Quantitative data were analyzed using descriptive statistics, and qualitative data were analyzed using conventional content analysis. Six themes emerged in the qualitative analysis: (1) cultural and social factors that can influence patient–provider communication; (2) barriers to effective patient–provider communication: patient, healthcare provider, and PMI levels; (3) facilitators of effective patient–provider communication: patient, healthcare provider, and PMI levels; (4) COVID-19 and remote interpreting barriers and facilitators; (5) strengths and weaknesses of in-person and stand-by interpreting appointments; and, (6) recommendations: system and provider levels. Proposed interventions could include advertising language services among Filipino communities and educating them about their language rights, providing additional resources for language assistance, employing more PMIs, training staff/providers, and supporting the use of PMIs versus untrained individuals.One in every eight persons in Hawaiʻi, USA, have limited English proficiency (LEP) and are entitled to free language assistance for federally funded services under Title IV of the Civil Rights Act of 1964. They also have the right to culturally and linguistically appropriate services (CLAS) provided by professional medical interpreters (PMIs). This study’s goals were to uncover barriers and facilitators of CLAS from the perspective of PMIs. PMIs for Filipino languages ( In the USA, almost 45 million people  . HawaiʻiFor people with LEP, there are multiple health inequities and long-standing disparities in their healthcare ,13. LEP Based on Title IV of the Civil Rights Act of 1964 and Presidential Executive Order 13,166 of 2000, patients are entitled to language assistance in both inpatient and outpatient settings . Any medThe provision of CLAS through language assistance via trained professional medical interpreters (PMIs) is critical for patient safety and effective patient–provider communication ,33. PMIsKnowledge gaps exist in the research focused on medical interpreter use, and there are few interventions addressing CLAS provision in healthcare ,43. ReseAlso, provision of CLAS by PMIs has been impacted by the COVID-19 pandemic . Some stThe objective of this study was to help fill the current research gap by exploring perceived barriers and facilitators to providing CLAS for Hawaii’s Filipino LEP patients, also referred to as clients, from the perspective of PMIs. Our aims were to (1) explore context-specific factors that influence communication, such as culture; (2) uncover barriers and facilitators to CLAS provision; and (3) elicit recommendations to improve CLAS provision.This study was conducted in collaboration with a community-based partner, Language Services Hawaiʻi (LSH), and used both quantitative and qualitative methods, i.e., surveys and interviews. Data were collected remotely via the Internet and in the English language.Participants were recruited via a community partner (LSH), the largest provider of interpreter services in the state of Hawaiʻi. In 2022, LSH completed a total of 2914 medical interpreting appointments for Filipino languages. Eligibility criteria included working as a medical interpreter and access to a device with an internet connection or a phone. Potential participants’ contact information was obtained from LSH. Recruitment was conducted via email or phone. Interested PMIs selected a date and time for the interview and were directed to an online consent form and questionnaire via secured Google Forms.®, except one, which was performed via phone due to connectivity issues. Participants (interviewees) and interviewer  did not have previously established relationships; participants were made aware of the study goals during recruitment and via informed consent. Participants knew that the interviewer had a medical background, was an immigrant to the USA (not from the Philippines), and had previous experience working with PMIs in the medical setting. In addition, three key informant interviews with community partners were performed one-on-one between October 2022 and May 2023 via Zoom® and phone.Individual semi-structured interviews were completed one-on-one in November 2022. All interviews were conducted via Zoom® software version 2023. The accuracy of transcription was verified by the principal investigator and a research assistant (U.K. and C.S.H.). Each interviewee was given a pseudonym to protect confidentiality, and all identifiable recruitment data were stored securely and separately from other study data. Each participant was remunerated for their time with an 80 USD e-Gift card. The study was approved by the Institutional Review Board at the University of Hawaiʻi at Mānoa.The audio recordings of interviews were transcribed using OtterThe questionnaire’s demographic data included age, number of years lived in the USA and Hawaiʻi, sex, race/ethnicity, country of birth, education, country(ies) where education was received, and level of education. Work experience-related data included interpreter training, experience with different interpreting appointment types , in-person, and stand-by), Filipino languages used for medical interpreting, months/years of experience as a PMI, and number of hours working as a PMI per week. Two Likert scale questions were “In your opinion, we need more trained Filipino interpreters in Hawaiʻi…” and “In your opinion, there are many healthcare appointments when an interpreter was needed, but none was provided…”. Response categories were as follows: agree completely, agree somewhat, disagree somewhat, disagree completely, and I do not know/no opinion/no experience.Semi-structured interview questions were developed by three researchers  using the Health Disparities Research Framework model to capture key components related to the levels and domains of influence . Questions were tailored to the study population with guidance from the Filipino cultural consultant (C.D.C.-U.) and community partner (S.M.Z.). See All data were collected and managed using the principal investigator’s secure Google Forms and Sheets. Quantitative data were analyzed using descriptive statistics: mean, standard deviations, range for continuous data, and percentages for nominal data. Qualitative transcript data were analyzed using conventional content analysis ,58. Two The collaboration with LSH facilitated access to the largest pool of PMIs for Filipino languages in the state. At the time of the study, there were 13 actively working PMIs for Filipino languages. The participation rate was 77% or 10 out of 13. Interviews ranged from 100 to 144 min. In February 2023, all interviewees received a written summary of their interview with an option to provide comments and have a follow-up call. One interviewee completed a 32 min follow-up call. In addition, there were three key informant interviews with the community partner.The participants’ age range was from 32 to 67 years old, but most were in their 50 s or 60 s. The number of years working as a PMI ranged from 5 months to 24 years. Seven worked less than 20 h per week, and three worked more than 20 h per week as medical interpreters. Of the 10 participants, 80% identified as female; all participants were Filipino immigrants from the Philippines and were college graduates. Most (70%) PMIs completed two or more training modalities. Ilocano (70%) was the most common interpreting language among PMIs. A total of 7 out of 10 were interpreters for two or more Filipino languages. Many (60%) were experienced in all interpreting appointment types: in-person, video, phone, and stand-by. The overwhelming majority (90%) agreed that there was a need for more interpreters for Filipino languages, and 80% agreed somewhat/agreed completely that there were health appointments that occurred without a PMI present while a PMI was needed. See Interviewees reported having interpreted in various inpatient and outpatient settings: pre- and post-surgery, during hospitalizations, and in various departments of all major hospitals in the state, such as oncology, endocrinology, cardiology, neurology, ophthalmology, gastroenterology, at the transplant center, during physical therapy, and in the geriatric, pediatric, pre- and post-natal, and mental health settings.Six main themes emerged from the qualitative analysis: (1) cultural and social factors that can influence patient–provider communication; (2) barriers to effective communication: patient, healthcare provider, and PMI levels; (3) facilitators of effective communication: patient, healthcare provider, and PMI levels; (4) COVID-19 and remote interpreting barriers and facilitators; (5) strengths and weaknesses of in-person and stand-by interpreting appointments; and (6) recommendations: system and provider levels. See The interviewees discussed several examples of how Filipino culture and family factors can influence patient–provider communication. Filipino patients were described as people who value respect and show respect, especially for older people, and defer to those in authority . Filipino patients put a lot of emphasis on communication, interactive engagement, being personable, and establishing a connection, especially with their healthcare providers. The interviewees described that often many family members participate in healthcare decision making, with the oldest family member usually making the final decision. One said, “It’s a family decision, especially medical treatment… It’s usually the oldest that makes that decision” (Rose). Plus, Filipino patients who are not digitally proficient or health literate rely heavily on younger and/or English-speaking family members for help. Interviewees also described that older Filipinos and recent immigrants are usually not familiar with the US healthcare system, may feel uncomfortable seeking care, and need extra support in their care. The interviewees noted that Filipino immigrants may mistrust providers, for example, because of perceived cost. An interviewee noted patients saying things like “‘I don’t want to pay for something I can’t afford’ or ‘I really don’t want to go to hospital. I don’t like doctors.’ There’s always the fear of going to a doctor, going to the hospital. ‘I don’t want to die in the hospital. I don’t! I’d rather die at home’” (Ginger).LEP Filipino patients were noted to experience multiple barriers to effective communication and interpretation. All interviewees perceived that feelings of shame and pride were Filipino patients’ barriers to acceptance of PMI services. The interviewees described a sense of embarrassment, “linguistic shame” (Basil), and a fear of looking incompetent. “What I found out is that a lot of it is pride. A lot of it is shame. It’s losing face by having somebody to interpret for you, speak for you” (Rose) and “Filipinos have a high pride” (Jasmine). The interviewees described Filipinos as feeling proud of learning English; in addition, English is required for social mobility. Thus, it may be difficult for some patients to admit to not understanding English well. The feeling of embarrassment coupled with the feeling of pride could be the reason some patients overestimate their English skills. One interviewee said, “They think that they [LEP Filipino patients] understood everything, but they did not think about the medical terminology” (Lilly). Additionally, Filipino patients may find it difficult to ask for help and speak up when they need help. The interviewees noted that Filipino patients did not want to appear needful. One said, “They don’t want to be seen as needy or poor, not to have money, and [that they are] not capable” (Rose). The interviewees also noted that some patients may believe that they have to pay for PMI services out of pocket. “Sometimes they’re afraid to ask for interpreters because they [LEP Filipino patients] are worried about the bills” (Basil). Others noted that some patients may refuse PMI services because they trust their family more to interpret, especially if the family member works in the medical field, or if they believe it is more convenient or more common to have a family member interpret for them. However, an issue noted with family interpretation included incomplete or inaccurate interpretation by family member(s). “A lot of times they [LEP Filipino patients] go in [to medical appointments] with their relatives. So, the daughter understood, the son understood, the cousin understood, the sister understood, but they did not try to relay it to the patient” (Fiona). Also, per interviewees, some patients may worry about confidentiality and the disclosure of personal or sensitive information. There is general confusion about the process of PMI services and their benefits. For example, “Because it [PMI service] is not presented to them [LEP Filipino patients] when they check in [for their medical appointment], I think they don’t know that it is even available to them” (Lilly).Per interviewees, healthcare providers’ barriers to effective communication were limited time and a perceived or actual rushed pace, including fast speech, which Filipino patients could view as a lack of compassion or attention. The interviewees described providers’ fast speech to be a challenge because of the complex and difficult terminology used in the medical field. Additionally, the interviewees had experience with providers who could not accurately assess the need for PMI services, discouraged PMI use, or asked a staff member or a family member to interpret instead of a PMI. One interviewee said, “If they [LEP Filipino patients] can answer ‘yes’ or ‘no’, they [providers] think they speak [English] well. So, they would say, ‘You don’t need an interpreter.’ I encountered two doctors saying that” (Iris). The interviewees also described their concerns related to communication when untrained medical staff act as interpreters, specifically when they have limited proficiency in Filipino languages, a lack of professional interpreting training, and possible feelings of resentment being pushed outside of the official role (job description).At the PMI level, several personal barriers to medical interpreter employment were noted. The interviewees described barriers such as variability of their income and needing to balance several income sources by choosing between interpretation and other jobs. One noted, “Few [people] want to interpret. There are no incentives. There’s no pension. There’s no 401-K. There’s no health insurance. So why would they [PMIs] [want to] interpret?” (Jasmine). It should be noted that most PMIs in the USA are independent contractors responsible for their own finances, including retirement savings, health insurance, etc. Lastly, the interviewees described medical interpreting as a high-intensity job requiring focused concentration and mental prowess, which can induce stress and fatigue, limiting the number of continuous hours a PMI can work.At the patient level, facilitators to effective communication and interpretation included an overall willingness to accept medical care, a previous positive experience with a PMI, and continuity of care with the same PMI. The interviewees noted that LEP Filipino patients tend to understand the value of PMI services after having experienced communication with their provider with the help of a PMI. One interviewee said, “A positive experience will provide future opportunities for families and providers if it’s done properly. That’s why the [PMI] training is very important. It [willingness to accept PMI] can change because they  have had a positive experience” (Ginger). The interviewees stated that having an established trust with a healthcare provider also helps improve communication. Plus, having the same sex PMI and healthcare provider may be important for gender-specific care .Per interviewees, healthcare provider-level facilitators included the ability to recognize language needs as well as health literacy and literacy barriers among their patients. Also, it is helpful when the provider has knowledge of available resources, plans for language services in advance, and can discern when a PMI is needed, such as for important decision-making conversations or surgical consents. Other communication facilitators were providers drawing or using pictures, speaking slower, and using simple or plain language. One interviewee gave an example, “I’ll ask the doctor, ‘Can you please draw the heart and the different valves? Which part of the valve is being replaced?’” (Fiona). The interviewees also noted that providers’ commitment to the principle of benevolence, treating patients with dignity, and following their professional ethics and standards also facilitated effective patient–provider communication.At the PMI level, the interviewees acknowledged multiple facilitators, such as the importance of strong motivation, commitment, and joy in providing services for those in need. For example, “It’s a personal commitment to really help my community” (Basil), and “…sometimes they [patients] cry too, many tears of joy, meaning ‘Without you [the interpreter], we cannot understand!’” (Cypress). Being personally requested by a patient or provider to return for a follow-up visit resulted in the continuity of PMI work and was perceived as evidence of having performed their work well (facilitating effective patient–provider communication). The interviewees also described the importance of medical interpreter training and knowledge of medical terminology in multiple languages. One stated, “I do tend to interpret word for word. However, there are some [words] that may not exactly translate because of just the idiosyncrasy of the Ilocano language. There might be some English terms that require more of an explanation rather than one word… because of just the way that the language is” (Rose). The interviewees viewed prior experience in the medical field as a facilitator while training in healthcare ethics and standards, professionalism, confidentiality, and neutrality during interactions were noted to be imperative. Other facilitators described the importance of being a “good listener” (Ginger), being patient and flexible, and preparing for appointments. The interviewees believed that PMIs could make appointments more efficient and save time. One interviewee said, “Bringing an interpreter is the key to making it easier for the patient and for the provider” (Mimosa). The interviewees viewed themselves as a “bridge” (Basil and Iris) between American Filipino cultures and patients–providers. For example, “They [LEP Filipino patients] will ask [questions to the provider] because I’m [interpreter] their comfort blanket that knows how to speak respectfully and not to embarrass them…” (Jade) and “They [LEP Filipino patients] will admit something to the interpreter, but they will not admit it to the doctor, like not being able to read and write” (Fiona). All interviewees were Filipino-born emigrants to the USA and believed in understanding Filipino cultural healing practices and being able to facilitate culturally sensitive communications. As one interviewee said, “You [PMI] speak my language—you will understand my [LEP Filipino patient] experience” (Basil). The interviewees helped with patient–provider communication by encouraging providers to slow down and create space for their patients to ask questions. One said, “They [providers] try to understand more, explain more, and spend more time with the patient… when there is an interpreter. They [LEP Filipino patients] talk more or they ask more questions’’ (Iris). Lastly, the interviewees discussed how their role allows the family to be there for support rather than to interpret. “Their [family] role is to be a moral support, to be with their loved one… not to interpret” (Rose) and “I’m here as your [LEP Filipino patient’s] mouthpiece, but also to empower you, to encourage you, and just give you strength to go through whatever it is that you’re going through” (Fiona).Prior to the COVID-19 pandemic, LSH did not offer video remote interpreting and had few interpreting appointments by phone. The interviewees reported that the pandemic reduced their job security because many in-person (face-to-face) appointments were canceled. However, the pandemic also enabled greater availability of remote interpretation through the adoption of new technologies for remote care and health communication. The interviewees had to quickly adapt to video remote interpreting in 2020, and by 2023, video and phone appointments comprised about 20–25% of all interpreting jobs at LSH.Barriers to remote interpreting included technical difficulties, such as not being able to hear, poor connection, echoes, and the critical need to have stable phone or internet connectivity. Several interviewees said, “Technology is great [only] when it works” (Mimosa and Ginger). It is imperative for all parties to have access to necessary devices  and to know how to use them. Per the interviewees’ experience, this was a serious challenge because some Filipinos did not have access to these technologies or were not proficient at using them. Furthermore, when interpreting over the phone or video, there can be pronunciation issues, making it extra difficult to communicate with patients and medical staff who have heavy accents. The interviewees did not recommend remote communication for older adults and patients with hearing, sight, speech, or other sensory impairments. Overall, interviewees perceived remote types of communication (via phone or video) as more difficult for patients to understand information, less personable, and a barrier for patients to speak directly with their providers. One interviewee said, “In general, I know a lot of patients don’t like the computer. Like I said earlier, I think because it’s not very personable. They [LEP Filipino patients] like to see somebody there [face-to-face]. Some say it is harder to understand [via video]” (Fiona). Plus, remote appointments can add logistical difficulties, such as connecting on time and locating the right department, phone number, and provider. Lastly, remote appointments tend to be canceled more often than in-person.Facilitators of effective communication and interpretation via remote options included convenience, specifically, not needing to drive and the ability to save time and money on gas. One said, “You don’t have to drive anywhere. If it’s on Zoom, you don’t have to get ready [physically], but I always get ready [preparation for the appointment] no matter what” (Iris). Other benefits included ease for the interpreter to access dictionaries as needed and a greater sense of privacy/anonymity for the patient.Besides remote interpreting, interviewees described other types of appointments to include in-person and stand-by or “shadow” interpreting. Stand-by can be performed either in-person or through video; it is when an interpreter helps only when the patient or provider needs help rather than doing word-for-word interpretation. Eight interviewees estimated that, in their experience, out of 10 stand-by appointments, at least half needed PMI assistance. The interviewees also thought that the stand-by option helped patients realize that they actually needed language assistance, become more accepting of help, and see the value of a PMI for better communication with their providers. The stand-by option was found to be a respectful way of allowing LEP Filipino patients to speak English at their level but ensuring that support was available for them and their healthcare providers on an as-needed basis. Despite that, many providers were not aware of the stand-by interpreting option for a situation when a patient or family member refused an interpreter.A few weaknesses of the “classic” in-person appointment included transportation challenges and the need to allocate more time and resources for driving, traffic, and gas. The interviewees perceived in-person appointments to strengthen communication because in-person, it is usually easier for all parties  to have clear and accurate communication, it is usually easier for PMIs to explain their role, and communication is more personable with greater ability to build rapport. Most interviewees described in-person appointments to be favored over remote by most patients and providers.At the system level, most interviewees agreed there was a need to better comply with existing Language Access law. From their perspectives, this could be achieved by continuously training more Filipino language speakers to become PMIs through educational and certificate programs. One said, “There should be enough resources to train interpreters, or to make materials out of these [Filipino] languages to make sure that eventually they become available for interpreters” (Basil). The need for additional resources included changes at the state level. “I think we should invest more funding in terms of providing language access for Filipino communities in Hawaiʻi because we are one of the major Asian groups here in the state of Hawaiʻi, and yet, our languages are not that supported” (Basil) and “The whole system of care, it is basically an unfunded law where organizations have to find ways to put it in their budget somehow” (Rose). One interviewee said, “You gotta make an incentive for providers. You gotta make it attractive to them to be able to provide it [PMI services]” (Rose). A recommendation for hospitals was to consider having more in-house interpreters, specifically for Filipino languages. A recommendation for language services providers  was to assign the same interpreter to a particular patient, if possible, for continuity and rapport. The interviewees stressed the importance of a culturally trained healthcare workforce. They recommended healthcare systems provide CLAS training for providers, administrators, receptionists, and all staff who engage with patients. In addition, hospitals should have an effective system to better identify patients in need of language services, including educating patients about the availability of and their right to ask for free interpreting services. The last recommendation was to increase public awareness of this right. The interviewees suggested encouraging local Filipino community leaders to aid in raising awareness utilizing the Filipino Community Center (“FilCom”), social media, Filipino radio and TV stations, and churches.For providers, the main recommendation was to support PMIs and to avoid using ad hoc interpreters (family members or untrained staff) as they might not have the skills necessary for interactive, critical, or complex medical conversations. The interviewees agreed that ad hoc interpreters should be used only in emergencies or for basic, comforting conversations . Additionally, providers should be mindful of the health literacy and literacy needs of their LEP Filipino patients and explain information in ways that can be understood, for example, with pictures or using simpler terms. The interviewees noted that providers should slow down when speaking, listen, and give patients time to speak. Lastly, the interviewees suggested that healthcare providers should be offered or required to complete continued education about CLAS, language access resources, the role and importance of PMIs, communication techniques, and the potential bias that may occur when family members are used as interpreters.The purpose of this study was to explore perceived barriers and facilitators to providing CLAS for Hawaii’s Filipino LEP patients from the perspective of PMIs. Interviewees described context-specific factors that influence patient–provider communication and barriers and facilitators to CLAS provision. They also provided recommendations about ways to improve CLAS provision.This study found that LEP Filipino patients in Hawaiʻi have been underserved. Based on the quantitative survey, the majority of PMIs for Filipino languages in the state are older and do not work full-time. A total of 9 out of 10 interviewees agreed that Hawaiʻi needs more interpreters for Filipino languages, and 8 out of 10 agreed somewhat or agreed completely that there were health appointments that occurred without a PMI present while a PMI was needed (this perception was based primarily on what PMIs heard from their clients). The LEP Filipino community in Hawaiʻi could benefit from learning more about their language access rights.To our knowledge, no prior studies have examined the perspective of PMIs for Filipino languages, but the findings of this study are supported by other research on the topic. In general, patients with LEP are at risk of being under informed and overwhelmed by the large volume of medical information given over a short time . This stPMIs are necessary for equitable healthcare because LEP patients should be able to understand communicated medical information the first time they encounter it. Healthcare organizations have a legal responsibility to provide information in a manner appropriate for all their audiences . This caWhile this study had many strengths, certain limitations and biases should be acknowledged. For instance, results may have been impacted by self-selection bias since involvement was voluntary. In addition, the use of interviews may have led to participants answering questions in ways that presented them in a more socially acceptable perspective. Moreover, all participants were recruited from a single community partner and worked for the same language services provider. This may have limited the generalizability of our findings, and since the study was focused on LEP Filipinos in Hawaiʻi, there could potentially be less generalizability to Filipinos living in other US states. The study is also limited by its specific focus on PMIs and their perspectives on the facilitators and barriers to effective communication. Although all interviews were extensive in length, with expert informants recruited via purposeful sampling, our sample size was limited. However, this can also be viewed as a strength of the study because of the focus on the perspectives of understudied PMIs’ Filipino languages. Plus, all interviewees were immigrants to the USA from the Philippines; thus, they had personal expertise and cultural competence. Research shows that as few as four expert informants can be sufficiently informative to develop a theory , and datFuture investigations should strive to create a more comprehensive understanding of the challenges to the provision of CLAS by garnering perspectives from patients, family members, healthcare providers, stakeholders, and leaders. Future intervention work may involve Filipino community leaders and organizations who strive to help educate the populations they serve about language access rights in healthcare settings. Other intervention work should include strategies to improve patient–provider communication with LEP patients. Furthermore, future research should also address other popular languages in Hawaiʻi, including Korean, Mandarin, and Chuukese (Micronesian language), among others.Language assistance is a patient’s right and not an option. The use of PMIs meets the legal requirements of Title IV of the Civil Rights Act of 1964 and should be offered to LEP Filipino patients. This study highlights the fact that there is an unmet need for language assistance for LEP Filipinos in Hawaiʻi. There appears to be a need for more resources and funding to adequately fulfill the Language Access law in the state of Hawaiʻi.To advance health equity, it is important to ensure LEP Filipinos are aware that language assistance via PMI is their right and is provided to them at no cost. At the system level, there should be more CLAS training for the healthcare workforce, and at the practice level, there should be more support for the consistent use of PMIs and not family or untrained individuals. PMIs should be included in all interactive medical conversations with LEP Filipinos. When LEP patients or their family members refuse PMI support, a stand-by option should be provided.


Psychological research examining the nature and workings of gratitude has burgeoned over the past two decades. However, few studies have considered gratitude in the palliative care context. Based on an exploratory study which found that gratitude was correlated with better quality of life and less psychological distress in palliative patients, we designed and piloted a gratitude intervention where palliative patients and a carer of their choice wrote and shared a gratitude letter with each other. The aims of this study are to establish the feasibility and acceptability of our gratitude intervention and provide a preliminary assessment of its effects.This pilot intervention study adopted a mixed-methods, concurrent nested, pre-post evaluation design. To assess the intervention’s effects, we employed quantitative questionnaires on quality of life, quality of relationship, psychological distress, and subjective burden, as well as semi-structured interviews. To assess feasibility, we considered patients and carers’ eligibility, participation and attrition rates, reasons for refusal to participate, appropriateness of intervention timeframe, modalities of participation, and barriers and facilitators. Acceptability was assessed through post-intervention satisfaction questionnaires.p = .034) and total score . Thematic analysis of interviews indicates that overall, the intervention had: (1) multiple positive outcomes for over a third of interviewees, in the form of positive emotional, cognitive, and relational effects; (2) single positive outcomes for nearly half of interviewees, who experienced emotional or cognitive effects; (3) no effect on two patients; and (4) negative emotional effects on two patients. Feasibility and acceptability indicators suggest that the intervention was well received by participants, and that it should adopt flexible modalities (e.g. writing or dictating a gratitude message) to ensure that it is feasible and adapted to individual needs and preferences.Thirty-nine participants completed the intervention and twenty-nine participated in interviews. We did not find any statistically significant pre/post intervention changes for patients, but found significant decrease in psychological distress for carers in terms of depression (median = 3 at T0, 1.5 at T1, Larger scale deployment and evaluation of the gratitude intervention, including a control group, is warranted in order to have a more reliable evaluation of its effectiveness in palliative care.The online version contains supplementary material available at 10.1186/s12904-023-01172-x. Whilst psychological interventions in palliative care have concentrated on the treatment of psychopathologies such as depression and anxiety, the past two decades have witnessed mounting interest in the positive psychological factors that can improve the quality of life of palliative patients and their family carers. One of these positive determinants is gratitude. The concept usually refers to either a personality trait, i.e. a grateful disposition that is “part and parcel of the good life” and helps people to perceive and appreciate the positive in their lives , 2; or tThese associations have underpinned the development of interventions designed to foster gratitude, usually through journaling, with participants listing the things they are grateful for, or behavioural expression of gratitude, whereby participants write and share gratitude letters with close ones , 6, 7. MIf the bulk of the research on gratitude has initially been undertaken in non-clinical contexts, notably involving college students , some eaBy contrast, few studies have considered gratitude in palliative care contexts , 19. YetOn the basis of these findings, we designed and piloted a gratitude expression intervention in palliative care for patients and a carer of their choice. The novelty of the intervention lies in reciprocal expressions of gratitude by dyads of participants (a patient and a carer), who wrote a gratitude letter to each other and shared it. We hypothesised that our gratitude intervention – through which participants were asked to reflect on what they were grateful for, express their gratitude, and receive the gratitude of others – might help people to gain greater awareness and appreciation of the positive in their lives. We also hypothesised that involving patient-carer dyads might lead to greater impacts on interpersonal relationships than interventions with single participants. The aims of this study are to establish the feasibility and acceptability of our gratitude intervention, and to provide a preliminary assessment of its effects.This study was conducted in three partner palliative care institutions in French-speaking Switzerland: Rive-Neuve Foundation, Fribourg Hospital, and Lausanne University Hospital. It was approved by the Ethics Committee of the Canton of Vaud. Recruitment took place between November 2018 and March 2020. We initially aimed to recruit 30 patient-carer dyads, following good practice recommendations for pilot studies , 29 – wiThis two-phase pilot intervention study adopted a mixed-methods, concurrent nested, pre-post evaluation design – characterised by a unique data collection phase, a predominance of quantitative methods, and the deployment of qualitative data collection and analysis methodologies to make sense of and enrich statistical findings . To asseTo assess feasibility, we considered: 1) patients and carers’ eligibility rates , participation rates (the proportion of informed patients/carers who gave their written consent) and attrition rates , 2) reasons for refusal to participate, 3) appropriateness of intervention timeframe, 4) specific modalities of participation, and 5) barriers and facilitators in undertaking the intervention. These criteria are aligned with the British National Institute for Health Research’s guidance for feasibility studies . AcceptaIn the first study phase, we collected baseline quantitative data on our four indicators, then asked participants to perform the gratitude intervention within a 7 to 10-day period. To do so, we provided them with short instructions on writing their gratitude letter . We shortened quantitative assessments in an attempt to improve feasibility , which enabled us to undertake post-intervention quantitative and qualitative assessments during a single appointment. The study was opened to patients wishing to participate on their own, without involving a carer, or wishing to designate a healthcare professional as the recipient of their gratitude message, instead of a family carer. We also proposed alternatives to letter writing, i.e. dictating or audio-recording messages of gratitude.In the first phase of the study, we used standardised and validated questionnaires to assess: (1) quality of relationship – Couple Satisfaction Index, CSI-4  and PosiIn the second study phase, we selected one to two items per indicator – quality of relationship: last two items of CSI-4; quality of life: single question about global, subjective quality of life from the MQoL-r and QOLLTI-F V2; psychological distress: two items of the Integrated Palliative Care Outcome Scale (IPOS) French version ; and subQualitative data was generated through semi-structured interviews  and 16 carers , whose socio-demographic and/or medical data are shown in Tables As shown in Fig. Twenty-three participants  provided us with quantitative feasibility data on timeframe and transmission modalities. On average, participants took 1h10 to write their letters . All respondents found that the time allocated to the intervention (7 to 10 days) was sufficient. Transmission modality were heterogeneous: eight people exchanged their letters (by post or by hand), four read it aloud to the other, three read together silently, three were hesitant about sharing their letters, and one person wrote after the recipient (patient) had passed away. Data is missing for four participants. Overall, 15 patients and 15 carers completed the study as part of a dyad, and 8 patients completed it on their own, as did a carer, whose relative completed T0 only. Whilst the majority of participants  wrote their letter themselves, two were helped by their relative, three dictated their letter to a researcher or volunteers, and two audio-recorded their message with a researcher.Thematic analysis of interview transcripts enabled us to identify three main intervention facilitators: (1) awareness of one’s own thoughts and feelings , which led some participant to experience letter-writing as self-evident (“the words were nearly ready to come out”); (2) ease with writing (“I write quite easily”); and (3) gratefulness in everyday life (“it’s an attitude that I cultivate”), which some participants experienced particularly strongly since the illness . Participants faced four main barriers: (1) written expression difficulties (the letter was “torn and torn again”); (2) physical difficulties (“I was very very tired”); (3) unprocessed memories (“there are things that I erased from my memories”); and (4) difficulties expressing or receiving gratitude (“I find it intimidating that someone can say “thanks” to me”).Through Likert scale answers , participants reported that the intervention was rather beneficial and had rather improved their quality of life, quality of relationship, meaning of life, psychological wellbeing, feeling of love or friendship, and the image they have of their relative (median: 3). They inferred that the intervention would be beneficial in the future (median: 3.5) and would absolutely recommend it to others (median: 4).p = 0.034) and total score , as shown in Table As shown in Table Thematic analysis of interviews indicates that overall, the intervention had: (1) multiple positive outcomes for 11/29 participants , in the form of positive emotional and cognitive effects and, for five people, positive relational effects; (2) single positive outcomes for 14/29 participants , in the form of either emotional or cognitive effects; (3) no outcome for two patients; and (4) negative outcomes for two patients, in the form of negative emotional effects. We identified seven main effects of the gratitude intervention, which are depicted in Fig. Gladness. When narrating their experience of the intervention, 21 interviewees spoke of the gladness – understood as “a positive emotional response to circumstances”  what a marvellous wife I have!” […] I was in a very very strong, very positive emotion of absolute gratitude and love”.Openness to emotions in everyday life. Four people were inspired by the intervention to express or practice gratitude more broadly . Others opened up to their emotions more generally, as a sister-carer explained: “it enables me to allow myself my emotions”.Personal strength. A fourth effect relates to a perceived increase in personal strength or worth, which was mentioned by six participants. Some people remarked that the intervention gave them the strength “to keep going forward” (partner-carer) or helped them be “more serene towards some reactions” (partner-carer). Others felt more worthy of gratitude , or anticipated that the intervention might help them stay strong in the face of adversity .Heightened awareness. Eight participants mentioned gaining greater awareness of the other’s support , difficulties , or gratitude . One patient further explained: “it made me understand a bit how I am on the inside […] in the illness and in pain”, which led him to “try to communicate differently when I feel I’m not well”.Strengthened relationship. Five participants talked about the intervention as strengthening their relationship with their relative . For a carer, the intervention brought out a “much more altruistic, much stronger” dimension and “a truly strengthened bond” to his relationship with his partner.The aims of this study were to assess the feasibility and acceptability of a gratitude intervention for patients and carers and provide a preliminary assessment of its effects. Our results indicate good feasibility: eligibility rates were particularly encouraging; patient’s participation rate was comparable to other psychosocial and existential intervention studies –52 and iSome people were particularly interested in gratitude and regarded the intervention as a welcomed opportunity to express emotions they were already fully aware of. Others found it difficult to express themselves, struggled with physical difficulties , or initially felt “unworthy” of gratitude. To overcome written expression and physical difficulties, gratitude interventions could rely on alternative forms of expression, such as recording a gratitude message, which enabled us to include people for whom writing represented a major obstacle.Reasons for refusal to participate highlight a lack of interest in writing a gratitude letter in 35% of informed patients. Some found the research context “artificial” or not “spontaneous”, which seems to echo a general tendency to underestimate the potential positive impact of expressing one’s gratitude –55. MoreThese findings, alongside notably heterogeneous modes of participation, expression, writing time, and transmission suggest that flexibility is key to ensure that the intervention is feasible and adapted to individual needs and preferences . For insUnlike other, larger scale gratitude intervention studies, we did not find quantitative correlations between our intervention and patients’ outcomes. We found a small but statistically significant post-intervention reduction in depression and psychological distress in carers, mirroring results from the wider literature on gratitude . The genStill, in interviews, the narratives of most participants were studded with the difficulties that they faced in their everyday lives, which might be affecting their quality of life but were not captured by questionnaire results. This trend points to the limits of our quantitative assessment in capturing participants’ experiences, as noted by several people in interview (“your questionnaire had nothing to do with what I wrote”), suggesting that our choice of quantitative indicators was not optimal. Whilst our quantitative results are less encouraging than other gratitude intervention studies in oncology –17, the In this context, interviews were key to gain a better understanding of the experiences, perceptions, and relations of our participants. Qualitative analysis reveals that 25 out of 29 interviewees experienced positive emotional, cognitive and/or relational effects of the intervention. Qualitative data suggests that the intervention contributed – even if in a small or transient way – to emotional wellbeing, with a majority of people experiencing gladness at some point during the intervention, and to personal growth, as nearly half of our interviewees gained a sense of personal strength, gratitude, greater openness to their emotions, or a heightened awareness of the other’s experiences and support. This is aligned with results from studies in oncology, which found that gratitude interventions increased daily gratitude, daily self-esteem, and positive affects in participants , 16. SucOur qualitative results also suggest that the intervention improved the quality of the relationship of over a quarter of our interviewees, awaking feelings of love and gratitude or directly strengthening relationships. This echoes results from a study in which women with breast cancer who undertook gratitude journaling experienced a significant increase in perceived social support from their partners and others . It alsoTwo patients noted overall detrimental effects of the intervention, in the form of anxiety and sadness. Both expressed distress thinking or speaking about their illness, suggesting that they faced difficulties living with severe illness. One person had to stop the interview after a few minutes because of the psychological distress she experienced when mentioning her illness. Indeed, this type of intervention can trigger difficulties and distress in participants, which are often not reported in the positive psychology literature but warrant particular attention. It is important for healthcare professionals wishing to suggest the intervention to their patients and / or their relatives to bear in mind that it can negatively affect participants, especially those for whom accepting life with severe illness is particularly challenging, and should not be proposed on a systematic basis.In this light, a promising way to utilise the gratitude intervention would be to integrate it into individual therapy, an approach that has proven effective in improving the mental health of adults seeking psychotherapy . Indeed,This study has several limitations. First of all, as this is a pilot and feasibility study characterised by low statistical power and without a control group, it is not possible to interpret our results in terms of intervention effectiveness or to transpose them to different contexts. It would be particularly interesting for future studies to consider gratitude interventions in different contexts worldwide to explore their relevance and potential effects across a variety of socio-cultural settings – as Tan and colleagues have done in Indonesia for instance . SecondlThis study has shown that our gratitude intervention, based on writing and sharing a gratitude letter, is feasible and acceptable. Qualitative analysis has highlighted beneficial effects on the majority of participants in terms of emotions, cognition and, for some, relationships. Larger scale deployment and evaluation of the gratitude intervention, including a control group, is warranted in order to have a more reliable evaluation of its effectiveness in the palliative care setting. To do so, quantitative indicators could be adapted to capture the effects identified through qualitative analysis. A simple quantitative design in the form of a short questionnaire would also ensure minimum burden on participants, which might help improve retention rates. Furthermore, identifying and including patients and carers experiencing relational or emotional distress might help to better understand the potential impact of the intervention and improve participants’ representativeness. Finally, the intervention should adopt flexible modalities (as in phase 2 of this study), whereby people could chose to participate on their own or with a person of their choice, and to write, dictate, or record their message.Based on our data, we believe that the integration of a gratitude-based approach into individual therapy may offer the greatest potential for clinical applicability and usefulness. We will explore this hypothesis in a future study.Additional file 1. Instructions for gratitude intervention.Additional file 2. Semi-structured interview guide.


Utilizing cognitive psychology as a foundation, this paper offers a deeper consideration of contemporary theoretical influences on coaching pedagogy. Countering recent dichotomies suggested between pedagogic approaches, we reintroduce key findings from the cognitive tradition and their implications for practice which coaches may find useful. Using cognitive load, novice and expert differences, desirable difficulty, and fidelity, we suggest that the lines drawn between different “pedagogies” may not be as sharp as suggested. Instead, we suggest that coaches avoid defining themselves as being aligned to a specific pedagogical or paradigmatic stance. We conclude by advocating for research informed practice, absent of strict theoretical boundaries and instead, considering contemporary pedagogy as drawing on the needs of the context, the experience of the coach and the best available evidence. Across all levels of sport, the role of the coach is to support athletes to acquire, develop and enhance sporting (and non-sporting) attributes, skills and understanding . ConsequDespite this necessity and the practical need, pedagogy has tended to be marginalized across research and coach education cf. , 7, 8]. , 8. 7, 8Exemplifying this, recent literature has seen a significant growth of skill acquisition as a pedagogical domain of study. Concurrently, differences in theoretical foundations have led to a domain specific dichotomy between pedagogical tools deriving from Information Processing (IP), such as contextual interference within practice design [cf. ], and EcRecently, a range of papers have discussed the notions of contemporary pedagogy, one that is underpinned by ED and in contrast to a “traditional pedagogy” based on earlier learning theories such as cognitivism, constructivism and pedagogical theories of instruction e.g., –19]. Fro. Fro19)]Thus, the purpose of this paper is not an attempt to advocate for individual pedagogic stances over others, nor to challenge the utility of any particular perspective. Instead, by highlighting elements of cognitivist learning theories, we aim to challenge their association with, and pejorative use of, the term “traditional” pedagogy [cf. ]. In turOne of the most prominent theories emerging from cognitive educational psychology is cognitive load theory (CLT). A core feature of CLT is the emphasis on prior learning as shaping the ability of the participant to engage with coaching . In esseIn contrast to the lay use of the term, Sweller  suggesteFrom a coaching perspective, it is essential to consider how learning design and coaching approach can impact the different forms of cognitive load; intrinsic and extraneous . IntrinsCognitive psychology has historically and repeatedly emphasized that effortless learning is ineffective . A reducThis notion of what is desirably difficult is based on the needs and stage of the participant. In understanding the needs of participants, a range of key theories, such as Fitts and Posner's  stages oExpanding this, across multiple performance domains, research has attempted to identify features which typify expertise. These include features such as speed with which decisions are made, in that experts may be slower at first to solve a problem when compared to novices but will be quicker overall , or thatThe final area for consideration is the notion of fidelity of practice. Highlighting the complementarity of theoretical positions, fidelity has roots in behaviorism  and hasThis pedagogic emphasis has been mirrored by the cognitive literature in motor learning with the specificity of practice being consistently emphasized . Theoriei)The necessity for valid assessment of prior knowledge and ability ii)A consideration of pedagogic methods designed to maximize the resources devoted to what needs to be learned, rather than extraneous factors iii)Tracking learning over time In this sense, learning is not always seen as resulting from engagement, but instead a process that can and should be planned for and orchestrated by the coach. For example, the “extended challenge based framework for practice design in sport” (Building from these concepts and to further challenge sharp dichotomies, here we outline evidence-informed implications. Thus, illustrative of meaning, we suggest three general pedagogic implications;n sport”  suggestsn sport” . Once thn sport” ], the len sport” . These dn sport” . Learninn sport” , 69. It Similarly, a coach's approach to practice should also be based on desirable learner experience. Here, more direct approaches may be appropriate for the early stages of learning, or when learning design promotes a significant intrinsic load, a more direct approach is likely appropriate . Later,In concluding, our aim throughout this paper has been to offer a perspective on the issue of “contemporary” practice in sport pedagogy and to gently challenge conceptions of practice that seem to associate cognitive theories with a very particular form of learning design that may be “traditional” in some settings. For us as practitioners and pragmatic researchers, we are interested in the value of knowledge for practice and the difference it makes . For thishould be what works for those we are coaching, based on the needs of the context and the best available evidence; the very essence of evidence-informed practice (Furthermore, whilst this perspective article highlights constructs developed through cognitive psychology, we by no means suggest that they present answers to all the pedagogic problems we face. Our aim is to progress beyond oversimplifications such as notions of a “contemporary pedagogy”. This is especially important with the growth of alternative representational theories beyond those of the cognitive tradition . Aspractice .


Improving medical students’ wellbeing and empowerment through curricular activities is a topic of interest worldwide. Mindfulness-based interventions (MBIs) are increasingly implemented in medical education often as part of elective courses. To better understand training outcomes and adjust curriculum to students’ needs, we will explore why will medical students participate in meditation-based education?We analyzed 29 transcripts from the first session of an 8-week MBSR program offered to medical students in French. Transcripts were coded and analyzed using a qualitative content thematic analysis and the constant comparison method.Analyses resulted in three themes describing students’ motivation: (1) Medical education and the physician’s role, i.e. improving interpersonal skills, acquiring skills oriented toward a more integrative medicine, being more productive in a highly competitive context. (2) Caring for my health i.e. aiming at stress reduction, emotion regulation, and improving self-compassion. (3) A quest for meaning, i.e. optimizing meaning of care, and meaning of life.The results highlight the congruence between the perceived motivations and the evidence on the effect of mindfulness on self-care, the development of humanistic medical skills, and the meaning of care. Some findings raise the issue of the limits of using mindfulness to enhance one’s productivity. Notably, participants articulated the need for self-care as in mindfulness training, with the ability to care for others.The online version contains supplementary material available at 10.1186/s12906-023-03949-2. Medical students are particularly at risk for mental health problems and academic burnout worldwide –3, incluone’s motivation sets the conditions for personal growth and the possibility of change [shifts along a continuum from self-regulation to self-exploration, and finally to self-liberation as the meditators continue to practice [Although much work has been done on how and when these electives courses should be offered in medical school, very little is known on the view of users. Moreover, since the impact of course, including the transformative aspect of mindfulness –20, depef change . Accordipractice . As in mFrom a psycho-educational perspective, ‘motivation to learn’ has been described as a student’s ‘energy and drive to learn, work effectively and achieve to their potential’, in addition to the behaviors associated with this energy and drive . Hence, Our study will use this clinical data from MBSR training to investigate the following question: why will medical students participate in meditation-based education? In this study, we wished to uncover their motivations as these could be key to explain future adherence and effects of MBI.In order to meet these objectives, the present study will analyze the transcript dialogue collected during the first session of an MBSR training proposed to medical students. Within the first session of the program, the dialogue period is framed to be a collective semi-directive interview focused on motivations to participate.The MBSR program was offered between November 2019 to January 2020 to medical students as an elective course. The courses took place in a research center affiliated to the Université Paris Cité. Potential participants were informed about this class through social media. They were then included after participating in an orientation session regarding the modalities of the program and the research. Students were informed that their participation would not affect their academic and clinical training. The class was offered as a pilot project to any level of medical training from the beginning (years 2) to the end (residency). Inclusion criteria were: (1) attendance to the orientation session, (2) studying in a medical school in Paris (year 2 to residency), (3) studying in Paris, (4) minimal age of 18, (5) volunteers, (6) never participated in an MBSR program before, (7) no mental health disorders as screened by a medical doctor during orientation session . The study was approved by an ethical committee (N°IRB : 00012019–34). The course was free of charge and participants did not receive financial compensation for their participation.Students signed up to attend the standard MBSR program, including 8-week group sessions of 2.5 h and a full day silent retreat . Each seDatas was collected during the first session of the MBSR program. This session was designed to explore, in depth, participants’ motivation to participate . At the “systematically identifying, grouping and, subsidiarily, examining the discourse of the themes addressed in a corpus” [step 1: familiarizing with data) and coded the transcribed text of each interview , and stayed semantically close to the participants’ wording. In a second step, we started the process of grouping codes into categories or sub-themes after coding the first transcript (step 3: searching for themes). During this inductive coding process, the researchers discussed the findings until mutual agreement was achieved (step 4: reviewing themes). Then, connections between categories were then examined to form overarching themes (step 5: Defining and naming themes). The process of coding and categorizing were discussed at a research meeting with all authors. The constant iteration of these steps led to a deep understanding of the student’s motivation to learn mindfulness. The Consolidated criteria for Reporting Qualitative research (COREQ) [step 6: Producing the report).Thematic analysis is the most common form of analysis in qualitative research . Themati corpus” . Themati corpus” . It pinp corpus”  At first (COREQ)  were appParticipants received complete written information about the scope of the research, the identity and affiliation of the researchers, the possibility of withdrawing from the study at any point, and confidentiality. All participants provided written informed consent and the study was approved by the ethics committee (IRB: 2019-92).Twenty-nine students voluntarily joined the MBSR class and attended the first session. 62% were undergraduate ; Clerkship, n = 12(41%)), 45%(n = 13) were residents (n = 13), 65% (n = 20) were women. Mean age was 25.9 years old. 3(10%) students have already meditated. Participant characteristics are shown in Table 5%; ClerkWe identified three overarching themes based on views shared by students on their motivations to participate in the mindfulness-based class. These themes varied on their nature of politically correctness, as well as their personal nature. The first theme gathers motivations relevant to medical training and the professional role of the physician. The second theme gathers codes pertaining to the need to take care of one’s own health. The third theme gathers reports on searching meaning in medical practice and life in general. Themes and subthemes are summarized in Fig. First, participants reported motivations related to medical education in line with their commitment to their studies. Participants wished to improve their skills. Within this theme, we were able to identify four subthemes.“I thought I liked being in a relationship, a real relationship with the patients and the people we were talking to(E7)”.“I hope to be able to find the right words a little more and to have a sympathetic ear(E24)”.Participants expressed a need to develop interpersonal skills allowing them to develop more meaningful relationships with their patients. They mentioned the lack of resources related to the communication skills they had access previously, before engaging in the MBSR program.“Why I’m really really here, I thought it might teach me to understand my emotions(E4)”.They wanted to learn how to develop a relationship being more centered on the patient’s needs. At the same time, they wished to acquire skills allowing them to step back from the overwhelming emotions they reported in the healthcare relationship. Some shared experiences of conflict, unpleasantness, or emotional contagion during care. The need to better control one’s own emotion, such as aggressiveness or emotional variability, was also underlined.“I like to test everything I offer my patients so I find it interesting to know what we’re talking about, so that was the primary reason(E21)”.Some participants would like to learn more holistic dimensions of care. They wished to participate in the MBSR program to learn about meditation as an element of a more integrative medicine that takes into account the body-mind connection. They also emphasized the desire to integrate meditation into their care activities, and therefore the need for training.“So there you go, as I was saying to M…, I was excited to do this (laughs)(E1)”.Some participants reported the too theoretical, perhaps too serious learning methods they experienced in their medical studies. Attending such a program seemed also a way to enjoy a new experiential learning experience. They wished to experience joy, desire, and enthusiasm and discover a new activity.“I wanted to __ not just to learn something but that __ or to learn things but to learn different things and that __for example we have time for exchanges. Finally, to have a__ a different pedagogy and to study in a way that is perhaps a little more interesting” (E11)”.They also reported the desire to be in a group and learn with and from others. Indeed, they looked for group training, insisting on fostering social bonds.“and actually what I was really interested in was the productivity (laughs) (…) __ I don’t know. I thought you’re able to multitask and be a better doctor(E5)”.Finally, participants mentioned aspects of productivity in one’s work. Medical students expected to improve their performance. Indeed, with humor and authenticity, some of them underlined their need to get better in order to be more productive. The challenge of medica studies and the competition was evoked, and some reported doubts to be able to do it. Meditation training could then represent a mean to enhance personal productivity.If the motivation turned towards others, echoing their function as future doctors, was often the first one mentioned by students, the motivation turned towards their own health was also rapidly put forward. Respondents produced a higher quantity of verbal material relating to this theme. It includes three sub themes: stress reduction and well-being improvement, taking time for oneself, and improving self-compassion.“I told myself that I was also doing it for myself. Because I realized not long ago that when it’s time to go to sleep, well, for me it’s more of an ordeal than anything else. And so I don’t sleep much and so I want to live it as a good moment and sleep well like everybody else. Yeah, to spend some good moments alone with myself(E26)”.Participants reported being motivated by stress reduction. They spoke about their anxiety and reported sometimes it had a strong impact on their daily life. Fatigue, lack of sleep or concentration issues were mentioned as elements related to stress, they wished to mitigate with mindfulness practice.I wanted to be able to better manage my emotions, to better take stock of them in order to be able to finally (speeding up of the voice) better take care of the patients(E3)”.Participants also mentioned the difficulty managing emotions, as an element often invading and impacting the quality of life but also the care relationship.“If I can understand myself better, I can understand my patients better (E27)”.At this stage of the program, they evoked the reciprocal link between their health and their role as caregiver. Participants spontaneously linked their responsibility to take care of themselves with their duty to take care of their patient.“to take the time to do things more slowly, to settle down, not to chain actions, thinking about what we were going to do afterwards etc. That’s what came to me first (E1)”.Another element of motivation seems to be simply the need to take some time without having a specific goal. Thus, enjoying time during the week to do something for themselves seemed to be an important motivator. Again, they recall the intense academic routine and a need to slow down. Participants expressed their wish to cultivate another relation with time, learn to anticipate less, and live more intensely in the present moment.voice trembling(E28)”. In response to the demanding nature of medical education, participants spoke of the need to learn to be more tolerant toward themselves. They thus reported a need to cultivate self-compassion. Some of the students had already been exposed to mindfulness practice and knew they would find in meditation.… a moment where I find I can allow myself to feel love for myself, it feels good(E28)”.“Taking care of oneself was evoked by some participants as an act of love, tenderness, and friendship. The evocation of this motivation emerged as a “surprising” need, giving way to emotions underlined in the non-verbal language “The content of the last theme underlies both previously presented themes, namely the care of self and others. This theme describes the need to find a greater engagement to continue learning, living, and caring along the medical studies and career. To train in mindfulness would support this quest, provide meaning to care and to life in general.“Because I knew that I had done meditation before and it felt good and I wanted to include it in my life in general and I couldn’t do it on my own so__ having some help is good(E9)”.In fact, many students had already heard of meditation, sometimes even had been meditating through yoga or other mind-body practices such as apps. They expressed a wish to deepen and pursue their experience. The desire to continue and integrate this practice into daily life as is proposed in MBSR practice was important.I also wonder if the fact that I take care of others is not purely selfish, to avoid thinking about myself. And so I want to help others because I want to help them and not only to escape from my head to head with myself(E27).I’ve always had a goal, always succeeded, to do this, that, that, so I move forward with a goal every time I’m given one and in fact I’m coming to the end of my studies... And so I think it’s important to sit down and say to myself what I want(E22).Through this quest for meaning, the quest for the meaning of the nursing profession is put forward. Indeed, as if the motivation to be there was to find an answer to the fundamental question of why I become a doctor, and how I wish to heal?“This question of doing actions that are right; so a need to have this guidance to really help me(E26)”.“I heard the word conviction that spoke to me, it’s more, I know it a little bit from experience that it feels good and there was a kind of certainty actually that surprised me(E26)”.For others, the questions raised were even more profound and dealt with the meaning of life itself. Participants mentioned a need to enrich their spiritual life. It seemed that in mindfulness practice they wished to develop a form of secular spirituality. They made connections between concrete aspects of training and some religious activities: using silence, fostering community, and developing goodness and non-judgment, and underlined their desire to cultivate it outside religion.In a qualitative analysis of verbal material collected in the first session of MBSR in 29 students, we found three broad categories of motivations. The first was a motivation to improve one’s own medical education and the physician’s role. It included motivations such as the need to improve interpersonal skills or other skills oriented toward a more integrative medicine or being attracted to an experiential learning framework. The second describes the need to take care of one’s own health, through reducing stress and enhancing self-compassion. The third refers to a drive of searching for meanings, of care and life. We will first discuss the coherence between the motivations of the students, their needs and the evidence available, then the new elements of understanding.The first striking aspect of the results is the fit between the perceived motivations of students and the objectives of the teaching as described in the scientific literature. This is particularly true with expectancies regarding mental health. In fact, empirical studies have demonstrated that in medical students, MBSR was beneficial to reduce anxiety, perceived stress and overall psychological distress , 32–34. The motivation to engage in a mindfulness course to cultivate a sense of care also seemed congruent with the development of curricula that offer a humanistic and holistic approach to medicine as is the case in Yale School of Public Health . These c“health is a relative state in which one is able to function well physically, mentally, socially, and spiritually to express the full range of one’s unique potentialities in the environment in which one lives”, spiritual care can be considered an essential component of medical care [Another interesting result in line with literature on mindfulness purpose concerned the motivation to cultivate one’s meaning of life. These results refer to the wisdom of mindfulness practice ,50. Conscal care . The spical care . In our (training to gain productivity). This search for increased productivity is actually at odds with the original spirit of mindfulness, more centered on the spiritual path for cultivating well-being and alleviating suffering [Participants from the present study mentioned the use of MBSR to enhance their performance uffering . This hiuffering  or in atuffering , have fouffering ,57, and uffering . They shTime was another important topic brought by participants. While some studies of medical students indicate that lack of time is seen as a barrier to participation in meditation programs ,59,60 ouWe should recognize the limitations of this work. First, the time allowed to each participant was limited and the format did not allow for each student to develop their thoughts with details. Second, some participants may have been reluctant to share personal feelings or motives as they were meeting for the first time. It is thus possible that transcripts contain the views of those who were sufficiently asserted to speak up. Other data collection methods should probably be used in the future . Some students, even if they had never participated in an MBSR program, had already meditated. This may have influenced our results related to congruence, although to a small extent as these were a small proportion.In a qualitative analysis of students’ motivations to participate in MBSR class we found a high consistency with the existing evidence on the effect of mindfulness concerning self-care, the development of humanistic medical skills, and the meaning of care. Some findings point to the risk of instrumentalizing mindfulness to use it as a tool to enhance one’s efficiency. One of the main motivations of medical students was to take care of themselves, in order to be able to take care of others, showing a paradigm shift for the new generation of physicians. Studying students’ motivations is essential to adjusting curricula.Below is the link to the electronic supplementary material.Additional file 1: Appendix 1 and 2


Implementation outcomes, including acceptability, are of critical importance in both implementation research and practice. The gold standard measure of acceptability, Acceptability of Intervention Measure (AIM), skews positively with a limited range. In an ongoing hybrid effectiveness-implementation trial, we aimed to evaluate clinician acceptability of induction standardization. Here, we describe an innovative mixed-methods approach to maximize the interpretability of the AIM using a case study in maternal health.In this explanatory sequential mixed methods study, we distributed the validated, 4-question AIM  to labor and delivery clinicians 6 months post-implementation at 2 sites . Respondents were grouped by total score into tertiles. The top (“High” Acceptability) and bottom (“Low” Acceptability) tertiles were invited to participate in a 30-minute semi-structured qualitative interview from 6/2021 to 10/2021 until thematic saturation was reached in each acceptability group. Participants were purposively sampled by role and site. Interviews were coded using an integrated approach, incorporating a priori attributes (Consolidated Framework for Implementation Research constructs) into a modified content analysis approach.104 clinicians completed the initial survey; 24 were interviewed (12 “High” and 12 “Low” Acceptability). Median total AIM scores were 20/20 IQR[20–20] in the High and 12.5/20 IQR[11–14] in the Low Acceptability groups. In both groups, clinicians were enthusiastic about efforts to standardize labor induction, believing it reduces inter-clinician variability and improves equitable, evidence-based care. In the Low Acceptability group, clinicians stated the need for flexibility and consideration for patient uniqueness. Rarely, clinicians felt labor induction could not or should not be standardized, citing discomfort with medicalization of labor, and concerns with “bulldozing” the patient with interventions. Suggested strategies for overcoming negative sentiment included comprehensive clinician education, as well as involving patients as active participants in the protocol prenatally.This study utilized AIM in an innovative sequential mixed-methods approach to characterize clinician acceptability, which may be generalizable across implementation endeavors. By performing this work during a hybrid trial, implementation strategies to improve acceptability emerged  for year 2, which will inform future multi-site work. In addition to the AIM questions, clinicians were asked demographic items including role, age, gender identity, and years in practice; survey responses were otherwise anonymous. At the completion of the survey, clinicians were asked if they would be willing to participate in the qualitative portion of the study, and, if willing, asked for their name and e-mail address to connect their survey response to identifying information.After survey closure, AIM scores were totaled and grouped into “tertiles”: highest 1/3 of scores (“High” Acceptability), middle 1/3 of scores (“Middle” Acceptability), and lowest 1/3 of scores (“Low” Acceptability) among all respondents. Tertiles were selected in order to ascertain positive and negative deviants and thus determine who would be the most data rich respondents for the qualitative section of our work. Skew of the AIM total score was determined using skew and kurtosis tests for normality.Clinicians who stated interest in participating were contacted from each of the High and Low Acceptability tertiles, with purposive sampling by clinician role  and site until thematic saturation was achieved for both the High and Low Acceptability groups. We monitored for thematic saturation in both acceptability groups by noting the emergence of themes by interview question at the conclusion of each interview. We determined the groups to be saturated when we ceased to observe novel themes in the answers to each interview question. A summary of this QUAN->QUAL approach is shown in Fig. The Consolidated Framework for Implementation Research (CFIR) was used to create the interview guide . InterviSemi-structured interviews occurred for those enrolled from June 3, 2021 to July 31, 2021 for Site #1 participants and September 1, 2021 to October 31, 2021 for Site #2 participants (9–10 months post-implementation at each site). Individual interviews were conducted in-person, via video conferencing software, or over the phone and lasted an average of 30 min. The primary investigator (RFH), an obstetrician trained in qualitative interviewing, conducted all interviews.Permission was obtained and all interviews were recorded. Audio from the interviews was transcribed by Datagain Transcription Services . The transcripts were then uploaded to NVivo 12 software for management and coding. A research coordinator trained in qualitative methods used an inductive process of iterative coding to ascertain recurrent relationships, themes, and categories and to develop the codebook. Then, we used an integrated analysis approach , identif104 clinicians across both sites completed the AIM survey, 61.5% from Site #1 and 38.5% from Site #2. Clinicians participating in the survey were evenly split among physicians and nurses, were primarily under 45 years of age, and 87.5% identified as female . In determining cut points for tertiles, those with scores ≥ 17 (n = 28) were placed in the “High Acceptability”, 14–16 (n = 33) in the “Middle Acceptability”, and ≤ 13 (n = 43) in the “Low Acceptability” groups. 42/104 (40.4%) of respondents reported willingness to participate in the qualitative aspect of the work at the end of the survey, which were distributed across acceptability groups . Those who agreed to participate in the qualitative work were overall similar in demographic characteristics to those who did not (results not shown).A total of 24 interviews were performed, 12 in the High and 12 in the Low Acceptability groups. Interviewees included 15 physicians , 2 certified nurse-midwives, and 7 registered nurses. Median total AIM scores were 20/20 [IQR 20–20] in the High and 12.5/20 [IQR 11–13] in the Low Acceptability groups, consistent with the positive skew of this value. Characteristics by acceptability group enrolled in the qualitative portion of the study are also shown in Table I love it. I find that there is a lot going on the labor floor, and so whenever there’s something [like] a protocol to rely on and actually physically point to, or just have at our disposal is very helpful.Broadly, participants reported positive sentiment regarding efforts to standardize obstetric care and to reduce rates of cesarean delivery. Regardless of acceptability group, providers were generally enthusiastic about the induction protocol and efforts to standardize labor induction. Participants cited a range of reasons for valuing standardized labor management, such as feeling that the intervention will make patient care more equitable and reduce variability between clinicians, that they appreciate being guided by evidence-based practices, or that they like having a tool for learning or to refer to if they receive pushback from patients or other providers.I think it’s good [to standardize labor practices], I think that aim to make sure that everyone is being cared for on the same level and given the same attention is good. I do think that there has to be room for specifications to the situation and to the patient, and so while it’s good to standardize things, I think you still have to be open to what happens and what changes with the patient specifically.While most participants reported they believed labor could be standardized, those in the Low Acceptability group were more likely to add nuance to this belief, noting that providers also need to be flexible and consider the specific needs of each unique patient.…Our clinicians are mostly lovely and are mostly telling women what they’re going to do, asking them if they’re okay to do it. I’ve just had a few incidents recently where I felt like people were being bulldozed a little bit.I don’t think women are standard. I think it’s very challenging to work with sort of a checklist checkbox model of labor, induction, birth, any of those things. I feel like a lot of our patients feel very vulnerable and almost assaulted by the process and in some ways I feel I’m almost in a position of needing to protect my patients from sometimes excessive intervention and rushing of interventions that they may not be fully educated about or really informed of, or consent to. Like people just walking in the room and saying, “We’re going to break your water now.“Occasionally, participants in the Low Acceptability group felt labor induction could or should not be standardized. Those who felt induction should not be standardized cited several reasons: (1) They felt patient education levels about treatment options vary. Clinicians did not always believe patients were given the opportunity to fully learn about intervention steps before being asked to complete one; (2) The perception that labor and delivery should not be medicalized more than is necessary.Participants discussed several key barriers to protocol use, which were primarily focused on the CFIR constructs of Inner Setting (such as lack of adequate staffing or time) and Characteristics of Individuals (including clinician and patient factors).[The barrier] is the volume [of patients] and the lack of providers being available at the right time. I feel like as a nurse, there are definitely times– like just yesterday—where…they said [the patient’s next cervical exam should be] around 1:00…And then generally, it’s like, ‘Oh, well, there are a couple of deliveries, but we’ll be in here soon.’ I’m like, ‘You’re on the list and we know we’re supposed to check you at 1:00’, but there isn’t anybody to check.Almost all participants, regardless of acceptability group, described their floors as being very busy, with high patient volume, or not having sufficient staff to meet all patient needs in a timely manner. Participants tended to say these demands on their or their peers’ time impeded their ability to implement the protocol because they simply needed to be elsewhere, other cases were more urgent and needed to take priority, or that juggling so many tasks led them to forget a protocol step.Especially when we first started, there was a lot of grumbling … about treating patients the same, when they are different people.In regards to clinician factors, those in the High Acceptability group, made up of more physicians than the Low Acceptability group, more commonly spoke about lack of buy-in to the protocol from other clinicians.There are some patients...that come with a birth plan, they come with a doula, and they are pushing back on treatment or exams.Those in the Low Acceptability group were more likely to speak about patient resistance, rather than clinician resistance, to the protocol. These participants spoke about patients who, despite undergoing labor induction, wanted to let their body labor naturally or were distrustful of the interventions proposed.I think our culture has some problems, but instituting protocols is not one of them. We are very used to that. I think our culture is also that, we want to improve outcomes for our patients, but sometimes we just feel a little helpless as to the best way to do that, because some of our patients do come in with a lot of co-morbidities. So, to have toolkits that we know actually do help our patients, I think we’re very willing to embrace.Participants often described the culture of the included labor and delivery units as facilitative to protocol implementation.I think it made perfect sense… when I was presented with the information and the data, it was all sensible.Many participants, particularly in the High Acceptability group, felt that they were well educated on the protocol going into implementation, and had the opportunity to ask questions with open discussion.[In reference to nursing], I am sure there has been some education, but there should be even more. If there is education, about why we do [these induction steps], then I think some of the resistance to each step might be reduced.I think constant rotation of residents makes it hard to implement a protocol, like they start every month, and then they forget that there’s even a protocol.From both groups, participants agreed that nursing and resident trainee education around the protocol could be improved. In particular, there was focus on the number of residents rotating through labor and delivery, largely on a monthly basis, and that reminders were needed with rotation changes.Well, I think education is really important … I think the nurses are doing a lot of education on the spot, but it would be great if the patients had more education about induction on the front end.If there was something, some sort of handout, that would make it really easy.Participants from both groups agreed that better education of patients on the labor induction protocol is needed, with a focus on counseling about the protocol prior to admission for labor and delivery.I think that we’re driven by trying to be better and I think by seeing the things that we are not good at, it’s motivating to be better at them.When asked about the audit and feedback reports clinicians received regarding their fidelity to the protocol, participants all reported that they were both helpful and motivating to improve compliance.Measuring the acceptability of interventions accurately has proven to be difficult, despite its importance in implementation research. While the Acceptability of Intervention Measure is a validated and increasingly used measure in implementation science, the tendency for both interventions and their implementation strategies to receive high scores on the AIM assessment limits its utility. This study utilizes AIM in an innovative, explanatory sequential mixed-methods approach that harnesses participants with positive and negative responses to the AIM measure. This work was performed during the first year of a two year type I hybrid implementation-effectiveness study, and allowed our team to obtain a deep understanding of acceptability, both of the intervention itself (a standardized labor induction protocol), as well as the implementation strategies. As a result, we were able to develop concrete strategies targeted to improving acceptability to optimize the intervention and strategies for its implementation for year 2 of the parent trial.In a study most similar to this work, Hoskins et al. evaluated parent acceptability of a S.A.F.E. Firearm Program in pediatric care. Here, a sequential mixed-methods approach was also used, beginning with the quantitative AIM survey, and finishing with semi-structured interviews with a convenience sample of respondents . Their wThe notion of studying closest those with the most positive and/or negative attitudes towards a healthcare concept or intervention is not new. Positive deviance studies have focused on surveying and interviewing individuals successfully implementing interventions, with the goal of ascertaining valuable data to support others in similar implementation endeavors –12. SimiIn interviewing only those grouped into High (positive deviants) or Low Acceptability (negative deviants), we aimed to interview only those most data-rich respondents. As a result, we were able to develop 2 concrete strategies to improve acceptability in our work. The first focused on education. We initiated routine, multidisciplinary clinician re-education, to foster an understanding as well as community around protocol implementation. Next, we focused on involving patients as active participants prenatally. We developed a plan to educate patients, involving printed and electronic patient-centered information on labor induction, distributed to patients when scheduled for induction, as well as initiate ongoing conversations about labor induction and our methodologies throughout the third trimester, allowing patients to ask questions and prepare. We will evaluate the success of these implementation strategy adaptations in year 2 of our parent hybrid trial.The strength of this study is in innovative measurement of acceptability using a mixed-methods approach, resulting in tangible changes to an ongoing implementation study. This study has several limitations. First, those who elected to complete the AIM survey may represent a self-selecting sample, which may already be biased towards High or Low Acceptability. Our methodology also assumes that the most data-rich individuals are those at both the extreme ends of acceptability, without evaluating the opinions of those in the Middle. We included clinicians from 2 sites, although both diverse and disparate from each other, which do not necessarily reflect the large variation in geography and practice model of labor and deliveries across the US.In conclusion, this sequential quantitative to qualitative methodology provided insightful data for the implementation outcome of acceptability around a standardized protocol for labor induction. The mixed-methods process described is likely applicable to assessing acceptability in other healthcare implementation endeavors, with benefits beyond either quantitative or qualitative evaluation alone. After application to other disciplines and interventions, this methodology may be refined and validated. Thus, we may be able to advance the scientific rigor and sophistication of the study of acceptability in implementation science, with the goal of eventually reaching a superior “gold standard” for acceptability evaluation.