Ethical management with minimum moral distress is one of the main duties of nurse managers. There is no doubt that a better understanding of the experiences of nurse managers in morally challenging situations could have an effective role in improving health care systems. The present study aimed to investigate the lived experiences of clinical nurse managers regarding moral distress. This hermeneutic phenomenological qualitative research involved the use of semi-structured interviews with nurse managers. The interviews were transcribed and analyzed by the Diekelman, Allen and Tanner approach. For this purpose, a total of 14 Iranian nurse managers with at least five years of experience in nursing management in hospitals were purposefully selected. The findings related to nurse managers’ experiences of moral distress contained two main themes  and four sub-themes .The findings of the study indicated that in order to understand the phenomenon of moral distress among nurse managers, it is essential to investigate the moral distress experienced by them. We also found that although they experience moral distress in their daily decisions repeatedly, they are not fully aware of this phenomenonAccording to the results, for clinical nurse managers, moral distress is an ambiguous situation like suspension along with uncertainty, fear and so on. They believed that experiencing this kind of conscious mistake is the reason for the occurrence of professional desperation syndrome and psycho-emotional trauma. Moral distress is a kind of response by human beings to a situation in which the individual is prevented from performing or following-up a right, moral act. In general, moral distress is a psychosomatic phenomenon that would cause a feeling of discomfort and dissatisfaction in the individual at any time . Since mThe importance of moral distress in nursing practice has been mentioned in various studies and has been discussed in the American Nurses Association and North American Nursing Diagnosis Association , 9. MostStrategically, nurse managers have a unique position in the health system as their actions, behaviors and decisions have the greatest impact on their work environment and the profession in general , 20. A mRespecting moral standards for decision-making is associated with tension in every field  - 25. EtIt is clear that managerial levels affect all stratums of care. Therefore, nurse managers require an environment free from tension and distress so that they can achieve effective care outcomes and job satisfaction along with the rest of the medical team , 28.In the reviewed national and international articles published between 2005 and 2016, no comprehensive report was found on nurse managers’ experiences of moral distress. However, some studies have shown that when clinical nurse managers encounter moral challenges and conflicts, their responsiveness to their organization, colleagues, and patients and their families will be affected . A revieIn fact, picturing the lived experiences of clinical nurse managers in their occupational context can help their managerial group resolve the moderator obstacles to moral distress. As a result, they will be able to make more appropriate moral decisions and decrease their moral distress. The most important product of phenomenology is gaining insight into a phenomenon, which adds to the nursing profession's knowledge in this field. Considering that ethical decision-making by nurse managers is the most important aspect that affects the overall quality of nursing care, this insight can increase nurse managers' ability to fulfill their management role in a more effective, holistic and comprehensive manner by enhancing the power of moral reasoning.The present study was based on qualitative research. The author used hermeneutic phenomenology to find an appropriate answer to the research question about clinical nurse managers’ lived experiences of moral distress.Participants in the present study were 14 clinical nurse managers including matrons, supervisors and head nurses. Participants had at least five years of nursing management experience in hospitals, and therefore boasted rich experiences of the subject. The study was performed in places where the participants lived their professional lives as clinical nurse managers. Interviews were conducted in the teaching hospitals affiliated with Tehran University of Medical Sciences.In the present study, the main method of data collection was in-depth semi-structured personal face-to-face interviews. Interviews lasted from 40 to 75 minutes. Fourteen participants (six men and eight women) were selected based on the mentioned criteria and using purposeful sampling method. The effort was to select participants with maximum diversity. The topic of the study was rather subjective and required pre-contemplation on the part of the participants to understand and remember the experiences. Accordingly, the researcher visited the study environment one week before every interview and gave the prepared narrative paper to the participants to ensure their understanding of the study topic. This paper included the title of the study, its aim, and definitions of the words and concepts. Also, it requested the participants to explain one of their experiences of moral distress in detail. On the day of the interview, the completed papers were gathered so that a comprehensive analysis could be performed on the data at the same time the data transcription took place. Interviews started with open questions such as “What comes to your mind when you hear the term ‘moral distress’?” or “What does moral distress mean to you?” Then the interviews continued with more focused questions in line with the topic of the research, which was the nature of clinical nurse managers’ lived experiences of moral distress. Four of the participants needed to be interviewed twice to clarify the ambiguous points in their first interviews.Data AnalysisData analysis was performed in line with the aim and method of the study using the Diekelmann, Allen and Tanner method (1989), which is a seven-stage process based on hermeneutic phenomenology . AccordiEthical ConsiderationsThe study protocol was approved by the IRB of the Tehran University of Medical Sciences; register number 9323199001. We provided the necessary information about the goals and method of the study to the potential participants and obtained their written informed consent at that time. The participants also provided permission for recording the interviews; moreover, they were reminded of their right to withdraw from the study at any time and were assured that their confidentiality, including anonymity and data protection, was valued. Study RigorConcepts of credibility, confirmability, auditability and transferability were used for maintaining the rigor of the study , 37. CreThe findings related to nurse managers’ experiences of clinical moral distress contained two main themes and four sub-themes. These themes were the result of 18 interviews with 14 participants. The main themes were psycho-emotional trauma and professional desperation syndrome. Psycho-emotional trauma contained the subthemes of shame and emotional dissociation. The second main theme was professional desperation syndrome, with the subthemes of helplessness and impaired professional identity.Main Themes:Psycho-Emotional Trauma:Psycho-emotional trauma was one of the main themes of moral distress among clinical nurse managers, and contained the subthemes “shame” and “emotional dissociation.” This theme indicated that clinical nurse managers’ experiences of moral distress had been associated with resentment, self-blame, and lack of peace of mind. Furthermore, some of the managers mentioned a kind of moping and embarrassment that accompanied them at all times. They also stated that tolerating the pressure for a long period would lead to breakdown and collapse.   a)     ShameThe first subtheme was shame, which is defined as feeling embarrassed or guilty because of one's actions, characteristics, or associations. In this regard, nurse managers from various levels stated that when an individual knows right and wrong but is forced to do the wrong thing for organizational reasons or on account of the work environment and lack of supportive laws, he or she will experience incomprehensible and constant pressure. It feels like constant self-blame and embarrassment, and will interrupt one’s professional performance.In this regard one of the managers stated:“For example, I may have a good opinion of anemployee and believe that he or she has an appropriate professional behavior, but when that person is punished by one of the supervisors, even though I know the employee is right, I cannot defend him or her and have to stay quiet. This will make me blame myself constantly. I feel stuck in a weak position and under great pressure.” [Participant No. 3]Similarly, another participant stated:“On one of my work days, the ambulance brought in a 70-year-old man and immediately started CPR on him by order of the emergency physician who was also one of the shareholders of the hospital. After the patient died, the physician ordered his secretary to admit him in the critical care unit. I could not refuse the orders because if I did, I would be fired. Whenever I think about it, I feel like something is stuck in my throat that I cannot get rid of, and I can’t speak to anyone about it either…” [Participant No. 5]   b)     Emotional DissociationOne of the extracted subthemes confirmed by the participants was “emotional dissociation”, which is a feeling of isolation, emotional management problems, sudden and unexpected conflicts, depression or anxiety. Participants expressed their general understanding and impression of the experienced moral distress through terms such as breakdown, collapse, conflict, contradiction and so on.“In the nursing profession, every day is filled with distress. For example, a physician visits a patient every day, and I know that the patient does not need daily visits, but the physician does it for financial reasons; I cannot object to this behavior because the entire system is working this way. This makes me break down silently every day from the inside” [Participant No. 11]Another participant mentioned that their experience of distress was a constant conflict and contradiction between learning and performance and stated:“I have been the head nurse for a long time. Sometimes we have patients who should undergo chemotherapy, and you know that chemotherapy drugs should be prepared in the incubator and under the fume hood. I know that without the necessary equipment, this procedure could threaten my nurses’ health, but I ask them to do it anyway. I know that it is completely wrong, but there is no other way. I have talked about this to the higher managers several times, and they have responded that we cannot afford the costs for a couple chemotherapy patients a month, and I cannot stop the treatment. But when I see the blisters caused by drug preparation on the nurses’ hands, I feel distressed and conflicted for several days” [Participant No. 9]Professional Desperation Syndrome:Another main theme that emerged was “professional desperation syndrome”, which is a feeling of despair and hopelessness, and typically one that results in a certain behavior. This main theme contained the subthemes of “helplessness” and “impaired professional identity”. It is clear that desperation at exhibiting professional behavior has become a disturbing issue in the nursing profession.   a)     HelplessnessHelplessness, which is a feeling or state of despair, or lack of hope, is one of the subthemes of desperation in performing professional behavior. Participants used the following phrases to describe their experiences of moral distress: loneliness, the sense of being in a black hole, isolation, self-absorption, and depression.“I was a manager in a center for lung transplant. The night before this particular case of transplant, a nurse from the medical human resources was assigned to the patient, and the physician went home. The charge nurse also took the day off, so a nurse with one year of work experience stayed with the patient. When we arrived at the center in the morning, the patient was deceased. While I was writing a report for the forensics office, I was stopped by theChief executive officer of the hospital, who was one of the friends of the physician in charge. There, I felt the worse kind of mental disturbance. I was filled with distress and desperation. I will never forget that day. Even as I think about it now, I feel completely drained” [Participant No. 14]Another participant also described their experiences of moral distress with concepts such as exhaustion and disability:“Occasionally, personnel should perform a procedure for the patient, such as dressing. But they did not have. You know that they overlooked it and performed the wrong action, so you should be on the patient’s side. On the other hand, if you say this to the patient, there will be trouble. The complaints and the [possible] refusal to pay the costs… it can get complicated. It might even cause the personnel to get fired. In such situations, I feel worried and mentally disturbed. My brain stops working, and I feel disabled for not reporting the incident” [Participant No. 9]   b)     Impaired Professional IdentityImpaired professional identity means diminished professional self-concept based on one’s attributes, beliefs, values, motivations and experiences, and was the second subtheme of desperation in performing professional behaviors. Regarding their experiences of moral distress, one of the participants said:“Sometimes it happens that the patient does not need hospitalization, but has been hospitalized in the ward for a long time by the physician’s order; or the patient receives daily visits while we know that these visits are not necessary. We just have to close our eyes and ignore these things and not report them. Here, we think we are incompetent in our profession, because we feel incapable and dishonest. This feeling eats you from the inside and will get worse every time you confront such situations” [Participant No. 4]Another participant said about their experiences:“There was once this person who applied for a job with us, but had not completed the medical human resources program and was still a student. We were not legally allowed to hire that person, but you know, due to a shortage in the nursing staff, we hire whoever comes for employment, unless they are really not qualified. Whenever I hire someone like this, I feel irresponsible toward my patients. These issues cause distress and exhaustion in me. But now I am used to the feeling, because I have no other option” [Participant No. 10]In order to understand the phenomenon of moral distress among nurse managers, it is necessary to investigate the moral distress experienced by clinical nurse managers. Although clinical nurse managers repeatedly encounter moral distress in their daily decisions and duties, they are not fully aware of the phenomenon . An examThe first main theme of the present study: As one of the main themes in the present study, “psycho-emotional trauma” has provided a clear image of nurse managers’ experiences of moral distress in their profession. The subthemes of “shame” and “emotional dissociation” are correlated with each other and with the main theme, and certainly confirm it. The term “psycho-emotional trauma” was selected due to the mental and emotional damage that nurse managers endure upon experiencing moral distress. Psycho-emotional trauma may not only lead to burnout in managers, but it can also cause them to lose motivation and quit their job.The first subtheme of psycho-emotional trauma was “shame”. In their study “Moral Reckoning in Nursing”, Nathaniel stated that nurses who are forced to take the wrong action despite their knowledge and awareness will experience self-blame, shame, embarrassment and regret . The resThe second subtheme was “emotional dissociation". This subtheme entails conflict and contradiction. Clinical managers described their experiences of moral distress using words and phrases such as breaking down, collapsing, conflict, contradiction and duality, inconsistency and conflict between learning and performance, paradox, and emotional destruction. When clinical nurse managers know what the right act or decision is but they are forced to commit an immoral act, their emotional integrity is damaged and they may consider quitting the nursing profession. In fact, the sense of conflict and paradox is like an alarm for managers that something is wrong. Hendel et al. has defined conflict as an internal inconsistency rooted in thoughts, values or emotions . In a quThe second main theme of the present study: The second main theme was “professional desperation syndrome”, which contained two subthemes of “helplessness” and “impaired professional identity”. Christodoulou-Fella et al. and Meltzer and Huckabay conducted a study about the factors influencing burnout and exhaustion in nurses as the main reasons for quitting the job. They stated that stressful work environment, moral or emotional distress, mental and emotional disturbance, exhaustion, lack of motivation, lack of professional self-esteem, inability, doubt, ambiguity and confusion were the main reasons for burnout and quitting the job in nurses. The above-mentioned reasons are in consistence with clinical nurse managers’ experiences of moral distress. In total, they led to the main theme of “professional desperation syndrome”, which contains various aspects that are mentioned in the results ( results , 43.Regarding the subtheme of “helplessness”, results of a study by Wilkinson is in line with those of the present study. They found that at various levels of nursing, the experience of moral distress was generally associated with sleep problems, anger, disappointment, discomfort and lack of energy, and would also cause severe helplessness in the individual. When lasting for a long period of time, this sense of helplessness could lead to professional burnout, and would affect the quality of care directly and indirectly . SimilarRegarding the subtheme of “impaired professional identity”, Harrowing and Mill found that in nursing, professional identity and integrity are influenced by moral factors, which is confirmed by the results of the present study. They also stated that experiencing moral distress would affect the professional identity of nurses . In a quFinally, it should be mentioned that in comparison with previously existing research, the present study presented a deeper description and interpretation of clinical nurse managers’ perception of moral distress. Understanding these experiences will be an introduction to modifying the associated negative outcomes in the future, and creating a suitable environment for moral decision-making. Therefore, recognizing moral distress in clinical managers can improve their planning and management skills in dealing with it, and this will be of great help to the healthcare system of any country.Moral distress is an important phenomenon in nursing management that affects the body and soul of managers. The present study explored moral distress based on Iranian nurse managers’ lived experiences. For clinical nurse managers, moral distress is an ambiguous situation like suspension between the earth and the sky in uncertainty and fear, and may be a reaction to having to knowingly cover up intentional and unintentional mistakes. The experience is like a hidden suffering and spiritual torment caused by betraying moral principles. In the experience of clinical managers, moral distress is equal to confusion, anxiety and concern about the outcomes. Not only would it cause unbearable mental suffering and self-blame, but it could also lead to resignation and quitting the managerial position. The managers stated that it seemed as if their organizational commitments had priority over their human obligations. They believed that experiencing this kind of conscious mistake was the reason for the occurrence of professional desperation syndrome and psycho-emotional trauma.


At a recent workshop I attended, the facilitators asked us all to describe how people look when they are open for a conversation. Many people willingly offered the standard signals: smile, open posture, and, of course, not looking at their phone. As usual, I spoiled the party confessing that I did not know how to tell if someone was open to connecting. I was being radically candid based on my own many mistakes.Not so long ago, while biking along a path in the west end of Saskatoon, I came up behind three youths walking abreast thus “blocking” the entire path. They were dressed in what I believe was “Goth”: trench coats (it was the middle of the summer), long unkempt hair, piercings and tattoos (I have two of my own), and other dark clothing. I recognized these outfit as likely “Goth” because for a time that was, during his forced high school career, my son’s chosen garb. (He is now entering a Master’s program on a scholarship.)Sir!” I nearly fell off my bike for surprise at what came out of his mouth. Moreover, I was ashamed at how badly I had misjudged . I was clearly guilty of clothesism. The way people present themselves does not accurately reflect the inner person. I foolishly judged those books by their covers.Not wanting to kindle their ire, I pedaled a few metres back, unobtrusively. Shortly after, one of the youths noticed me. I don’t have the quietest bike. He stepped in front of his friends leaving me a clear opportunity to pass. Knowing that people behave the way they are treated and wanting to keep a calm situation from escalating (fear and ignorance muddles one’s brain), in my calmest and most sincere sounding voice with the hint of a warm smile, as I passed the party of three, said, “Thank you!” The lad who had let me pass - of the three the one whose appearance really shouted, “Rebel” and “I don’t give a s—t” - responded, “You are welcome, There have been other recent examples along the same theme where I misjudged … badly. Perhaps, to answer again the question posed at the workshop, “how do you recognize someone open for interaction?” the way people respond may have more to do with how I initially interact with them than their own dispositions. Maybe a warm invitation to them, one that intentionally communicates openness and a willingness to connect, can conjure up a similar response. I do notice (warning – unscientific findings) that when I pass strangers on the sidewalk and am able to meet their furtive glance with a smile and/or a nod of peace sign I am rewarded - almost always - with a smile or similar gesture in return. Perhaps the people I encounter are mirrors exhibiting behaviours in response to what they see in me. We may get what we expect. I feel I cannot predict how people will act by how they look, who they are by their appearance.3To amplify and fix this seemingly simple point into your memory - as it seems to be in mine - I offer this quote from “A Gentleman in Moscow”:…, what can a first impression tell us about anyone? Why, no more than a chord can tell us about Beethoven, or a brushstroke about Botticelli. By their very nature, human beings are so capricious, so complex, so delightfully contradictory, that they deserve not only our consideration, but our reconsideration—and our unwavering determination to withhold our opinion until we have engaged with them in every possible setting at every possible hour.based on the belief that one's own race is superior (emphasis mine).” This first type of racism I will call malignant racism. The second definition provided by Google is actually the foundation, the real reason why the first type of racism thrives, and is included within the first definition: “the belief  that all members of each race possess characteristics or abilities specific to that race, especially so as to distinguish it as inferior or superior to another race or races.” This type of racism I call ignorant, lacking a full understanding, perhaps due to poor research.Making incorrect judgments about people is, at the base, bad research: poor data collection, premature closure, false generalizations, confirmation biases, and other insidious cognitive errors. Racism, too, at the base, consists of at least poor research. Wikipedia tells me that there are two common definitions of racism. The first seems to be the one most often used in the media and at the coffee shop: “prejudice, discrimination, or antagonism directed against someone of a different race To hold the belief that one’s own race is superior, one needs first to believe that there is something such as a race. Then we need to believe that most people of one race are very similar to others in that race, more than they share similarities with people of other races. We need to believe that our differences define us and not that our common humanity shapes us. We also need to believe that there are objective criteria by which one can judge races and individuals within races, and that judging is actually a legitimate activity even if it were accurate. The road to malicious racism (the first kind described by Wikipedia) seems long and tortuous. One has to commit many cognitive and I think moral errors. Once people, often intellectuals and politicians, establish a dominant, dogmatic discourse based on race, the malignant variety of racism takes hold. Once entrenched it is hard to uproot.2 hearts and minds can change and eventually we can restrain both ignorant and malignant racism.Can the truth, obtained through rigorous research, save us from racism? Likely not on its own. We also need the disposition and openness to allow our views to be challenged and modified. And we need, perhaps most importantly, the willingness to connect with others who are different. Among people of good will, courageous research can set us free to embark on a different path. Through open dialogue and friendly argumentation,4 that you will learn to expose wrong thinking and poor research and root out the prejudice it feeds.As you read and respond to the articles in this issue, we hope that you will think creatively and courageously,Rajendran with the image and accompanying text, “The emotional brainbow,” provides us with some profound insights on the beauty and complexity of one person genuinely connecting with another. This is an antidote to racism. We need people who are willing and able to connect with fellow human beings, however unfamiliar.Dubé et al. in “It takes a community to train a future physician: social support experienced by medical students during a community-engaged longitudinal integrated clerkship” describe, from the perspective of medical students, the social supports that allow them to adapt to and meet the demands and challenges of a longitudinal integrated clerkship.Harms et al. in “From good to great: learners’ perceptions of the qualities of effective medical teachers and clinical supervisors in psychiatry” explore the excellent educator by examining narrative comments from psychiatry faculty evaluations. They analyzed almost three hundred narrative comments to discover what undergraduate and postgraduate learners notice about effective educators in psychiatry. Researchers have already observed many characteristics before. Novel themes include the importance of relationships, learner security, and inspiration through role modeling.Smith and her team in “The Calgary student run clinic in context: a mixed-methods case study” explore how stakeholders in the University of Calgary’s student run clinic perceived its purpose. Drawing on 13 interviews and electronic medical records, they found there was great uncertainty about the role of the clinic. Most people saw the clinic as an effective referral provider while others thought of the clinic as primarily an educational unit.Abbiati et al. in “Construct and predictive validity of the Strength of Motivation for Medical School- Revised (SMMS-R) questionnaire: a French validation study” evaluated the construct and predictive validities of the French version of the Strength of Motivation for Medical School-Revised questionnaire (SMMS-R-FR). Using a sample of 372 students at three French-speaking medical schools in France and Switzerland, they confirmed the three-factor structure of the original SMMS-R questionnaire. Both Total Strength of Motivation and Readiness to Start positively predicted a deep learning approach and negatively predicted a surface learning approach. Willingness to Sacrifice positively predicted a deep learning approach and Persistence negatively predicted a surface learning approach. Educators should use these findings cautiously as predictive power here does not indicate a causal relationship.“Lines in the sand: pre-interview rank and probability of receiving admission to medical school” explore how the probability of receiving an offer varies based on the applicants’ pre-interview rank. This may help determine whether the cut-off point for number applicants offered interviews is congruent with the probability these applicants will be given an offer of admission. Using 2,659 pre-interview rankings from 2013-2017, they calculated a linear-by-linear association Chi-square test and a Spearman Correlation between pre- and post-interview ranks. They found that all applicants had between a 50.0% and 76.4% chance of admission. These results indicate that the cut off for interviews does not include individuals with a relatively low chance of admission.Burgess and her team from McMaster University in “Can adaptive expertise, reflective practice, and activity theory help achieve systems- based practice and collective competence?” explore the practice context of autism spectrum disorder through the framings of collective competence and activity theory. They then connect with and argue that adaptive expertise and reflective practice will prepare learners to be more responsive to the dynamic needs of the systems in which they work.Orsino and Ng in Hunter and Thomson in “A scoping review of social determinants of health curricula in post-graduate medical education” used only studies where program had described, implemented and evaluated such curricula. Academic outcomes were frequently positive. One study reported a positive patient- related outcome. They incorporated these results into design recommendations for a post-graduate curriculum to address social determinants of health.Monteiro and Xenodemetropoulos in “Resident Practice Audit in Gastroenterology (RPAGE): an innovative approach to trainee evaluation and professional development in medicine” describe the development of RPAGE and its utility. RPAGE captures assessments of knowledge, professionalism, and technical skills, in real time using an electronic platform. Using 2635 anonymized competence assessment data the authors analyzed the acceptability of the audit and tested the hypothesis that more experienced residents would have higher ratings than less experienced residents. Overall reliability was high (α >0.8) with evidence of validity. RPAGE may be an acceptable electronic log of practice data, but may not be acceptable for workplace-based assessment.Karwowska and Tse in “Keeping busy learners informed: email is most useful for medical residents!” looked for the best method of three to distribute orientation information: email, online, and paper. They found that email is efficient and effective. Resident did not access the wiki site much at all but this may be worth further exploration.” explore whether there might be differences in learning between self-regulated and algorithm-regulated practice. First year medical students at the University of Calgary completed a dermatologic morphology module. The authors randomly assigned them to either a self-regulated arm (at their own discretion students removed cases from the practice pool) or an algorithm-regulated arm . They collected data on mean diagnostic accuracy of the practice sessions and tests and the time spent practicing. Students in the algorithm-regulated arm completed many more cases than those in the self-regulated arm . There were no differences between the two groups of students on the post-test  and both groups improved. While the sample was very small and the testing done for short- term retention only, it seems the self-regulated group was more efficient.Traboulsi et al. in “Does self-modulated learning vs. algorithm-regulated learning of dermatology morphology affect learning efficiency of medical students?Riva and his team of authors in “Medical students’ challenges and suggestions regarding research training: a synthesis of comments from a cross- sectional survey” analyzed comments from 360 medical students who responded to a survey on research opportunities. Among other findings they discovered that students wanted active participation when identifying research opportunities and interested mentors and that there was some uncertainty about research training translating into useable skills. This should give us some pause when pushing students into the research rat race.Bharwani et al. in “Perceptions of effective leadership in a medical school context” describe how multiple stakeholder groups associated with medical school leadership programs conceptualized the construct of leadership. They conducted 77 semi-structured interviews with six major stakeholder groups: Trainees, Mid-Level University Leaders, Clinician Leaders, Senior University Leaders, Medical Scientists, and Senior Leaders, external to the University. Among other things, they found that participants expected leaders 1) to create a compelling vision and a foster a motivating culture within the organization and 2) to possess integrity, technical competence, communication skills, and a sense of passion about leading.Rajwani and his team in “Improving the competence and confidence of pulmonary and critical care medicine fellows in performing a cricothyrotomy” describe an evidence-based cricothyrotomy course following the 4-phase lesson plan for simulation. Pulmonary and critical care medicine fellows reported greater confidence (p<0.005) and competence (p<0.002) following this educational intervention. They also showed improvement in knowledge (p<0.003) and skills in two cricothyrotomy techniques. This is a promising module worth trying in other settings.Pero and Marcotte in “Scaffolding for assessment success: using gradual release of responsibility to support resident transition to competency-based medical education” describe how the General Internal Medicine (GIM) program at Queen’s University uses “scaffolding” in its assessment strategy. The program coordinates early assessments with specific scheduled learning experiences and gradually releases the responsibility for assessment initiation to residents. Other residency training programs could easily implement this approach that is well suited to support Competency by Design.Elfassy et al. in “Direct-to-consumer advertising of prescription medications: what the Canadian medical trainee needs to know” describe the known risks of direct-to-consumer advertising and what medical students and residents need to know. They end with a call to integrate effective education into existing programs.We hope you find truthful and useful research in this issue of the CMEJ and that it will help you to avoid both ignorant and malignant actions.


To identify and analyze the criteria, approaches, and conceptual frameworks, used for national/international priority setting.We performed a search of the main biomedical databases , and we reviewed assessment agency websites, among other sources.An systematic review of the literature was carried out.Eligibility criteria for inclusion were based on set of predefined criteria. Systematic reviews and/or qualitative studies  that aimed to identify prioritization criteria or develop general operational frameworks for the selection of health priorities were included. A critical analysis is made of all the aspects that may be useful for any public body that intends to establish priorities in health.We found that there are no standardized criteria for priority setting, although common trends have been identified regarding key elements. Eight key domains were identified: 1) need for intervention; 2) health outcomes; 3) type of benefit of the intervention; 4) economic consequences; 5) existing knowledge on the intervention/quality and uncertainties of the regarding evidence; 6) implementation and complexity of the intervention/feasibility; 7) justice and ethics; and 8) overall context.Our review provides a thorough analysis of the relevant issues and offers key recommendations regarding considerations for developing a national prioritization framework. Findings are envisioned to be useful for different public organizations that are aiming to establish healthcare priorities.The online version of this article (10.1186/s40545-019-0181-2) contains supplementary material, which is available to authorized users. A health technology is defined as an intervention that may be used to promote health, to prevent, diagnose or treat acute or chronic disease, or for rehabilitation. Health technologies include pharmaceuticals, devices, procedures and organizational systems used in health care .The World Health Organization (WHO) state that defines health technology assessment (HTA) refers to the systematic evaluation of properties, effects, and/or impacts of health technology . It is aThe main purpose of conducting our assessment is to develop an explicit priority setting methodology to support decision-making regarding Medicines and Medical Devices to be included in Hospital Pharmacy practice. The development of a comprehensive prioritization system is the outcome essential for an important benefit to the healthcare system . The aimInternational Journal of Technology Assessment Health Care) [A systematic search of the literature was carried out in December 2017, in the main biomedical electronic databases: Medline/PubMed, Embase, Centre for Reviews and Dissemination (CRD), and Cochrane. For this, a specific search strategy was designed combining the terms: “medicine”, “technology assessment, biomedical”, “technology”, “intervention” with “priority”, “prioriti*”, “selection” with “criteria”, “Setting”, “approach*”and “procedure*”. The detailed search terms for different electronic databases is listed in Additional file th Care) –8. In adA total of 17 documents complied with eligibility criteria, out of which 15 were published in scientific journals –23 and tThe current work includes eight studies that address the identification, selection or classification of criteria used in the international arena for the establishment of health priorities. –16 ThreeThe results of our review show that, despite a general agreement regarding the need to establish rational and transparent procedures to prioritize medicinal products and medical devices, and a certain concordance with respect to critical domains exists, there is scarce information available on the explicit processes employed by the evaluation agencies for the establishment of priority issues –29.This review can be used by different bodies interested in priorization framework. All domains and criteria have advantages and limitations, despite the fact all themes were devised rigorously. It should be noted that the present review is limited by the difficulties inherent in the bibliographic search. To improve efficiency, the search has been restricted to the title, so it is possible to have lost some relevant article despite using different combinations of keywords and related terms. In addition, in many cases this type of information is not published in scientific journals and is difficult to recover due to the serious shortcomings of the search engines of web pages, or because it is published in other languages. In any case, we believe that this would not detract from the current work, since we do not intend to describe all international experiences, but to identify those criteria and elements that may be key to the development of a national prioritization proposal. The implementation science principles for pharmacist and other healthcare providers, discovering and applying strategies designed to incorporate evidence-based interventions into routine practice is a must .Our review provides a thorough analysis of the relevant issues and offers key recommendations regarding considerations for developing a national prioritization framework. Findings are envisioned to be useful for different public organizations that are aiming to establish healthcare priorities.Additional file 1:Search strategy. (DOCX 11 kb)


These silken fellows are painted images—outsides, outsides, Rose, their inner linings are torn.1(11:40–41)2 This play, which became The Shoemaker’s Holiday, reworked Thomas Deloney’s 1598 The Gentle Craft, building on its story of Simon Eyre, the London shoemaker who becomes Lord Mayor, and adding the new subplot of injured shoemaker Ralph/Rafe and his lost wife Jane.3 The play would have been performed sometime in 1599, and seemingly played well, since it was acted by the Admiral’s Men for Queen Elizabeth on New Year’s Day, 1600.4In 1599, Philip Henslowe recorded in his diary that he had paid “thomas dicker” the sum of three pounds for a play about “the gentle craft”; that is, about shoemaking.The Shoemaker’s Holiday has remained among the most popular of the era’s citizen comedies, with several twentieth- and twenty-first-century productions, and a substantial body of criticism devoted to the play’s structure,5 characterization of the “gentle craft,”6 and relationship to Shakespeare’s Henry V.7 In recent years, scholars have emphasized the play’s obsession with commercialism, material goods, and craftsmanship.8 Meanwhile, the matter of journeyman Ralph’s “lame” form has attracted relatively little critical attention.9 However, this essay will demonstrate that Ralph’s missing or injured leg and the plethora of material goods that populate the rest of the play are not divorced concerns, but closely wedded.Despite sounding, and feeling, very much of its own time, The Shoemaker’s Holiday, Dekker shows himself to be interested in prostheses in the broad sense of that word. He shows how various characters rely on clothing and material goods not only to express, but actually to construct their identity, such that the boundary between person and thing becomes indistinct. However, the play also shows that this kind of identity is not the only or the best model. Ralph, whose disability renders him in need of prosthesis in the traditional sense, is unable to participate in this material putting-on of identity. He cannot shed his lameness, of which the economic and social significance is so great that his friends need not, and dare not, acknowledge it. Unable to assume a different identity based on the sumptuary “transformation” of his body, he must embrace an alternative ontology. As Dekker shows, there is a less showy but nonetheless valuable place in the world to be established via the bonds of matrimony and fraternity, and the enduring value of artisanal skill. This identity is no more an “essential self” than that of the man “made” by clothes, but it is reliable, self-directed, and inalienable. Finally, I will show that even as Dekker makes his argument for reconstructing identity in terms of interpersonal relationships, he complicates and interrogates that model. Ralph’s reintegration into the shoemakers’ society is promising, but not complete. Moreover, the fact that Ralph’s disability is “put on” by an able-bodied actor in front of a  audience returns us once more to the problematics of physicality, identity, properties, and prosthetics.I argue that in The Shoemaker’s Holiday is, in its simplest form, a dream of upward mobility; of nice clothes, parties, and good things to eat and drink. The play is filled with characters seeking to move between different social and economic modes: Lacy, who seeks to circumvent the aristocratic principles that prevent him from wedding Rose; Firk and Hodges, riding on the coattails of their rapidly rising master; and Simon and Margery Eyre, whose canny use of labor allows them to move into the mercantile world, trading in shipments and holding administrative office.10 Ralph’s place in the story is unusual in that he partakes of few of the play’s good things, its rich clothes and feasts. Yet his identity is formed in relation to the riches that populate the play while he is absent. Other characters become deeply invested in self-fashioning through material goods, and I will argue that Ralph’s sense of self appears all the more lucidly as an alternative to that kind of identity.Shoemaker’s has centered on the play’s interest in material goods and their production, locating the play in the context of a commercial sea change that saw the importation of large quantities of luxury consumer goods. Natasha Korda, for instance, reads “the sign of the last” as a token of the shoemaker’s trade (the “last” which stretches shoes) and as a play on words—shoemakers as among the last bastions of traditional trade in a London increasingly driven by mass production and importation.11 Matthew Kendrick goes further in his reading of the play as an economic fable, claiming that “what we find in the play is a tension between three models of economic and social value: an aristocratic sense of inherent value and social importance, a mercantilist or proto-capitalist vision in which all value is understood in commercial terms, and a counter-discourse which locates the labouring body as the source of value and meaning.”12 In this commercial, status-obsessed world, it is fitting that when Ralph is pressed into the army to fight a war in France, his parting gift to the “loving, lovely” Jane (1:224) is a pair of shoes: Here, take this pair of shoes cut out by Hodge,Stitched by my fellow Firk, seamed by myself,Made up and pinked with letters for thy nameWear them, my dear Jane, for thy husband’s sake,And every morning, when thou pull’st them on,Remember me, and pray for my return.Make much of them, for I have made them so,That I can know them from a thousand moe.(1:228–35) Jane’s shoes are not only a material property; throughout the exchange, they are closely aligned with Ralph’s hand-work and his cooperation with his fellows, Hodges and Firk, as well as his skill at “pinking,” also known as “pricking.” For Jane’s part, the shoes are emblematic of the faithfulness with which she will guard access to her body, despite the jeopardy which attends being left alone in the city, and which leads Firk to suggest she might earn a living as a prostitute (1:137–41). This alignment of goods with bodies and bodily status sets the stage for the action to come, in which the equation between material and personal properties becomes increasingly apparent. Significantly, the shoes are also a collaborative effort between Ralph and his fellows. The capacity of manual skill to bring people together and enable social mobility is repeatedly emphasized in the play. In scene 4 alone, the journeymen and their “Gentle Craft” are described as “fine” eight times, as well as “proper,” “brisk,” “good fellows,” and “true Trojans.” “[T]he play,” in Kendrick’s terms, “subjectivizes labour, giving it a prominent voice and determinant place within the social.”13Much recent criticism of Shoemaker’s makes elision between self and thing particularly easy: “The social world, from the artisanal perspective, is made, not given.”14 More generally, the significance of clothes as transformative items in the early modern period has long been recognized by historians of dress. In their Renaissance Clothing and the Materials of Memory (2000), for instance, Peter Stallybrass and Ann Rosalind Jones argue persuasively that “To understand the significance of clothes in the Renaissance, we need to undo our own social categories, in which subjects are prior to objects, wearers to what is worn. We need to understand the animatedness of clothes, their ability to “pick up” subjects, to mold and shape them both physically and socially, to constitute subjects through their power as material memories.”15 The notion espoused here, that “fashion fashions,” transforming and becoming identical with the body, corresponds closely with readings of material goods as “prostheses,” items that both signal and materialize one’s way of being in the world.16 This reading in turn relies on an idea of prostheses, broadly defined, as “supplemental” in a Derridean sense. That is, the items that are added to the body both supply a deficiency and make that deficiency conspicuous, at once transforming the “original” and remaining apart from it. In his Materialising Gender, for instance, Will Fisher adopts what he terms a “free-ranging” definition of prosthesis that includes items such as hair, handkerchiefs, and codpieces.17 Fisher views these items as “auxiliary organs” mediating the body’s form and function.18 He describes the codpiece, for example, as a “constitutive accessory”: “I believe that the codpiece wasn’t simply a sign of masculinity, but that it quite literally helped to mold the body and make the man. Or, to use the language of a writer from the period, the codpiece had the ability to make an individual ‘man in body by attire.’”19An emphasis on material goods therefore underlines the place of artisanal economies at the heart of commercial London. More than this, however, the play’s characters—with the notable exception of Ralph—find their identity in the sumptuary. As Kendrick observes, the primacy of handiwork and artisanal skill in Shoemaker’s, the idea of sumptuary transformation is played out in spectacular style. With the aid of manual skill “learned in Wittenberg” (3:21), a phony Dutch accent, and a set of new clothes, idle nobleman Lacy is able to disguise himself as Hans the shoemaker. This transformation is not only one of “semblance,” but an alteration of the bodily and mental state, a “change [from] / High birth to baseness” (3:20–21), which Lacy equates with the metamorphoses of the classical gods (3:1–2). Even more noticeable is the play’s obsession with Margery and Eyre’s new clothes—garments that go hand-in-hand with Eyre’s new venture into buying and selling luxury commodities.20 Immediately as the couple are attired in fine clothing, they acquire new status in their own eyes and those of onlookers: irk. Ha, ha! My master will be as proud as a dog in a doublet, all in beaten damask and velvet.Fyre. Softly, Firk. For rearing of the nap, and wearing threadbare my garments. How dost thou like me Firk? How do I look, my fine Hodge?Eodge. Why now you look like yourself, master! I warrant you, there few in the city but will give you the wall, and come upon you with the ‘Right Worshipful’.Hirk. ’Nails, my master looks like a threadbare cloak turned new and dressed. Lord, Lord, to see what good raiment doth!F(7:98–107) Clothes make the (wo)man in these cases in a profound sense. These garments not only transform the couple in their outer appearances, but are, as Jonathan Gil Harris has commented, envisioned as acting upon the very flesh of their bodies, “not just arous[ing] the characters but ultimately eras[ing] them.”21 In characterizing Eyre as looking like a cloak, Firk collapses the distinction between his master and the garment he wears, so that new clothes possess the alluring power to remake one’s essential self. Hodge, meanwhile, responds that “now you look like yourself,” backdating Eyre’s transformation to imply that the new cloak has merely revealed his master’s hidden qualities.In Faith, yet, I’ll try” . When she responds negatively to his offer, he redoubles his insistence on the commercial nature of their exchange: ane. My hands are not to be sold.Jammon. To be given, then.HI come to buy.Nay, faith,  Hammon’s treatment of Jane is not only crassness; he is equally willing to equate his own body with material items, as when he remonstrates, “Look how you wound this cloth, so you wound me” (12:24). Neither are Ralph and Jane themselves entirely immune to this pervasive metaphor, though they ultimately reject the mercantile model of identity. When Ralph discovers Jane’s shoe, he declares of the item that “This is her size, her breadth” (14:46). Later, when they are finally reunited, Jane frames the choice between Ralph and the wealthy Hammon as a choice between fine garments and “humble weeds” (18:57).Clothes may also confer power. At the end of the scene, Margery comments, “I do feel honour creep upon me, and which is more, a certain rising in my flesh” (7:134–5). The bawdy subtext of “rising . . . flesh” implies a newfound agency that is so potent it is imagined as phallic. While she may be quick to put on airs, Margery’s assessment of her new “honour” is accurate; by the end of the play, Eyre is Lord Mayor, and she is no longer Dame but “Mistress.” The equation between bodies and garments, between personal and commercial value, takes on a darker side in relation to Ralph’s abandoned wife, Jane. Attempting to woo Jane in the shop where she works, Hammon fails to understand the difference between buying a ruff or a handkerchief and purchasing a wife. When Jane asks “What will you buy?” he replies “That which thou wilt not sell. 22 The importance of such goods also inevitably implies that the people they prostheticize are in some sense incomplete or incapable of enacting social transformations without material additions.The effect of material goods as prosthetic markers of identity is, for Dekker, largely positive. It enables social mobility in a play which is pitched to present mobility as a desirable aim. Nonetheless, such markers are, by their nature, unstable, able to be passed around, lost and gained, and reproduced. Inevitably, the more accessible a social marker is, the more liable it is to be tarnished by association with the “wrong sort” of wearer, hence the period’s persistent anxiety about women’s use of cosmetics and both sexes’ adoption of courtly fashions.Narrative Prosthesis (2000) treats disability as a sort of metaphorical prosthesis, acting on (and in) the “body” of literary texts.23 The presence of a disabled character in a narrative, they argue, provides “unusualness.” The anomaly of disability drives forward plots and lends a corporeal grounding through which intangible themes may be discussed: “disability has been used . . . as a crutch on which literary narratives lean for their representational power, disruptive potentiality, and social critique. Yet, at the same time, literature avoids designating disability itself as a source for derisive social myths that need to be interrogated.”24 Ralph’s disabled body works as a narrative prosthesis, according to this description, because it facilitates both the subplot of Ralph and Jane’s reunion, and the wider focus on identity with which I argue that the play is concerned. Where, though, do these narrative prostheses leave the disabled user of actual prostheses? Talk of material objects as supplemental to the body undermines the notion of any body as fixed and complete, since, as Margaret Shildrick argues, “the supplement is necessary in constituting the object as such, and in turn its necessity exposes the undecidable nature of categorical distinctions between self/other, natural/artificial, and so on that are usually taken for granted.”25 Writing on the philosophy of prosthetics and embodiment, Shildrick astutely points out that the dependence of humans on items from canes to contact lenses undermines the notion that the body should reliably “end at the skin,” and points instead toward the human self as a Deleuzian assemblage. In other words, even normatively bodied persons—in this case, Margery, Eyre, and Lacy—have need of prosthetics, though they use them for purposes of social advancement rather than everyday survival.26 It is worth pointing out here that anxieties about supplementarity raised by prosthesis may not necessarily make much difference to the experience of disability. Shildrick acknowledges that despite the indistinction between self and thing implied by our universal reliance on material objects, those with “anomalous corporealities” continue to be associated to a greater extent with material-fleshly “hybridity.”27 Likewise, Vivian Sobchack—herself a prosthesis user—cautions against focusing on the theoretical possibilities of the prosthetic to the exclusion of the “literal and material ground of the metaphor.”28 In the lived experience of disability, she contends, the prosthesis is unremarkable, and “becomes an object only when a mechanical or social problem pushes it obtrusively into the foreground of the user’s consciousness.”29Taking “prosthesis” in a broad sense thus exposes the instability of that category in ways that are useful to disability studies scholars as they seek to interrogate the very concept of the “whole” or “deficient” body. Central to such scholarship has been the idea that disability itself is perhaps being made to do ideological and narrative work. David Mitchell and Sharon Snyder’s now-seminal Shoemaker’s, it is not only the extent but the changeability of one’s prosthetics that is at issue. In her work on the “Cripple” of Thomas Heywood’s The Fair Maid of the Exchange (1607), Katherine Schaap Williams demonstrates that the difference between nondisabled and disabled bodies is most visible in one’s ability to assume different identities as the occasion demands. That is, the nondisabled person can pretend to be disabled, but not vice versa. In Fair Maid, able-bodied Frank’s ability to assume the “habit” of Cripple enables him to woo Phyllis and seamlessly return to the social and economic advantages of the normatively bodied: “Notably, however, in a play that has thematized exchange, the key thing to see is that the exchange is never equal. Cripple cannot participate fully: Frank can impersonate Cripple, but Cripple cannot impersonate Frank. . . . Distinguishing between prop and prostheses at the level of character, the play differentiates between bodies that appear to be whole, self-sufficient, and capable of impersonating other bodies, and those that are not.”30 Williams’ thesis is partially applicable to The Shoemaker’s Holiday. Cripple and Ralph both have bodily differences that become visible in relation to the play’s other characters. However, the degree to which they are thus determined is very different. When Frank impersonates Cripple, he pays attention almost exclusively to Cripple’s disability. Far from seeking to reproduce Cripple’s manner of speech or professional knowledge, he attributes new qualities to his character based solely on his disability, declaring himself “Crooked in shape, and crooked in my thoughts.”31 Cripple has never shown any sign of a “crooked” mind, but genuine acquaintance is here overridden by the determining factor of bodily impairment. Ralph too has an identity constructed largely through difference. In this case, however, the result is far hazier. As we have seen, many of Shoemaker’s characters actively seek to (re)make their identities with the help of material prostheses. By contrast much of Ralph’s character is constructed in the negative; he does not do and acquire the things that his companions place so much emphasis on doing and acquiring. This may be because, as I shall discuss, his disability places him at a socioeconomic disadvantage, or because he expresses little desire for wealth beyond that required to support himself and his wife. Most likely, it is both.In social dramas such as those played out in odge. What, fellow Ralph! Mistress, look here—Jane’s husband! Why, how now—lame? Hans, make much of him: he’s a brother of our trade, a good workman, and a tall soldier.H(10:53–55) This list of Ralph’s roles—husband, brother, worker, soldier—underlines the bonds of fellowship within which the returning journeyman’s identity is constituted, and sounds like an attempt by Hodge to deflect attention from his friend’s altered appearance. Hodge refers to Ralph with the same epithet—tall—as before he left for the wars, though it becomes clear that Ralph’s body is emphatically not the same: argery. Trust me, I am sorry Ralph, to see thee impotent. Lord, how the wars have made him sunburnt! The left leg is not well; ’twas a fair gift of God the infirmity took not hold a little higher, considering thou camest from France—but let that pass.M(10:61–64) Margery’s description of Ralph’s injury is the most explicit in the play, but it is still frustratingly vague. We know from Dekker’s text just how to recognize Lacy/Hans in his Dutch attire, and Margery and Eyre in their high heels and cloak, respectively. In Ralph’s case, however, the text is less forthcoming. This passage is usually interpreted as meaning that Ralph has lost all or part of the left leg, which seems a reasonable reading given the frequency with which catastrophic injuries and gangrene were treated by amputation at this time. Lengthy instructions for amputation appear in virtually every book of military surgery of the period, despite the high death rates that attended so radical an operation. The preeminent surgeon of the sixteenth century, Ambroise Paré, recognized that “This remedy is miserable and worthy of compassion . . . but it is the only and last refuge, which one must still prefer to death, which will follow if one seeks other means than section of the mortified part.”32The difference between Ralph’s portrayal and that of other characters is visible from the moment he returns home from the wars in scene 10. Here, the contrast between the overdetermined materiality of Margery, Eyre, and Lacy/Hans’s new identities and the indeterminacy of Ralph’s status is striking. At first the returning soldier is unrecognizable, and when he is recognized, he receives a strange reception: Thou [Ralph] do for her? Then ’twill be a lame doing: and that she loves not. Ralph, thou mightest have sent her to me: in faith, I would have yerked and firked your Priscilla (13:23–24)Thou lie with a woman, to build nothing but Cripplegates! (14:66) Firk’s jests partake in a tradition of curiosity about the sex lives of disabled people with which the audience would have been familiar.33 As Farr has noted of the eighteenth century, disabled bodies existed “along a similar social continuum to that of unauthorized genders and sexualities . . . in a liminal space where unmonitored, unmentionable, or merely mockable forms of courtship and sex abound.”34 Montaigne’s famous essay “On the lame” demonstrates the extent to which bodily anomaly might be fetishized as particularly apt for the “sport of Venus.”35 Nonetheless, these jokes at Ralph’s expense fail to elicit much reaction from the other characters; they are apparently too preoccupied with the business of refashioning themselves, or, more charitably, are embarrassed for the injured man.Margery and Eyre’s encounter with Ralph is soon truncated by the news of Eyre’s promotion to Lord Mayor, their halting acknowledgment of Ralph’s altered materiality overtaken by the promise of the new materials that will accompany civic office. Thereafter, the text’s engagement with Ralph’s disability is (like his leg) conspicuous by its absence. When it occurs, it is in the rather discordant form of jokes about his sexual prowess. Perceiving Ralph’s distress at his injured state, Margery puns on the double meaning of “thing”: “He does but as I do, weep for the loss of any good thing” (10:98–99). Firk, meanwhile, repeatedly teases him about his virility: text largely ignores Ralph’s materiality, however, the play cannot do the same. Ralph’s missing leg is on stage—or rather, not on stage—whenever he is. So too is the insistent tapping of his crutch on the wooden boards, punctuating the dialogue despite the exclusion of his body from the script. Ralph’s onstage presence thus insistently confirms that difference which his friends are loath to acknowledge. It may also help to explain their lack of acknowledgment. In a society wherein disabled veterans are a significant social and economic problem, Ralph’s body is so visually readable that it shuts down rather than invites comment. In other words, nobody needs to point out that Ralph’s injury renders him vulnerable to poverty and exclusion, since they, he, and the audience are already painfully aware of that fact. With his body so readable and yet unspeakable, Ralph is excluded from the focus on bodily accoutrement and material goods by which the play’s other characters are determined. However, he remains an active character, with whom the audience is invited to sympathize. He must therefore maintain an identity on some other grounds. These grounds, I argue, are the bonds of fraternity and matrimony, the same bonds that are emphasized at Ralph’s impressment, before Lacy’s disguises and the Eyre’s rise to wealth.If the alph. Where lives my poor heart [Jane]? She’ll be poor indeed Now I want limbs to get whereon to feed.Rodge. Limbs? Hast thou not hands, man? Thou shalt never see a shoemaker want bread, though he have but three fingers on a hand.H(10:72–76) Despite certain problems with Hodge’s statement, which I address below, Ralph can and must accept their renewed comradeship: [. . .] Since I want limbs and lands,I’ll trust to God, my good friends, and my hands.’(10:101–2) Being a man neither of property (lands) nor of parts (limbs), Ralph harks back to the fraternal model which supplements flesh with emotional bonds and skills. Moreover, he does so with remarkable ease. In the face of his real bodily alteration, Ralph’s easy (or hurried) assimilation back into his old role contrasts strikingly with the rigmarole of Lacy’s feigned accent and odd clothes, the Eyres’ putting-on of the trappings of nobility, and Hammon’s efforts to buy a wife like a ruff or a handkerchief. These bodies need constant attention; their appearance, gesture, and status must be diligently fashioned, though their substance is far less radically changed than that of the returning journeyman.In the play’s opening scenes, as I have shown, the bonding properties of shared labor and artisanship are valorized. Moreover, the value of a skilled worker is reiterated in Eyre’s promises to his journeymen and his willingness to accept their demand for a new colleague in Hans. In response to Ralph’s legitimate worries about his economic future, Hodge immediately returns to this language: [. . .] this shoe, I durst be sworn,Once covered the instep of my Jane.This is her size, her breadth. Thus trod my love.These true-love knots I pricked. I hold my life,By this old shoe I shall find out my wife.(13:44–48) Ralph gestures here to the equation between things and bodies that has defined other characters’ social positioning: “This is her size, her breadth.” However, he understands the shoe as a separate, lifeless thing, an empty vessel by which he may recover his lost wife. The shoe—tellingly, now “old” despite having been made only weeks or months before—is valuable only as it relates to his marriage and his craft. Encountering his wife as he fits her new shoes, he reports that she has failed to recognize him on account of “my lame leg and my travel beyond sea” (18:11–12). True to form, however, Ralph sees this physical misrecognition as unimportant, since “I know she’s mine” (18:12). He apprehends Jane and Hammon on the way to their wedding, supported by his coworkers and another “five or six shoemakers” seemingly invested in this quarrel by dint of their shared profession with Ralph. In a moving speech, Jane eschews Hammon, explicitly rejecting “his attire,” and returns to her estranged husband (18.55–61).The precedence of relationships to Ralph’s identity comes to the fore during his reunion with Jane. Ralph learns of Jane’s location through the shoe which he made for her, and which is now brought to be copied for her impending marriage to Hammon: The Gentle Craft (1597), from which Shoemaker’s is adapted, relates the story of brothers Crispin and Crispianus, who, on being exiled from their homeland, both become shoemakers.36 Crispin woos a local princess, Ursula, in the course of fitting her shoes, and they are secretly married. Crispianus meanwhile, is pressed into the wars in France, proves his valor in combat, and is knighted. The story is resolved when it is revealed that both brothers are of noble birth. The Gentle Craft incorporates numerous motifs of Renaissance romance, including that of a quest away from home and “subject-matter concerning love or chivalry, or both.”37 Unsurprisingly, since this story is in turn related to the hagiography of Crispin and Crispinian, the story also dwells on ideals of kinship, bravery, and fidelity.Ralph, for Jane, is “him whom heaven hath made to be my love” (18.56). As such, they share not only a mutual desire, but a mode of expression which links the pair even when they are far apart. Ralph and Jane are the only two lower-class characters to speak in verse. Ralph slips between prose and verse, using the latter most powerfully when he speaks about his wife in scene 14. Jane, meanwhile, has some of the most eloquent rhymed and unrhymed verse in the play. The couple’s linguistic link echoes their marital one, and aligns Jane with her husband even when she is unaware of his survival . Verse was also, of course, associated with characters of higher status and gentility, a fact which accords with the story’s roots in a tale of beleaguered nobility. Deloney’s A Gentle Craft echo through Shoemaker’s in the elegant speech of Ralph and Jane. Their relationship, while ostensibly humble, draws on the Homeric notion of a steadfast Penelope, besieged by suitors, awaiting her husband’s return from sea. Jane, in this reading, is both an appropriate wife for a man of valor, and a narrative compensation for the fact that Ralph, unlike Crispianus, does not return home from the wars unharmed and triumphant. The action of Shoemaker’s thus makes clear Ralph’s devotion to his wife and friends, but the play’s intertextuality, making itself felt through moments of unexpected lyricism, casts Ralph and Jane’s relationship as romantic in both senses of the word.Dekker adapts rather than retells this story. His version substitutes Lacy for Crispin and retains the pressing of Crispianus  into service, but loses both his knighthood and his noble birth. Nonetheless, the romantic motifs of 38 Still, there are some nagging aspects of Ralph’s happy ending that suggest this solution may not be as neat as it appears. Ralph’s fellow shoemakers have neglected his explicit charge to protect Jane by allowing her to be bullied out of the shop by Margery. Even in the face of his obvious distress, they are unwilling to admit their fault. Moreover, as Lindsey Row-Heyveld has pointed out, Ralph’s reintegration has its limits. Margery casts doubt on Ralph’s sexual and economic usefulness when she describes him as impotent. Moreover, when Hodge enters the shop decked in a gold chain in scene 10, he does not acknowledge Ralph, much less offer him any share in his newfound wealth. Row-Heyveld concludes: “Ralph may be offered charity, but, as with the loss of Jane, it is a charity with distinct limits; Ralph may be welcomed back into the cadre of shoemakers, but it is clear that his disability shifts their interpretation of his commercial and sexual labor, and, therefore, segregates him from his ‘brothers.’ Even within the play’s fantasy of masculine unity, divisions between men—especially those created by disability—never fully disappear.”39 Why does Dekker not follow his “wish-fulfilling logic” to secure an unequivocally warm reception for Ralph? Why also allow Ralph to be insulted by another man offering money for his wife? I contend that the ambiguity which remains around Ralph’s reintegration works as tacit acknowledgment of the junction between Dekker’s use of disability on stage as a tool for thinking about identity, and the fact of disability as it was lived by members of the audience. The actor who played Ralph feigned lameness for dramatic purposes, but he played to people for whom impairment may have been anything but imaginary. Sobchack describes this junction eloquently: “there are both an oppositional tension and a dynamic connection between the prosthetic as a tropological figure and my prosthetic as a material but also a phenomenologically lived artifact.”40 In the early modern period, this tension and connection were present, and pressing. War plays were popular, and depictions of martial peril included the dangers of war wounding alongside the potential for honor.41 Christopher Morrow describes lame soldiers as having been “a staple on the Renaissance stage,”42 while Cahill identifies at least eight plays published or performed between the late 1590s and 1602 featuring a lame soldier.43 Perhaps to a greater extent than before or since, these plays were viewed by people who had actually seen, and been disabled by, military service, men who looked more like Ralph than his companions.44 In his The Seat of Mars, Charles Carlton estimates that under Elizabeth, around 55 percent of all males between the ages of 18 and 39 saw some kind of military service.45 Like Ralph, a significant minority of soldiers were forced into fighting; the numbers of those impressed by the military rose sharply from 4,835 in 1597 to 7,300 in only the first half of 1599.46 Messy, prolonged, and often poorly organized, these conflicts produced large numbers of wounded as well as fatalities. War had always created casualties, but the increased use of firearms and artillery from the mid-sixteenth century onward inevitably resulted in more catastrophic and complex injuries for which the only remedy was radical surgery.47 The situation was so grave that only seven years before the first performances of The Shoemaker’s Holiday, the “Act for the Necessary Relief of Soldiers and Mariners” was passed in order to alleviate the plight of those who returned from wars unable to work and were forced to beg in order to survive.48 Moreover, despite the formalization of relief for maimed soldiers provided by the Act, it is clear that wounded veterans faced an uncertain fate, struggling to avoid being lumped in with vagrants or mistaken for malingerers and to emphasize their deserving status.49Ralph’s restoration to the community of shoemakers and to the arms of his loving wife appears to confirm the value of interpersonal relationships over and above material goods. In what Kastan describes as an example of “wish-fulfilling logic,” the pair even get to keep the money and clothes offered to Jane by Hammon.Shoemaker’s. Ralph, as I have shown, is the character whose body most “speaks for itself” and the one who makes least use of sumptuary prostheses. Yet Ralph’s is also the body on stage which is least “like itself,” because his disability is “put on” by an able-bodied actor.50 How exactly this was achieved is uncertain. Farah Karim-Cooper has recently shown how hand amputation might be represented on stage using a wax or wood prosthetic that was lopped off, leaving the actor’s real hand inside the sleeve.51 A similar effect could be used for leg amputation, with the actor’s leg bent double inside his breeches or slops.52 As Vin Nardizzi has speculated, Ralph’s lameness might thus be represented with his leg absent and the actor balancing with a crutch, with a wooden peg leg, or with an “injured” prosthetic leg.54 The fact that Dekker left the exact nature of Ralph’s injury unstated was perhaps a deliberate move designed to allow theatrical companies to stage Shoemaker’s according to the props and actors they had available.This brings one to a fundamental irony of prosthetics and identity in Shoemaker’s in particular, troubles the always-tremulous distinction between props and prosthetics, between objects that disguise the body and objects that transform it, and between playing a role on stage and in daily life. Describing this phenomenon as “disability drag,” Lauren Coker-Durso argues that seeing the same actor in disabled and nondisabled roles created the impression of disability as something that might be removed at will: “The performance of disability and fraudulent disability in non-dramatic settings works in a dialogue with the onstage interpretations in historical and cultural contexts. An openly acknowledged performance often portrays disability as a choice, as something autonomously constructed. In other words, deliberately staged enactments of disability in dramatic texts foster a cultural push towards denying or questioning disability as a material corporeality in various contexts. In many ways, disability is constructed as only performance.”55 Early modern performances of disability might thus be said to create some of the same problems as modern “super-crip” narratives, which present disabled people as overcoming their impairment to achieve heroic feats. While they have the potential to change public attitudes toward disability, such stories all too often elide the social and economic barriers affecting many people with disabilities, and may imply that all disability can be overcome with sufficient effort.56What is clear, however, is that the actor’s putting-on of disability in general, and in 57 Endless medical texts and cony-catching pamphlets detail the nefarious means used by vagrants to fake sores, amputations, and blindness—means which, ironically, may have brought about real illness and injury.58 The ruses described in such texts were inventive and frequently theatrical in nature. Paré, for instance, recalled having seen (and exposed) a number of remarkable instances of illness-shamming, including fake cancerous ulcers made of sponge, animal blood, and frog skins, a woman feigning a prolapsed bowel using cow intestines, and a man who stole a decaying arm from a corpse to pretend it was his own diseased limb.59 Accordingly, a large proportion of disability represented on stage was faked disability. Row-Heyveld identifies over 30 characters in early modern plays who pretend to be disabled, a trend which she argues was exacerbated by a post-Reformation shift away from the semi-reciprocal, “alms-for-prayers” mode of charity.60 Furthermore, it was believed that both disabled and able-bodied vagrants commonly masqueraded as discharged or wounded soldiers in order to access the public goodwill and official lenity that was (sometimes) afforded to that group. In the 1616 edition of Dekker’s own O per Se O, he detailed at length how unscrupulous beggars faked soldiers’ passports and created sores from lime and soap.61A somewhat puzzling moment in Dekker’s play confronts directly the uncomfortable juncture between disability drag and the real lives of disabled people. Shortly after their reunion, Ralph and Jane—he, lame, and she wearing a veil—are accosted by Oatley and Lincoln, who assume first that his lameness is feigned, and second that her veil constitutes an attempt to counterfeit blindness (18.114–40). They are soon proved wrong, but the older men’s assumption is founded in a widespread suspicion of disability that was fueled by literary and theatrical representations of impairment. Audrey Eccles, Linda Woodbridge, and Row-Heyveld, among others, have demonstrated how suspicion of disabled people in general, and the disabled poor in particular, reached fever pitch in the sixteenth and seventeenth centuries, driven by legislative and economic changes that formalized the obligation of communities toward their “impotent” members and clamped down on the itinerant poor.Shoemaker’s therefore recognizes the contradiction between presenting one sympathetic disabled character and reaffirming the belief that disability might be put on. By muddying the waters around Ralph’s happy ending, by recognizing the fragility of his reintegration, Dekker recognizes that the disability he employs on stage as a storytelling tool and that which actually affects members of the audience have an important but difficult relation to one another.Disability and theatricality thus constantly informed one another, as actors feigning disability played to audiences including disabled people who might or might not be “acting” their impairment, and able-bodied people for whom the spectacles of real and faked injury were worryingly indistinct. Depictions of fakery made life harder for genuinely disabled people, not only because it rendered them objects of suspicion, but because the intense focus on verifying or falsifying impairment allowed able-bodied people to avoid thinking about more troublesome matters. While wondering about the mechanics of feigning a missing leg, onlookers were not addressing the significant hardships faced by the genuinely impaired, or recognizing their own vulnerability to disabling accidents and illness. Dekker’s hesitation to complete the wish fulfilment of The Shoemaker’s Holiday epitomizes the puzzle of disability on the Renaissance stage. On one hand, this is a play about being oneself. Dekker makes clear that Ralph, whose body is “lacking,” nonetheless resists the prostheticized identity which other characters embrace. Margery, Eyre, and Lacy fashion themselves through material goods, which both express and transform their social and economic status. By contrast, Ralph uses a traditional prosthesis, with an inescapable auditory and visual presence on stage. However, the things that make Ralph Ralph are those which persist despite his prosthetic alteration—fellowship, work, and marital harmony. On the other hand, we might argue that “Ralph” is not really Ralph at all. In fact he is, physically, further from being Ralph than the other actors are from being Eyre or Firk, and Ralph’s onstage body is far more analogous to the offstage bodies of certain members of the audience. This fact brings home the constant tension between lying, playing, and truly presenting oneself that troubles both the early modern stage in general and the issue of representing disability in particular.Both these considerations can, I think, coexist, and the play is more interesting for acknowledging this puzzle. The fact that Ralph’s disability is acted does not render the play’s emphasis on his alternative ontology obsolete, any more than the fact of boy actors renders presentations of the lives of women untenable. Audiences suspend disbelief in the real physical attributes of characters and actors just as they do in cases of magic, unlikely circumstance, or indeed incredible social climbing. Nonetheless, Dekker’s optimistic presentation of a disabled veteran reconstructing his identity in interpersonal terms takes place in an environment in which the distinction between disguised and transformed bodies is decidedly vague, and in which the theatricality with which disability is imbued does real harm to those suffering from illness and injury. The result is a play that heralds with optimism the possibility of creating genuine relationships based on empathy and personality, but acknowledges the difficulties encountered by those living with an anomalous body.