeking within a family context. The perception of a positive social response enables the possibility to ask for help for CPV.Mothers, such as Laura, indicate family is a good support for CPV and details her family’s closeness as a reason why, n = 8) experienced IPV in the past, with some of this enacted by the children’s fathers. The effects of the absence of the father is amplified in the mothers’ experiences of violence, whereby the absence is still influential on the mothers’ relationship with her child and perceptions of gender and safety. Richard, a practitioner, in the co-analysis discussion provides a symptomatic quote of practitioner views in relation to the absent father, “I’m asking, ‘Where’s the father in all of this?’ If we’re looking at attachment issues, and the first 2000 days, ‘Where’s the father, or the other parent for that matter?’ It takes two to tango to make a baby, where are the two parents or adult role models?’ The sociomaterial condition of fathers who use violence makes it difficult for the mother to engage the father as a support for CPV. Single motherhood in this view, limits the options of pre-existing relationships to draw for support. While other male family members may be available, only three mothers identify approaching males for assistance of which one was a brother, and two were current partners.A notable absence in the help-seeking pathways is the option to engage the child’s father for help. Many of the mothers actions of a child are such that outside help is required, is a challenge for CPV. There is an accepted level of violence from teenagers towards parents, such as Holt  states iMothers experience of both IPV and CPV has been identified in the literature with a recent review terming this “the intergenerational nature of domestic violence” actions of a child towards a mother. “Parenting surveillance” is a phenomenon experienced in refuges, whereby mothers who leave a violent relationship and temporarily reside in a refuge, report scrutiny and regulation applied to their parenting  survey (cited in Holt, Meyer  found soThe reluctance to engage police for CPV has been found in other research (e.g. Fitz-Gibbon et al., Fathers were absent from help-seeking pathways in this study. Although limited by all the parents interviewed being mothers, the complications of safety for parenting with a father who uses violence towards the mother is present in this study. The conflict of the perceived need for both parents to play a role in child rearing, equally alongside the need to protect children from harm Simmons, , is presA strength of this current study is the theoretical framework and methodology. Notably, the inclusion of co-analysis discussions provided depth of analysis in the study. The conceptual frame for the research, utilizing response-based practice and intra-action, provides a structure to elucidate new knowledge. Aligning with Barad  to not pThe findings of this study should be considered in respect to the limitations. First, the sample size for this research was modest and COVID-19 impacted recruitment. Second, although limited by the cross-over of participants, as practitioners aided the recruitment of parents and thus parents had attended services of practitioners, there was diversity of practice experience drawn on for the research and not all practitioners connected parents with the research. Third, as this study included remote data collection over phone and Zoom, mothers’ may have constrained stories of violence due to other family members being present. Finally, the study is limited by the help-seeking pathways not being temporally mapped.The findings from this study propose a range of implications for practitioners, research and education. First, practitioners should consider their framing of the violence in respect to family relations and responsibility for the violence. Consideration should also be given to parents framing of the violence, in respect to both family relations and responsibility. Practitioners should consider CPV may arise within the context of other issues, may not be the presenting problem when families seek help, and time may be needed to establish a relationship before a disclosure of CPV. Practitioners should be aware of the intra-actions with/in help-seeking for CPV. The heightened risk of violence present in a pathway of seeking help from police needs to be considered by practitioners. Practitioners should consider the sociomaterial conditions which make possible and impossible the help seeking of parents, notably: a rural location or small community; experience of IPV; negative perceptions of social responses; and the need for help-seeking to occur within a pre-existing relationship. Practitioners ought to consider the additional surveillance in refuge settings. Practitioners should acknowledge they are a part of a mothers’ pre-existing network when asked for help, and even if they are unable to deliver a response within service capacity, the support offered at this point may enable or impede further help-seeking.Second, research is required to identify what role schools may have in identifying and responding to CPV. Further research is required to explore the connection between CPV and other violent behaviors. The ‘threshold’ of violence gap identified in this study requires further research. The implications of practitioner identified CPV warrants examination, as well as if and how this influences the acceptance and willingness of parents to engage in responses for addressing CPV.Third, training should be provided to alert practitioners to perceptions and experiences of judgement entangled in the help-seeking for CPV. Training should be provided for practitioners to build relationships in the context of help-seeking for CPV. Further research and training is needed to investigate appropriate responses to CPV, which may in turn alleviate feelings of shame, fear and judgement that limits a mothers’ help-seeking for CPV.This current study suggests five pathways are traversed by mothers when seeking help for CPV. The analysis points to the pertinence of pre-existing relationships in help-seeking for CPV. The entanglement of CPV with other issues such as IPV, homelessness and school refusal is further elucidated in this study along with concerns of fear, and judgement when seeking help. Incorporating a response-based lens and ‘intra-action’ provides scope for new insights in this current study. Further research to identify the ‘threshold’ for seeking help in CPV is required, alongside the framing of responses from practitioners when parents present to them for help with CPV.