Low health literacy results in health inequity are linked with poor adherence to medical care. In the globalized Japanese context, the number of migrants with Japanese as a second language is increasing year after year. Since limited Japanese proficiency may pose a greater health risk, dentists are expected to manage cross-cultural communication and provide dental care to foreign patients. This study explored dentists’ experiences of treating patients with limited Japanese proficiencies. Semi-structured interviews were conducted with 11 community dentists and the qualitative data were analyzed through a thematic analysis approach. Their major challenges were classified into three themes—linguistic aspect , sociolinguistic aspect , and sociocultural aspect . Several management strategies were employed, including linguistic accommodation, avoidance of complexities, use of various communication tools, and getting help from others. However, they were unsatisfied with their practice because they could not understand the patients’ psychosocial aspects due to incomplete communication. These findings provided insights into dentists’ practice in the globalized context. The social determinants of health are the conditions in which people are born, grow up, work, live, and age and include a broad range of socioeconomic, environmental, political, and cultural factors that influence health status and equity . GlobaliMany previous studies investigated migrant patients’ perspectives on patient–provider communication and access to health services ,10,11. AAn effective communicative strategy, in a cross-cultural situation, is using plain language ,17. It iThe majority of research participants in previous studies were physicians and nurses. Although the oral cavity is a mirror of the rest of the body, as Sir William Osler recognized , dentistForeign residents in Japan amounted to 2.03 million in 2012. The number increased to 2.76 million by March 2022, which is about a 2.2% growth in the population (124.75 million) . MigrantForeign residents are required to obtain the public national health insurance in Japan. Patients pay 30% of the total cost to the clinic. Dental services under the health insurance system are available for most restorative, prosthetic, and oral surgery treatments, such as fillings, endodontic treatment, crowns, bridges, dentures, and extractions. However, higher cost items  are excluded. Preventive services are also excluded, as the current health insurance system only covers treatments for existing diseases .This study adopted an exploratory case study approach, which was informed by an interpretivist paradigm, for an in-depth analysis of the complex phenomenon of migrant patient encounters in community dentistry. Yin defines a case study as “an empirical inquiry that investigates a contemporary phenomenon within its real-life context”  (p. 16).Language management theory was employed as the conceptual framework. In this theory, comprehensive competence that integrates linguistic, sociolinguistic, and sociocultural aspects is essential for maintaining cross-cultural interactions in contact situations ,32. SpecThis study purposively selected 11 dentists with more than 20 years of clinical experience and who were practicing community dentistry in mid-size regional cities in Japan with some experience in treating and caring for migrants . In thisPlease share about the migrant patients with whom you have dealt, such as their countries, ages, the average frequency of visits per week, and their Japanese language proficiency level.What were your most memorable experiences in treating and caring for migrant patients? Please share in detail.If you have been seeing the same patients regularly, how did you build a relationship with these patients?Have you experienced any difficulties or challenges when communicating with migrant patients? Please share in detail.Did you have any special considerations for migrant patients? Please share in detail.Semi-structured interviews with the dentists were conducted in person or online, which lasted 30–50 min each. They were asked to share their experiences of cross-cultural communications with migrants with limited Japanese proficiencies, including the difficulties and management strategies used during these encounters. The interview questions were developed based on language management theory to show the processes of managing problems in cross-cultural situations. The main questions are as follows: The interviews were audio-recorded and produced verbatim as transcripts by the researchers. The excerpts of Japanese transcripts were translated into English by the first author. Subsequently, all members discussed the accuracy of the translation and reached a consensus on the final version. Translated excerpts were proofread by a professional English editing company. During this process, private identifiers were replaced with anonymized data, such as D1. For reporting this research in an audit trail, this study maintained careful documentation of all the components of the data analysis process, including raw data, coded transcripts, researchers’ notes, and analysis products.This study employed Braun and Clark’s reflexive thematic analysis in an inductive way for data analysis ,34. FollThis study was approved by Gifu University Institutional Review Board (No.2020-037). Confidentiality was assured for the content of their interview regarding patient–provider communication.The following sections provide the details of dentists’ experiences of providing oral treatment and care for migrant patients.In this study, the dentists did not have any major problems when working on a simple treatment and care for migrant patients, such as early cavities. However, they faced challenges when providing complex oral treatment and care, such as root canals, for migrant patients with limited Japanese proficiencies. This study categorized these challenges into three aspects—linguistic, sociolinguistic, and sociocultural issues. The dentists struggled with pronunciation, lexicon, syntax, and listening and speaking during conversations, including dentists’ lack of vocabulary for the patient’s language, difficulty in expressing complex, conceptual phenomena and procedures in simple Japanese, and difficulty in understanding patients’ feelings and symptoms in detail. For example, D7 found it difficult to explain the oral condition to a Brazilian patient and provide instructions for wearing dentures in simple Japanese. Moreover, although D7 recognized the necessity of a long-term treatment plan for the Brazilian patient, he had no way to explain this matter to the patient. In the end, he gave up on discussing the treatment plan and created the “temporal” dentures.I made dentures for a Brazilian patient. He had already lost some teeth, and his oral condition was terrible. … As it was the first time for him to wear dentures, he took a long time to do it, … and felt uncomfortable with them. Eventually, he gave up wearing the dentures, and returned home immediately after payment. If you think about his oral condition after 5 years or 10 years, these “temporal” dentures will not work, but I could not explain the long-term vision of his oral condition and treatment plan.(D7)Sociolinguistic issues relate to knowing whom to speak with and when, about what, and how to speak. This partially overlaps with the linguistic and sociocultural aspects as it addresses communication concerning the patients’ status, expectations, and perceptions of the dentists’ roles. For example, the dentists found it difficult to communicate with migrants with limited dental knowledge and inadequate oral hygiene habits. Communicating effectively with such patients to explain the treatment plan and encourage them to adopt better oral health habits is challenging. D6 had difficulty when there was a gap between the patient’s expectations and his treatment plan. Specifically, D6 felt that many migrant patients wanted the decayed tooth to be extracted to relieve toothache, whereas he, as a dentist, wanted to treat these teeth as much as possible.When foreign patients have a toothache, they want to pull it out right away because they couldn’t bear the pain, but, as a dentist, I see that some teeth can be treated without extraction. In such cases, it is very difficult to explain and persuade the patient to have dental treatment. Umm, if the patient was Japanese, it would be much easier to convey my opinion. As a dentist, I cannot extract teeth simply because of a toothache.(D6)Sociocultural issues include difficulties caused by different cultural values, norms, and social systems between Japan and the patients’ home countries. For example, D5 thought that the migrants prefer white filling for their dental aesthetics. However, white fillings for the back tooth are not covered by health insurance in Japan, therefore, they need to pay for this treatment out of their pocket. D5 struggled to deal with this case, complexly intertwining their aesthetics, cultural values, expectations, and health insurance coverage. One of the biggest challenges is explaining health insurance system in Japan to foreign patients. Particularly, people from Brazil dislike silver fillings. … So, if they wish to have white fillings, it would be at their own expense. In this situation, it is difficult to explain why it cannot be offered within the insurance application range.(D5)Responding to the identified problems, the dentists planned and implemented adjustments for the cross-cultural encounters. This study identified five management strategies that they employed, including linguistic accommodation, the use of various communication tools, sharing interests to build rapport, seeking help from others, and avoiding complexities.Dentists employed linguistical and para-linguistical adjustment strategies to help in cross-cultural encounters, such as speaking slowly, using short phrases and words, mixing Japanese with English vocabulary, written conversation, and expressing it clearly. Moreover, if a patient was from China, the dentists communicated by writing Chinese characters, which are ideographs. For example, although the Japanese language, culturally, prefers indirect expressions, the migrants could not fully understand this nuance. Therefore, D11 avoided indirect expression regarding dental treatment and paid attention to straightforwardly explaining tooth extraction. If the patients are Japanese, I can say to them, “I’ll do my best” or “I try to do what I can” because the subtle nuance of my meaning is conveyed to them. I feel that I need to express my opinion clearly and in a straightforward manner to migrant patients …For example, if I say, “I’ll make an effort not to extract your tooth,” the migrants may not fully understand my meaning. So, I would say that “I will pull out your tooth when I find it difficult to treat your tooth.”(D11)The dentists adopted several communication tools, such as translation apps, visual information , and multilingual manuals for dental communication. In case a dentist found it difficult to “verbally” explain the complex treatment procedures and materials, another medium of communication, particularly visual information, was employed. For example, D2 visually explained root canals to migrant patients by using a video of treatment planning. This was useful in explaining the procedure. Nevertheless, if the patients had further questions and opinions, the interactive conversation was difficult to develop.We have dental practice management software, which includes visual treatment planning with explanation videos. Using this software, various treatment procedures, such as root canals, and types of fillings can be visually explained. If I really want the patients to understand what I explain, I use this software. … I think it works to some extent.(D2)D3 emphasized the importance of sharing common interests to build a better relationship with migrant patients. Particularly, D3 thought that many migrant patients feel nervous when seeing dentists or doctors due to different cultural contexts. A better understanding of the patient’s country and a casual conversation would be important for a relaxed atmosphere. If the patient is from Brazil, I will talk about football in the opening conversation. … I think, a casual conversation allows me to build a better relationship with the patient in a relaxed mood. … The patient may feel nervous in a dental clinic in Japan due to a different language and system. So, soothing their anxiety and making them feel relaxed are key to build rapport.(D3)As If I can’t communicate on their first visit, I explicitly say, “please come back with someone who can speak Japanese and your language because I am unable to have one-to-one communication with you.” This is the best way. When receiving a booking call from foreign patients, I ask the clinic staff to explain that we request them to come with an interpreter if their Japanese is not very good.(D9)On the other hand, some dentists noted the difficulties in communicating through an interpreter. Specifically, when the interpreter is a patient’s family member or friend, the dentists are unsure about the translation accuracy. D3 said: I’m not sure to what extent the interpreter, like the patient’s family and friends, can understand what I said. Moreover, when the interpreter translates my words into the patient’s language, I totally don’t know the accuracy of the translation. In the end, I’m worried whether the patient understood what I’m saying through an interpreter.(D3)Avoidance of complexities includes simplifying the content of the explanation, omitting the details, and providing the most necessary explanation and treatment related to the chief complaint. In most cases, for dentists, the minimum necessary treatment is the last resort and would be performed against their intention because they believe that dentists must improve the patient’s oral health, as a whole, in addition to the chief complaint. For example, D8 provided only the tooth treatment related to the patient complaint even though he identified the necessity of treating other decayed teeth. D8 said:Some foreign patients strongly said, “treat only these teeth,” “don’t treat others except this even though you found a decayed tooth in my mouth,” and “just remove the toothache.” For them, I don’t suggest the necessity of treatment for the other parts and treated only their complain. In fact, I should have removed the tartar and treated other decayed teeth. I needed to provide complete oral care to them. However, many foreign patients request me to do only what they want to be treated.(D8)Likewise, D1 selected a short-term treatment plan rather than continuous treatment to improve the patient’s oral health due to communication challenges in a cross-cultural setting. To avoid further problems caused by such communication challenges, D1 had to treat only the tooth directly related to the complaint. D1 said:I was not sure how much a Brazilian patient can understand what I explained. So, in this case, I selected not a continuous treatment but a treatment, which could be completed as quickly as possible. For example, I used an inlay and finished the treatment on the next visit. That’s it! So, I just focus on handling the patient’s chief complaint rather than focusing on the whole oral cavity.(D1)When the minimum necessary explanation and treatment were performed, the dentists felt unsatisfied with and regretted their own practice. In fact, they wanted to provide proper treatment to the migrant patients as they provide to the Japanese patients. However, they could not do so due to the challenges of the complex situation. In other words, they were in a dilemma. Regarding this issue, D4 said:The foreign patients might want to say something to me. After the dental treatment, I really feel like it was unfinished business. If the patient is Japanese, I can convey what I want to say. … Actually, I want to treat them as I do Japanese patients, but I have no choice but to focus on completing their treatment quickly. That’s why I’m unsatisfied with my practice with the foreign patients.(D4)The present study investigated dentists’ management processes for communicating with migrants with limited Japanese proficiencies. Dentists employed several management strategies to deal with linguistic, sociolinguistic, and sociocultural issues. These findings are congruent with previous studies that explored the experiences of other health professionals in providing treatment and care for migrants ,14,15. IAlthough the dentists in this study accepted migrants in their oral healthcare practice, they faced a dilemma between what they could do practically and what they wanted to do ideally during their practice . The parIn terms of health equality, the minimum necessary treatment provided by the dentists is problematic. To ensure the quality of oral care for migrants and reduce dentists’ psychological burden, the development of medical interpretation services is important ,40. TherIt is important to support the dentists to “get by” the migrant patient encounters. Of the three main “get-by” strategies in this study, language accommodation is crucial for providing oral treatment and effective care for migrants, which echoes the findings of previous studies ,15. As tThe patients’ socioeconomic statuses and educational backgrounds are an important aspect of the quality of treatment and care ,7. AccorThis study is, to best of our knowledge, the first qualitative inquiry focusing on the perspectives of dentists in Japan about their experience of providing oral treatment and care to migrant patients with limited Japanese proficiency. The analysis of dentists’ reflections on their cross-cultural experiences allowed the researchers to examine the processes of their communication management in community dentistry. However, there are certain limitations to the study. The results were not generalizable due to the small number of participants from dental clinics in a regional city in Japan. Particularly, the different contexts, such as metropolitan cities and rural areas, may lead to different results due to differences in human resources, availability of communication tools and interpreter services, and demographics of the migrant population. Thus, based on the findings of this study, further surveys across Japan need to be designed and conducted regarding the status quo of providing oral treatment and care for migrant patients. At the same time, fine-grain analyses need to be continuously conducted to include actual dentist experiences, such as social interactions during migrant patient encounters. Furthermore, as the data were collected only from the dentists, the perspectives of migrant patients and other dental staff need to be further explored.This study revealed the process by which the dentists managed to provide oral treatment and care for migrant patients with limited Japanese proficiency. The dentists encountered linguistic, sociolinguistic, and sociocultural challenges and tried to overcome them by employing several strategies. When the minimum necessary explanation and treatment were provided, the dentists felt unsatisfied with their practice and faced the dilemma between real and ideal practice. The findings of this study have provided new insights into dentists’ practices in the globalized context. Particularly, the use of plain language, as a part of language accommodation, has the potential to enhance dentists’ cross-cultural communication with migrant patients.


Three themes emerged from the inductive qualitative analysis: Coaching Requires a Mindset Shift, Change is a Journey, and Impact on Clients. Occupational therapy students perceived that coaching required a different way of thinking and reimagining their role, saw the value of learning to coach in the clients' outcomes, and recognized the potential for their future practice regardless of settings. The study findings suggest that incorporating coaching skills into OT education could be beneficial to students when they enter the profession.Coaching, an evidence-based approach in other fields, is relatively novel within occupational therapy (OT) and is not yet widely taught in OT programs. In recent studies, experienced occupational therapists have reported that coaching added value to their practice, but OT students' perspectives are missing from the literature. This phenomenological study explored OT students' ( Coaching is an evidence-based approach used in various professions to help clients reach their goals . The useThe International Coaching Federation (ICF), a premier coaching credentialling organization, defines coaching as partnering with clients in a thought-provoking and creative process that inspires them to maximize their personal and professional potential . Over thWithin OT, different ICF-related coaching models have been developed, including solution-focused coaching, occupational performance coaching, occupation-based coaching, and coaching in context (CinC) , 22–24. Connect, Discover, and Plan, and five distinct attributes: active listening, reflective responding, skillful questioning, grounded in context, and leveraging strengths . T. T2 Prog2 Program who became participants in this study completed the didactic portion of their OT education in one of three programs within one university. The participants had received minimal coaching training as part of the didactic portion of their OT educational program. Some of the participants had received a two-hour lecture and laboratory experience within a course, whereas others had heard of coaching briefly in coursework.The OT fieldwork students with the GOALSThe data for this phenomenological study were collected through audio-recorded semistructured interviews that took place within two weeks of the end of each participant's 12-week fieldwork experience. The interviews were conducted by trained graduate assistants using an interview guide that included a series of open-ended questions and follow-up probing questions. The interview questions focused on the participants' experience within this fieldwork without asking specifically about coaching to minimize the risk of biasing their answers . InterviA multistep, iterative process including preparing the data, developing the codebook, coding, and data interpretation was used as described below.Data Preparation and Code Book Development. To prepare the data for analysis, all interviews were transcribed verbatim using a transcription protocol, checked for accuracy by a 2nd transcriber, and deidentified by trained graduate assistants. An inductive approach was utilized to develop the codebook using an iterative multicoder process. This process included reading interview transcripts to identify codes, writing and refining codes' definitions, creating and adjusting codes' hierarchies, and consulting with a senior researcher. This process was conducted by two researchers (author 2 and author 3) with guidance and input from a senior researcher (author 1). An audit trail and reflexive journals were maintained throughout this process and the data analysis more broadly.Coding. Once the codebook was finalized, all transcripts were uploaded into NVivo (Version 12). Two of the researchers (author 2 and author 3) coded all 14 transcripts independently. These researchers then compared their coding to identify differences, and all differences were resolved through discussion. Intercoder reliability for each transcript was consistently above ~95% agreement. Saturation was achieved, as no new insights or understandings emerged beyond the codes included in the codebook.Interpretation. With all interviews coded, themes were identified from that data using a nonlinear, phenomenological, and narrative inquiry process, in which two of the researchers (author 2 and author 3) independently examined the data organized by codes to illuminate themes. This was followed by peer debriefing between the two researchers to examine areas of agreement or disagreement and gain a deeper understanding of what the data was revealing  needs 2 hours, you can give them 2 hours. If they only need 45 minutes, that's fine too” (L215-216). While a coaching session can be effectively completed in as little as 20 minutes, participants noted the additive value of multiple coaching sessions on clients. One participant stated, “the [coaching] process builds on itself” . Another participant described how they “needed to get more comfortable with [progress] taking a longer time than I expected. Sometimes you just need to plant the seed in somebody's mind” .Participants remarked on needing to be adaptable when working with clients using a coaching approach. This adaptability took many forms and went beyond what they would have typically experienced as occupational therapists. One participant stated, “I love the flexibility of [coaching]. I think that this [flexibility] benefits the clients” . In coaching, flexibility is in part related to adapting to clients' shifting priorities. The OT coaches work on what is important to the client at that moment. For example, one participant recalled that “clients can come in crisis modes. [They have] emergencies, projects, or something that's weighing heavy on them and takes the focus away from their [long-term] goals” and the need in these instances to “embrace [the fact] that things were unpredictable,”  and “to adjust strategies, [for example] how I paced my questioning” . One participant reflected, “the coaching model helps us as occupational therapists [to] meet people where they are” adding “coaches [don't] project [their thoughts] on the situation, [they simply] work with them” .Change is a Journey: Motivation is Key, Developing Skills and Confidence, and Therapeutic Relationships.Participants remarked on the development of their own coaching skills and clients' progression toward change. One way that participants conceptualized this transformation within the coaching model was employing language from the Transtheoretical Model of Change: “understanding where each client was in their journey to change” . Developing an understanding of their client's patterns of behavior was a crucial element of enacting change. One participant noted that “it's about trying to peel back the layers and get to why they are doing what they're doing or not doing… Until you can get to that, there really isn't going to be much change” . Taking a deep dive to better understand client motivation and participation was a coaching skill that participants, as novice practitioners, noted had the potential to enrich their future OT practice, regardless of the setting. One participant explained, “The traditional [OT] model is to label clients who aren't following recommendations as non-compliant. [Through coaching you realize that] it is not the case. It's probably that they're not [motivated] about the plan, [unsure] how to implement it, [or] confused by the directions” . Another participant reflected, “[I'm] going to take that idea of figuring out what my client's end goal is,… their motivation,… [and] why they want to be in therapy … into more traditional OT settings” .Participants reflected on their journey of developing coaching skills and professional reasoning through the process of coaching clients. One participant asserted, “[through] my experience over the course of the semester, I've evolved as I've continued to work with clients” . One participant explained that coaching enables them to enact core OT principles when explaining that professors “talk about [being client-centered] the whole time we've been in school … [but] that's easier said than practiced. I am going to have a much stronger ability to be client-centered now [after learning to coach]” . When describing the skills and confidence they built, participants noted the following areas of improvement: “[client] interaction, interviewing [and] being comfortable but professional” ; “therapeutic use of self, clinical reasoning, active listening, [and] being able to really understand what my client needs, meet them where they're at, and support them” ; “getting the full story” from clients ; “slowing down instead of jumping right in and trying to fix” ; “learning what I can do as an occupational therapist outside of typical [practice]” ; and “confidence establishing relationships with clients” . Many of these skills are related to therapeutic relationships and thus directly applicable to more traditional OT practice.2 Program,… clients' different needs, and different things that would help them to succeed” . Participant Twelve emphasized that trust is vital to the therapeutic relationship alongside technical skills as a practitioner, asserting, “if you cannot build relationships with people, [even if you are otherwise] the most skilled practitioner in the world, [clients won't] trust you. They're not going to want to work with you” (L153-156). Thus, developing a therapeutic relationship is a skill critical to coaching that is transferable to other areas of practice. Therapeutic relationships led to client open-mindedness and enjoyment of OT-led coaching sessions. One participant stated, “if you build this connection with a client, then they're more willing to be open to you. GOALS2 Program clients were really excited to come back to their sessions” .As participants reflected on the knowledge they gained through learning about coaching, the importance of therapeutic relationships emerged. Participant Twelve explained, “I think that the foundation of any type of therapeutic work is to be able to build that relationship” (L117-119). Participants reported that building a therapeutic relationship is essential to coaching. One participant remarked, “the coaching process is all about discussion, connection, rapport building, and therapeutic use of self” . Building this collaborative relationship allowed for greater insight into clients and improved professional reasoning on the part of the fieldwork student. One participant stated that the client-practitioner relationship allowed them to understand “what exactly [clients were] trying to get out of the GOALSClient impact was inextricably linked to participants' assessment of their own skill development and implementation of coaching. Every participant mentioned the effect they perceived they had on clients through coaching. One participant noted that clients developed self-confidence while working toward their goals, observing “how much confidence people could build by coming up with solutions for themselves” . Another participant stated that clients would say things such as “‘wow, I thought of that on my own'” , which was empowering for clients.When it Works, it Works! and Is Coaching for Everyone?The positive impact of the coaching model shifted the dynamic of the session, which became evident when participants moved away from the client-led approach and became increasingly directive. For example, participant Five recalled, “throughout the semester, we were working on what [clients] wanted to work on, but if at any point that changed and we started acting in a more directive way, you could see the client become a little less interested” (L197-202). All these skills increased follow-through and improved outcomes for clients. As one participant stated, “[coaching] helps with [client] outcomes because people are more invested, and it's actually a solution that [is] achievable for them. And I don't know that I would have seen it quite that way if I hadn't [learned to coach]” . Two subthemes emerged from this larger theme of the impact on clients: One participant captured this theme when stating, “it's magic” . [Clients] “know what their issues are, by and large” . Participant Fourteen found that brainstorming was the most helpful, asserting, “brainstorming especially was where I saw the biggest shift in our clients and the most progress” (L173-180). Participants “tried the strategies”  on their own and “modified them throughout the week” . The coaching process also promotes long-term independence; one participant stated, “we've given [clients] tools to do it on their own. That's our goal, to support them now [so] they can transfer those skills later” . Overall, the Level II OT fieldwork students found that coaching helped clients, but coaching is not necessarily for everyone.Participants in this study noted that some clients had trouble with the coaching process. For some, the difficulty was perceived to be grounded in motivation. One participant asserted, “coaching really only works if there's some self-motivation in the client” . However, motivation can be fostered in clients; it is not an impasse. This was illustrated by a participant who stated, “[Clients] would come up with a strategy, and [I would ask] ‘Are you going to try it?' [The] clients would admit ‘No, because I'm not really motivated.' [We] researched how to help them find motivation” . For other clients, the challenge was the conversation-based nature of the coaching approach. Participants recalled a client who “had been coming to the program and participating for a long time, but it was hard to make a connection and follow the process with him because there just wasn't a whole lot of back and forth [conversation]” . The participants needed to adapt the coaching process given the clients they were serving, some of which had difficulty communicating and engaging in abstract conversations. Finally, the client's ability to self-reflect is key to success in coaching. One participant assessed, “the coaching model was really challenging [with some clients] because sometimes that ability to reflect deeply or think of creative new ways to do things was really a challenge [for the client]” . Although coaching works for many, adapting the coaching model or considering other approaches is necessary for some clients. Coaching is only one tool in an occupational therapist's toolbox.This study aimed to explore OT students' perceptions of learning and using the CinC model while completing Level II fieldwork. While ICF-style coaching has a large body of evidence in other fields, it is relatively new within the OT profession . Most ocMindset Shift is consistent with prior research with licensed practitioners who remarked that implementing coaching fostered a positive change in their practice [Coaching requiring a “mindset shift,” even for novice practitioners, permeated the data. In the view of participants, coaching allowed for a more collaborative and flexible approach compared to traditional OT practice by shifting the power dynamic that exists between clients and practitioners toward the empowerment of clients. As found in previous studies, the coaching relationship emphasized the expertise of the client in their own life and the expertise of the coach as the facilitator of problem-solving and self-efficacy for the client , 19 as tpractice , 12. By practice , the cliWithin this study, participants experienced a shift in perspective from therapist-expert to client-expert and identified this shift as a difference between traditional OT and OT-led coaching. Consistent with the participants' perspectives, experienced occupational therapists noted in previous studies that they had to change their role from expert to facilitator and that preventing oneself from intervening as an expert was difficult . This shOT students in this study and experienced occupational therapists in previous studies grounded their evaluation of the coaching process on the effect it had on clients . ParticiParticipants in this study remarked on coaching as a means of improving practitioner competency and confidence, in addition to increasing clients' personal insights. Student practitioners placed emphasis on the therapeutic relationship as the foundation of any productive clinical interaction and a means to client involvement and success, applicable to any practice setting. This is consistent with experienced occupational therapists who noted that the rapport built via coaching, by improving listening skills, engendered greater disclosure from clients . Other sOverall, the participants in this study valued learning coaching in their Level II fieldwork; they saw a congruency between coaching and core OT principles. Learning to coach, in their view, equipped them with skills to more fully enact core OT principles, such as client-centered care and therapeutic use of self. They perceived that the value of learning to coach within this setting would benefit them in any other practice setting. This study adds to the fast-growing body of evidence about the value of coaching within OT practice. This evidence suggests that incorporating coaching into the OT curriculum would be advantageous, as students would learn coaching skills early in their careers and could apply those coaching principles to improve future client outcomes. Thus, entry-level OT educational programs should explore ways to incorporate coaching training within their curriculum. OT practitioners are encouraged to seek continuing education opportunities in which they can learn to infuse ICF-style coaching within their own practice. Knowledge translation takes time; however, organizations such as the American Occupational Therapy Association and the World Federation of Occupational Therapy play key roles in fostering changes in OT practice when new research evidence emerges.n = 14) was appropriate for a qualitative study, the transferability of the study results is limited given that all participants completed their fieldwork within the same role-emerging fieldwork site. While efforts were made throughout the study to minimize research bias , as in all qualitative studies, there is still the possibility of research bias within the results. Interviews, as a data source, rely on participants' subjective experiences, which are not an objective indicator of a participant's growth in skills. The results are also limited by the participants' own ability to self-reflect.Although the sample size (Duplication of this study with participants from various fieldwork sites would help differentiate between the coaching and site-specific experiences of participants. Further, exploring the value of teaching coaching within the didactic portion of the program could be explored. Another logical next step would be to explore the degree to which coaching principles learned in fieldwork are utilized by licensed occupational therapists once practicing in a variety of settings. Finally, studies exploring the characteristics of individuals and the context in which coaching is less efficacious are needed.Coaching requires a different skill set than what most occupational therapists traditionally learn in academia and use in their day-to-day practice. Level II OT fieldwork students perceived coaching as a useful approach that improved their therapeutic relationships, skills, flexibility, and confidence. Moreover, coaching allowed students to empower clients to be experts, explore clients' contexts, and develop professional and realistic expectations of client change. Participants discussed the coaching concepts and skills they utilized in this Level II fieldwork as beneficial for clients, including individuals whom they will work with in future practice. Coaching was characterized as a valuable intervention to execute concepts taught within the OT curriculum, such as emphasizing client-centered care and initiating a shift away from a practitioner-directed model toward a more effective model that emphasizes greater client autonomy.


Routine assessments of patient safety culture within hospitals have been widely recommended to improve patient safety. Experts suggested that mixed-methods studies can help gain a deeper understanding of the concept. However, studies combining quantitative and qualitative approaches exploring patient safety culture are still lacking. This study aimed to explore patient safety culture as perceived by operating room professionals of two university hospitals in Sousse, Tunisia.Based on a mixed-methods approach, a cross-sectional survey followed by semi-structured interviews were conducted over a period of two months (December 2019 to January 2020). This study took place in all the operating rooms of two public university hospitals in the district of Sousse, Tunisia. To collect data for this survey, the French version of the Hospital Survey On Patient Safety Culture was used. For interviews, 13 participants were selected purposively using a critical case sampling approach and a topic guide was prepared. Anonymity and confidentiality were respected.Overall, twelve operating rooms, with different surgical specialties, were included in the study. Survey feedback was provided by 297 professionals representing a response rate of 85.6%. Concerning patient safety culture, the 10 dimensions had low scores (below 50%) and were considered “to be improved”. The highest score was found in ‘teamwork within units’ (45%). Whereas, the lowest scores were allocated to ‘non-punitive response to error’ (22.9%), followed by “frequency of adverse event reported” (25.6%) and “communication openness” (26.3%). Per qualitative data, participants provided a more detailed picture of patient safety issues such as underreporting, absence of an effective reporting system, lack of freedom of expression, and an existing blame culture in operating rooms.The findings of this study showed a concerning perception held by participants about the lack of a patient safety culture in their operating rooms. It seems essential to design, implement and evaluate strategies that promote a positive patient safety culture and obliterate punitive climate in operating rooms.The online version contains supplementary material available at 10.1186/s12913-022-08175-z. Accordint care” .Although there has been a major rise in international interest in patient safety over the past years, Adverse Events (AEs) remain a global challenge and and no country has been able to overcome all patient safety issues . A systeThe situation in developing countries is more critical , 5. For A growing body of evidence shows that the majority of in-hospital AEs are associated with surgical care , 7. ConsAccording to the Higher Authority of Health, the origin of these AEs is rarely related to a lack of technical skills but rather to a lack of safety culture among caregivers . Creatina coherent and integrated set of individual and organizational behaviors, based on shared beliefs and values, which continually seeks to reduce related to care harm among patients. " [This concept has been defined by the European Society for Quality of Care as: “ients. " .A literature review has found a link between safety culture and patient outcomes . For exaIn most cases, PSC in health care settings is assessed using a questionnaire . UndoubtHence, to obtain a deeper understanding of the concept, an assessment that combines both quantitative and qualitative methods has been highly recommended . ExpertsIn our study, we sought to expand on the quantitative survey findings and better understand some of the contextual aspects of PSC, particularly in the Operating Rooms (OR) which are a separate unit within hospitals with several specificities that may affect PSC differently from other settings. Besides, and to the best of our knowledge, there isn’t any published study that used a mixed methods approach to assess PSC in this particular setting.Thus, we aimed to explore PSC as perceived by OR professionals of two large university hospitals in Sousse (Tunisia) using a mixed-methods approach.Based on a mixed-methods approach, a cross-sectional survey followed by semi-structured interviews were undertaken, providing a phenomenological context around the data. Data collection was conducted over a period of two months (December 2019 to January 2020). This study took place in all the OR of two public university hospitals in the district of Sousse, Tunisia.n = 347) that were employed in the 12 OR in the aforementioned hospitals, without performing any sampling.In order to have a representative sample of optimal size, the study was exhaustive and targeted all healthcare professionals  questionnaire user’s guide .The HSOPSC was originally developed by the Agency for Healthcare Research and Quality (AHRQ) and it is the most extensively used instrument to evaluate PSC . To collAlso, reliability was tested for this sample of OR Tunisian caregivers by measuring internal consistency; Cronbach’s alpha was 0.886 for the whole questionnaire and ranged from 0.689 to 0.875 for the 10 dimensions.Overall, the questionnaire consisted of 51 items: 2 items examined the overall perception of patient safety and the number of AEs reported during the last 12 months, 7 items for demographic and professional characteristics of participants , also to estimate frequency  . If the Prior to data collection, the study protocol was reviewed and approved by the institutional ethics committee of the Faculty of Medicine of Sousse and the administrative authorizations from the two hospitals and OR head chiefs were obtained. Then, the investigator handed out a self-reported questionnaire to participants, after explaining the study purposes and outcomes to the participants and obtaining their consent to take part in the study. Also, they were all asked to return the filled in forms to the investigator who immediately placed them in a box. Anonymity and confidentiality were respected.The questionnaire consisted of positively and negatively worded items. For items with a positive formulation, “Strongly Agree” and “Agree” or “Most of the time” and “Always” were considered positive responses. For items with a negative formulation, “Strongly Disagree” and “Disagree” or “Never” and “Rarely” were considered positive responses for PSC. Afterwards, for each dimension, a score that represents the average percentage of positive responses to items was calculated. The data analysis was conducted using SPSS version 20 for windows , with descriptive analysis displaying the frequencies, percentages, means and standard deviations.Following the mixed-methods approach, the second part of the study consisted of semi-structured interviews. Participants were selected purposively from the two included hospitals using a critical case sampling approach in which individuals that are likely to provide the most information are selected . To colln = 13) accepted to take part in the interviews, which were conducted with 4 surgeons (2 seniors and 2 assistants), 4 OR supervisors, 3 OR specialized nurses and 2 anesthesiologists.All the contacted participants  were assigned to conduct the interviews. With regard to their background, they were PhD candidates and, originally, OR nurses. Thus, they were familiar with the OR context, which enables them to properly guide the interviews and analyze the data.After the interviews were audio-recorded, they were transcribed verbatim and the transcripts were reviewed by the participants to make sure that their thoughts were accurately reproduced. Afterward, the final transcripts were translated into English by the main researcher.Participation in interviews was entirely voluntary and informed consent was given by all interviewees; they were notified that they could refuse or withdraw from the study at any time without any given reason. Besides, before each interview, participants were asked if they minded being audio-recorded and permission to record the interview was granted by all. Also, the collected data were kept anonymous and all identifications were removed before to analysis.The research team conducted a thematic analysis of the English transcripts to draw out the significant expressions from each interview. Then, over several meetings, expressions with similar meanings were further studied and subdivided into multiple themes  represented paramedical staff  and 31.6% were surgeons. As for work experience, 46.5% (n = 138) of participants had a work proficiency of more than 10 years and 60.3% (n = 179) worked specifically in OR for more than 6 years  and were considered “to be improved”. The highest score was found in D5 ‘teamwork within units’ (45%). Whereas, the lowest scores were allocated to D7 ‘non-punitive response to error’ 22.9%), followed by D2 “frequency of adverse event reported” (25.6%) and D6 “communication openness” (26.3%) . The majority of them had more than 10 years of work experience (10/13) and more than 12 working years in their OR (7/13).Thematic analysis revealed six main themes  that were extracted from the 13 interviews Table .Table 4FMost of the interviewees (8/13) declared that the care provided in their OR was relatively safe, but that it could be improved. All the participants felt that there were many issues that threaten patient safety on a daily basis.“Most nurses and technicians in my unit know the importance of the surgical site preparation and how it is supposed to be done, however, it is not always performed and if it is, usually it’s sloppy work that does not respect the guidelines”. Nurse 2.“Despite the display of many educational posters in the OR serving as reminders to ensure patient safety, I feel that compliance with these guidelines remains low. For instance, in my OR, the surgical hand scrub, which is a process with determined steps and duration, is rarely correctly performed”. Nurse 6.The majority of the interviewees (10/13) highlighted that practitioners often struggle to integrate knowledge learned in training sessions with real-world OR practice.“I remember one day; we had an urgent surgery first thing in the morning and the anesthesiologist was late. He couldn’t be replaced at the moment, which led to canceling the surgery that day”. Surgeon 1.“Sometimes, in between surgeries, the cleaning worker is nowhere to be found and there is no one to clean the OR and prepare it for the next surgery. This neglect usually results in delaying the surgical schedule or canceling scheduled surgeries”. Nurse 5.Participants pointed out that acquiring knowledge and attending training sessions do not necessarily lead to a good surgical practice due to several reasons such as misbehavior of OR workers (5/13). According to the interviews, the aspects of misbehavior ranged from laziness or lack of dynamism to tardiness and absenteeism. Most participants (7/13) recalled cases of tardiness and absenteeism that happened in their OR and stressed that it posed a threat to patient safety and the working climate.“Equipment failures are frequent in OR; it’s common that surgeries get delayed just because either the equipment is damaged or we don’t find the needed one. No doubt, you heard about the surgical light head that broke down during a C-section and the surgical team had to carry out the rest of the intervention using phones flashlight”. Surgeon 2.“Sometimes, the operation has to stop momentarily until we find another electric scalpel”. Anesthesiologist 1.Equipment failures were highlighted by the majority of interviewees (11/13) as the most common cause of surgical schedule delays in their OR.“We only see the maintenance team, when something is broken down. It shouldn’t be the case; maintenance of OR equipment should be performed periodically and appropriately”. Surgeon 2.According to participants, equipment failures, in most cases, were caused by maintenance omissions, such as an improper or lack of scheduled maintenance of OR equipment.“You spend more than half of your awake time in the OR, surrounded by your colleagues. If you don’t feel supported and respected, I am not sure you can do your job correctly”. Nurse 5.Regarding teamwork, participants believed that it was fairly acceptable in their OR. More than half of them felt that there was sufficient mutual support between them and their fellows (7/13).“It feels like we are many different teams: nurses, surgeons, anesthesiologists, and each team works solely. For instance, we are never included in briefings/debriefings as a whole multidisciplinary team”. Anesthesiologist 1.The majority highlighted the importance of effective communication to ensure a fluid surgical workflow in the OR (11/13). However, during interviews, participants expressed dissatisfaction with the quality of communication in their unit (9/13).“When it gets tense during an operation, the senior surgeon gets pissed off, assumes that it’s his responsibility only to save the patient, and starts ordering everyone around, sometimes, even in a disrespectful manner.” Nurse 1.Also, participants stressed that facing difficulties during surgery often results in creating tension that impairs teamwork and weakens communication (4/13).“Not all information is shared among the team. As a nurse, it feels like we are omitted from discussions around patient care”. Nurse 1.“I don’t think that we understand teamwork correctly. According to some, nurses should not be included in the decision-making process. Their sole role is to take orders from surgeons and execute them”. Nurse 3.In terms of nurse-physician relationship, nurses made clear that there were some difficulties concerning information sharing and participation in the decision-making process.“Many near-misses and errors happen and they are not reported just because the problem is usually resolved without any harm to the patient. This leads to the recurrence of such events because we did not treat their root causes.” Surgeon 3.During interviews, participants asserted that not everything is reported in the OR (12/13).“Look, in my unit, personnel involved in patient safety training and motivated to ensure a better quality of care do report AEs but, in most cases, there isn’t a response and it doesn’t go any further, which I find it, personally, frustrating”. Anesthesiologist 2.In addition, participants noted the absence of an effective incident reporting system. They stressed that motivated personnel usually have to make an extra effort to report AEs and see them through to the analyzing committee, but the existing reporting system lacks reactivity and it doesn’t go any further from there.“I feel like I don’t have the liberty to report AEs, and if I do, I will be treated as a snitch and get called out for turning my back to my colleagues. It happened to me before, and it wasn’t a good place. I mean I tried to explain that it wasn’t personal, that it was the right thing to do… but they didn’t listen”. Nurse 4.With regard to communication openness, participants declared that they don’t feel free to talk about errors or report them (5/13). This issue wasn’t only associated with supervisors but also with fellow colleagues.“Committing errors is treated generally as a lack of skills and recklessness. The person who commits an error is accused and it is rarely considered as a shared responsibility of the team”. Surgeon 1.All the participants associated the underreporting in their OR with a perceived culpability and a fear of punishment when they needed to disclose an error.“Due to inadequate working conditions, so many “good” surgeons are leaving the hospital and migrating to the private sector without being replaced”. Surgeon 3.All the interviewees thought that there wasn’t enough personnel and that the lack of staff in their OR compromised patient safety. Particularly, according to most participants (9/13), the unsatisfying working conditions have led to a strong shift towards the private sector and reinforced the staff shortages in hospitals.“On busy days, which are common, I wish I could press hold and take a breath. My only concern is that if I am tired, I won’t do my job right and the patient could suffer”. Nurse 7.“The orthopedic surgical unit is the only unit of its kind in all of central Tunisia so it gathers thousands of patients from so many districts, resulting in a huge workload that we have to handle with limited staff. It is tiring!” Surgeon 3.Regarding workload, it was noted that most participants (8/13) weren’t satisfied with how much work they handled during their daily shifts. Some acknowledged that sometimes it gets chaotic in the OR and they fail to manage the excessive workload (3/13). Also, they stressed that the latter created a climate of pressure and stress, and was error inducing.Most informants highlighted the importance of hospital management to ensure surgical patient safety (7/13). They recognized all the efforts made by the management, pointed out the weaknesses and suggested some areas of improvement.“It seems to me that the hospital management moves only after an accident happens.” Surgeon 3.“As an OR supervisor, I know that double gloving is recommended to lower the risk of surgical site infections and pathogen transfer, yet when I ask for more gloves, the hospital management asks me to reduce glove usage. Don’t they know that double gloving costs less than surgical site infections?”. Nurse 6.The interviewed OR staff (5/13) stressed that the hospital should focus more on risk management and reinforce proactive strategies that identify and predict system weaknesses and adopt changes to minimize patient harm.“No matter how many printed protocols and guidelines are displayed, their application remains limited because there is a huge lack of supervision”. Nurse 2The majority of participants (10/13) made clear that adherence to existing protocols and guidelines was not constantly observed, and the main reason was that there wasn’t sufficient supervision.“I believe that if people knew that they could be supervised at any moment, it would definitely improve their respect and compliance with the guidelines”. Nurse 7.More than half of the interviewees (8/13) felt the importance of a constant practice evaluation aiming to increase protocols respect and prevent AEs and errors in the OR.“Usually, if there is a training session, you would have to obtain the OR supervisor’s permission and find someone to replace you. It’s like you are going on a vacation but you are not!!”. Nurse 1.“Sometimes we learn about new techniques and information from junior staff and trainees… It is embarrassing! Aren’t we supposed to have scheduled training sessions to update our knowledge?”. Nurse 4.During interviews, participants stressed that training and continuous education were essential to keep up with surgical practice progress. They pointed out that the quality of trainings they were receiving was fairly satisfying (7/13). However, some issues were raised as barriers to training adherence, such as the difficulty to have permission and the lack of scheduled educational sessions.Besides, three nurses, during interviews, declared that the medical staff benefits from a more solid training program and is privileged by the hospital management in terms of granting leaves and funds.Recently, routine assessments of PSC within hospitals have been widely recommended to improve patient safety . The sur. In fact, 75.8% of the study participants declared that they have patient safety problems in this facility, and only 34.3% stated that the existing procedures are efficient to prevent errors from happening. These results were confirmed during interviews as all the interviewees felt that there was an array of factors that jeopardize patient safety, such as theory–practice gap, misbehavior, and equipment failures. With regard to equipment failures, Wubben et al. found that equipment-related incidents occurred frequently in the OR (up to 15.9%) and resulted in an extra work and additional minutes of delay per event [. In fact, obtaining functioning medical equipment is a challenge particularly in low- and middle-income countries [According to our findings, only 33.8% of participants had a positive overall perception of safety (D1) in their OR. According to Verbeek-van Noord et al., the perceptions of caregivers regarding patient safety in their units could be relevant and revealing, as they might be the first to notice safety issues . In facter event . In factountries . Accordiountries ..Survey data revealed that ‘non-punitive response to error’ had the lowest score. Findings from other studies conducted in the OR found that this dimension also had a very low score , 29.Qualitative data supported survey results and provided a more detailed picture of patient safety issues such as underreporting, absence of an effective reporting system, lack of freedom of expression, and an existing blame culture. During interviews, participants pointed out that errors were recurrent because usually, in case of an error, immediate corrective actions were taken without addressing the root causes. In fact, according to Argyris, reporting errors is considered as double-loop learning, starting by detecting errors, learning from them and proactively treating the underlying causes to prevent their reoccurrence .Along with that, results have shown that 85.9% of the respondents haven’t reported any AEs in the past 12 months, proving the absence of an AEs reporting system, which was addressed by the majority of interviewees. In fact, an effective error reporting system is crucial to establish a reporting culture in which people feel safe pointing out and reporting errors without fear of retaliation .However, there is an existing punitive climate that was corroborated by the qualitative and quantitative data. For the most part, fear of discoverability, reprisals, and possible litigation are still real challenges making error reporting uncommon and menacing for surgical patient safety .With regard to hospital management, the absence of adequate supervision was pointed out as the reason for non-adherence to existing protocols and guidelines. Studies by Labat et al.  and AbdiClinical supervision is a professional activity where the more experienced clinician supervises the knowledge and experience of the less experienced ones . This suIn light of our findings, we recommend the standardization of the Surgical Safety Checklist (SSC) in the Tunisian context. Using the SSC can prevent communication and equipment failures and decreases the likelihood of committing errors, especially in a distraction-prone environment like the OR , 38. AlsIn addition, and to help bridge the gap between theory and practice, we recommend the use of clinical simulation. Indeed, there is a growing body of research that supports the idea that simulated experiences can offer an engaging teaching method to reinforce and evaluate competence in practical skills, critical thinking and decision-making through the use of knowledge, promoting a connection between theory and practice , 41.Regarding AEs, an effective incident reporting system should be installed that includes error identification, reporting, analysis and corrective actions. Importantly, reporting errors should be encouraged and endorsed by supervisors as an integral part of a continuous cycle of improving patient safety, and quality of care and confidentiality and legal protection are therefore required to encourage health practitioners to come forward .To the best of our knowledge, this is the only mixed-methods study that focused on PSC in OR. In fact, experts suggested that mixed-methods studies can help gain a deeper understanding of the concept. Furthermore, studies combining quantitative and qualitative approaches to explore PSC are still lacking in the literature .As for the study limitations, it was conducted in two public hospitals in Sousse (Tunisia) which may limit the generalizability of the findings to other healthcare settings and geographical areas. For future studies, it is suggested to perform a nationwide study including more Tunisian hospitals.Another limitation was related to a self-reporting bias which is common in this type of studies. In fact, when answering a self-reported questionnaire, participants may fear of being identified and, thus, may change or distort their responses. To reduce this bias, the investigator emphasized the confidential and anonymous nature of the study .Additionally, qualitative data are, also, prone to a reporting bias as participants may not give answers that are fully correct, either because they do not know the full answer or because they seek to make a good impression. Stopping interviews only after reaching data saturation can limit the impact of this bias. In future studies, we suggest that even after reaching data saturation, further interviews should take place (with one or two more participants) to ensure that data saturation was really reached, which is a common practice in qualitative studies .The findings of this study showed a concerning perception held by participants about the lack of a PSC in their OR. Indeed, the 10 dimensions had very low scores and were all in need of improvement. We highlighted different areas of concern, such as frequency of AEs reported, non-punitive response to error, teamwork, and staffing. Per qualitative data, participants provided a more detailed picture of patient safety issues such as underreporting, absence of an effective reporting system, lack of freedom of expression and an existing blame culture in OR.For future studies, it is suggested to implement the recommended strategies and evaluate their effectiveness to improve patient safety attitudes and practices in the OR.Additional file 1: Appendix 1. Interview topic guide.


Gene drive is a controversial biotechnology for pest control. Despite acommitment from gene drive researchers to responsibility and the keyrole of the media in debates about science and technology, littleresearch has been conducted on media reporting of gene drive. Weemploy metaphor and discourse analysis to explore how responsibilityis reflected in the coverage of this technology in the U.S., U.K., andAustralian press. The findings reveal a rhetorical strategy oftrust-building by evoking the moral attributes of gene driveresearchers. We discuss the implications of these findings for thecommunication of new technologies. Gene drive is an emerging biotechnology designed to control pests, includinginvasive rodents and insect pests in global health, conservation, andagriculture. It differs from traditional genetic modification in that amodification is designed to be driven through a population, potentiallychanging the whole species. Although gene drive technology is at an earlystage of development, it has attracted controversy and led to calls to banits development as it is considered high risk . ResearcThe media are a key site where science and technology are debated andlegitimized—or de-legitimized—through the use of language with importantimplications for influencing social attitudes and understanding . Public Although contributions to science debates in the media have become morepluralistic and now include a wider range of voices , scientiHowever, the concept of responsibility and responsible research, despite beingwidely debated in academic literature, remains vague. While it is nowconsidered as part of international discussion in academia and policycircles, it remains open to interpretations, especially as to how it couldbe put to practice by scientists themselves . Respons is an area of research where the issues of risks, benefits, andscientific responsibility have stimulated much debate, not least as itpromises to help control vector-borne diseases and to manage invasivespecies , the appeal to emotions(pathos), and appeals to the good character of thespeaker and the shared values (ethos)  . Appeals (ethos) .Of particular interest are metaphors of war and destruction, which are oftenused to convey hopes and fears, or risks and benefits of emerging fields.They are ubiquitous in some areas of science and medicine, especially inconservation biology, pest management, and control of infectious diseases. These aGoing beyond the customary analysis of metaphors, this study also examines therole played in scientific communications by other discursive devices, suchas hyperbole, simile, clichés, and especially buzzwords. Unlike metaphorswhich received extensive attention in research on the language of sciencedebates, the use of buzzwords remains understudied .BuzzworWe analyzed media coverage in the United Kingdom, the United States, andAustralia, countries which are at the forefront of gene driveresearch. We concentrate on major news sources, including elite media,which play an agenda-setting role in defining what is newsworthy and whicThe New YorkTimes and The Washington Post in theUnited States, The Times and TheIndependent in the United Kingdom, as well asThe Australian and The CanberraTimes in Australia. We used a Factiva function tobrowse the database with the exact search phrase “gene drive” to avoidconfusion with other terms, such as “cancer gene drivers” Our analysis drew on We examined the conceptual metaphors underlying discourses about genedrive and their expressions at the level of media representations ofthis technology.We combined metaphor and discourse analysis with thematic analysis, whichrelies on identifying, analyzing, and reporting patterns (themes)within data , p. 78. Across the media sample, the coverage stayed close to scientific andinstitutional sources, and it relied heavily on scientists at the forefrontof gene drive research. The most visible of these were Kevin Esvelt (MIT),as well as Austin Burt and Andrea Crisanti . In contrast, there were no “visible scientists” in our sOur analysis revealed four main themes in the media coverage: (a) the natureand mechanisms of gene drive; (b) the hopes related to potential benefits ofusing gene drive; (c) fears, risks, and unintended consequences of usinggene drive in the wild; and (d) the role of scientists driving gene drive.These themes were discussed in the media with the help of discursivedevices, most importantly metaphors, but also clichés, simile, hyperbole,and buzzwords. The media in the United States and the United Kingdom, wherecoverage about gene drive was more extensive, used the most metaphors andthe most diverse metaphors and discursive tools. These themes are discussedin turn below.The New York Timesdescribed gene drive as a “revolutionary genetic technique” thatoffered control over insect-borne diseases such as malaria . In Australia, gene drive was hailed as “a real breakthroughwith feral cats” that threaten the survival of many native species ofbirds and mammals .Newspaper articles drew on a range of discursive tools to explain thescience and the mechanisms of gene drive. The cliché of “revolutions”and “breakthroughs” was used to convey the promissory nature of thisemerging field. For example, Evolution is design. It linked the theoryof evolution with the new technology which now enabled scientists tomodify the make-up of entire populations of animals and to change thecourse of their evolution. This was explained through metaphoricalexpressions which explored the power of scientists to “assist” theevolution or to “bend it to our will” , to “sculpt”  or even “reverse” it. At the sametime, the media emphasized the harmful properties of genetic traitsdesigned to spread rapidly within populations of disease-carryingmosquitoes or invasive species. This was conveyed through metaphoricalexpressions and simile which depicted gene drive as engines ordiseases spreading harmful modifications. For example, it wasdescribed as a “technique to spread ‘supercharged’ genes” , or a technology “whichenable[s] GM genes to spread rapidly like a viral infection within apopulation” .The control over nature provided by gene drive technology and thepossibility to alter entire species was conveyed through theconceptual metaphor The Age, February 24, 2018), as a “powerfuldouble-edged technology” , or as “a power for good orevil” . Overall, themetaphors and clichés explaining what gene drive is and how it worksdrew on the well-trodden tropes of control over nature and evolution,but did not convey an unwarranted optimism. The language ofbreakthroughs and promises overlapped with the one of risks anduncertainties. The focus on risk or danger was also evident in therepresentations of hopes and fears conveyed through metaphoricalclusters of destruction and apocalypse, as we show next.Despite the promise of power over nature, the coverage was notunanimously optimistic. Instead, the media displayed an ambivalenceabout gene drive, highlighting its potential advantages and pitfalls.This ambivalence was reflected in wordplay, such as “dangerousdriving” , and“wiping out a species” ,as well as more hyperbolic ones, such as “epic annihilation” and “perennial battlebetween humans and mosquitoes” . Some articles drew explicitly on declarations ofwar, such as “Mosquitoes, this time it’s war” , “war against invasive zebramussels” , or “genewar strategy to rub out feral cats” .The use of war metaphors is linked to well-established conceptualmetaphors exploited in discourses of disease and invasive speciesmanagement, such as The Financial Times, May 27, 2016),“supercharged killer mosquitoes” , or a mosquito as “man’s deadliest enemy” . An extreme example of suchcoverage and hyperbole appeared in Australian media where feral catsand foxes were accused of “genocide” of native species, and of turningAustralia into “a marsupial graveyard” .The urgency of using this technology was emphasized through expressionswhich personified animals as villains . Thus, tSt. Louis Post-Dispatch, June 12, 2016),“anti-disease mosquitoes” , or “risk-free mosquitoes” . This linked gene drive mosquitoes to antimalarialdrugs or bed nets, and described them as public health tools forcontrolling infectious diseases , which used the metaphorof mutagenic chain reaction to arouse fear and advocate for amoratorium on this technology. As Jim Thomas, program director of theETC group, argued, “a gene drive might be better regarded as a‘gene bomb’: dropped into the normal course ofinheritance, it annihilates natural variety (. . .).It may even annihilate the species itself”.In the press, a wide range of metaphorical expressions were underpinnedby the conceptual metaphor The Wall Street Journal,July 7, 2017), or as “genes that act as a time-delayed bomb in thepopulation” . Although themetaphor of the nuclear bomb eventually died out in the coverage, theimage of gene drive as a destructive technology was supported by a webof other metaphorical expressions, such as “genetic extinctiontechnologies” , a“tool that spreads catastrophic mutations” , or “exterminator technology”.The notion that gene drive is a bomb was a recurring feature of thecoverage, especially at the beginning of our reporting period. Genedrive technology was described as “a sort of genetic time bomb thatcould wipe out the species” ,especially after James Clapper, former Director of NationalIntelligence, had listed it as “a potential weapon of massdestruction” . Inthe United Kingdom, the focus was on the threat of bioterrorism andthe fear that “mozzies” could become a “new ISIS weapon” , and to a lesser extent ongene drive use by the military, the prospect raised, for example, bythe ETC Group .The destructive power of gene drives was also highlighted by themetaphorical expressions evoking terrorism. The U.S. media speculatedabout the use of gene drive as a “terrorist bioweapon” . A piece inThe Washington Post warned that “Without propercaution . . . gene drives could deliver ecological disaster . . . wecould unleash monsters” . Things were different inAustralia where catastrophic language and metaphors dominated thecoverage of the impact of invasive animals on native species, thusreinforcing the case for the use of gene drive in conservation.Other risks, such as unforeseen consequences for the animals orecosystems, also prompted speculations about disasters, especially inthe U.K. and U.S. coverage. For example, describing the impact ofmosquito eradication on food chains, Overall, scare metaphors and imagery of a nuclear bomb, bioterror, secretmilitary deployment, and ecological disasters denoted the fears andmistrust of the gene drive technology, and were used as a rallying cryagainst its use. While some of these metaphors originated inscientific and security circles and were initially intended as morespecialist terms, they were picked up by the media, where journalists,as well as various experts or opponents of gene drive used them towarn against this technology.Although the press drew on striking linguistic devices to emphasize thetransformative potential and dangers of gene drive, their depictionsof the scientists behind this technology differed remarkably in theuse of language. Few, if any, metaphors were used to describe thescientific community. Instead, the coverage emphasized the way inwhich scientists were said to conduct their research, highlighting keyattributes such as responsibility and caution, transparency andopenness, as well as commitment to public engagement and shared publicvalues. While the meanings of these attributes were not clearlydefined, they were evoked or repeated in various contexts describingscientific conduct or the interface of science and society. As such,the notions of responsibility, caution, and other characteristicsacted like buzzwords which often drew their meanings from context.Science,in which scientists, including gene drive developers, advocated publicdebate and called “on the scientific community to be open andtransparent about both the risks and benefits of gene drives”. Thiscreated an image of gene drive researchers self-imposing new ethicalnorms of scientific conduct on their own community.The press described the gene drive community as transparent about theirresearch. The insistence on transparency and openness characterizedscientists’ and media descriptions about scientists from the verystart. For example, across the three countries we studied, the mediareported on a prominent letter published in The New Yorker, February 2, 2017). The needfor transparency was thus emphasized not only as a moral duty but alsoas a pragmatic strategy for winning public support.The emphasis on scientific transparency was most salient in the UnitedStates, where Kevin Esvelt became associated with a new way of doingand communicating science. In a popular essay, The Age, February 24, 2018). In theUnited Kingdom and the United States, NGOs opposing gene drive, suchas GeneWatch and the ETC Group suggested that developing gene drivefor malaria control could in turn lead to its widespread use incommercial applications, and without public oversight .There were a few exceptions to the treatment of transparency in thepress. In Australia, reports about Defense Advanced Research ProjectsAgency (DARPA) funding for gene drive sparked fears that controversialresearch on genetically engineered rodents was being conducted withoutpublic scrutiny .On the whole, however, media coverage supported the image of scientistsas trustworthy, transparent, and not hiding inconvenient facts. In thepress, scientists were the key source of both hopeful statements andwarnings about risks, a finding also reported by The New York Times,November 25, 2015). Similar accounts of scientific caution appeared inthe U.K. press where Andrea Crisanti was quoted as saying, “There is arisk we all rush, and that shouldn’t be done. [. . .] And we shouldn’ttake shortcuts in the regulatory process. We don’t want it to backfirewhen it could be a gamechanger for public health” .Newspaper articles not only presented scientists as advocatingresponsibility and caution but also as already doing research in aresponsible way. In contrast to previous debates about biotechnologieswhich promised imminent cures and solutions , gene drThe New York Times andthe Boston Globe. In the United Kingdom as well,scientists speaking to the media advocated the need for publicengagement and consent for the potential use of gene drive. Forexample, Austin Burt, who leads Target Malaria, argued in the pressthat his research consortium “is advancing cautiously, consultingwidely and being as transparent as possible. Its job is simply todevelop the tool and let others decide whether to use it, he says . .. It’s up to the Africans to decide” .Scientists were represented not only as conducting research and providingexpert opinion but also as engaged in activities demonstrating theirsocial responsibility . ThisinThe SydneyMorning Herald, April 22, 2019).The idea that decisions about gene drive were ultimately in publics’ andpolicy makers’ hands recurred in the coverage, but—apart from theaccounts of Esvelt’s public engagement activities—it tended not to bediscussed in much detail. Instead, it was often subsumed in generalstatements, such as, “There are many unknowns and potential risks must[be] discussed transparently in public forums” . Thestock book title of the “sorcerer’s apprentice” was used in an articlein which Ali Tapsoba from the nonprofit organization Terre à Vieopposing gene drive trials in Africa accused Target Malaria of“medical colonialism”: “If Bill Gates [who funds Target Malaria] wantsto help us, then he should ask us what we want, not do something wedon’t want” . Thesewere rare instances in which the talk about scientific responsibilityand democratic commitments was challenged by other stakeholders.Future research could usefully investigate challenges to the notion ofscientific responsibility from diverse communities, especially whengene drive research enters the stage of field trials.Only rarely was doubt cast on scientific responsibility and competence.Occasionally, articles made reference to scientific irresponsibilityand hubris, conveyed by the metaphor of “playing god” or by stock booktitles such as “Frankenstein,” “Jurassic Park,” and “sorcerer’sapprentice.” These expressions were deployed in past debates about GMfood or cloning to raise doubts about these technologies andscientists’ motivations . In geneOverall, scientists were represented as trustworthy, transparent, andtaking their social responsibilities seriously. Rather than talkingabout the need to educate lay publics, scientists quoted in thearticles emphasized the need to work with publics, and stressed theircommitment to listen and address people’s concerns . With a This study set out to analyze metaphors and discursive tools used in the mediato discuss the science and controversies surrounding gene drive technology.It sought to examine if and how the notions of scientific responsibility andcaution are reflected in the linguistic features of media reporting. Ourstudy uncovered competing strategies for discussing this technology. Inparticular, it identified a strategy of eliciting trust in the gene drivetechnology by invoking moral attributes of the gene drive community, notablyscientific responsibility and caution. We reveal four major themes thatdominated reporting of gene drive: the science of gene drive, hopes as wellas fears related to this technology, and the role of the gene drivecommunity. Each of these themes was conveyed through a range of metaphors,clichés, buzzwords, and other discursive tools. These linguistic devicesplayed a rhetorical function and appealed to logical arguments, emotions, orthe good character of scientists and shared values.Persuasive arguments about the science of gene drive were expressed with thehelp of clichés of breakthroughs and metaphors of control over evolution.These discursive tools are well established in standard accounts ofscientific fields which draw on the tropes of progress and mastery overnature and which emphasize the expertise and credibility of scientists. JournalAppeals to emotions were pervasive in the media coverage. Both proponents andopponents of gene drive used emotive language to get their point across in aforceful way. On the one hand, hopes that gene drive could provide asolution to pressing problems such as malaria and invasive species wereexpressed in an aggressive language, notably in metaphors of war which arewell-established ways of talking about pest and disease control. Warmetaphors emphasized the urgency of global health and conservation issues,highlighted the efficiency of gene drive, and sought to mobilize support forthis technology. On the other hand, discursive devices evoking fears andmistrust of gene drive were also used by opponents of gene drive to spurresistance and to delegitimize the research. This happened throughhyperbole, simile, and scare metaphors which conveyed the threat of nucleardisaster, bioterrorism, secret military deployment, and ecologicalapocalypse. Such catastrophic language is also a well-known strategy toattract attention to potential risks .Finally, this analysis reveals a strategy of promoting the moral authority ofthe gene drive community. Rather than focusing solely on scientificcompetence which confers credibility and respect to scientists as experts intheir field, the media accounts highlighted other trust-building attributes, which rOur article demonstrates the importance of studying communication at an earlystage of technology development, when various actors attempt to influencethe debate and public understanding of gene drive despite uncertaintiessurrounding this technology. The gene drive community has been active inshaping the language of gene drive to engage lay publics and to build trust, and ourOur findings indicate an ongoing struggle over the language of the gene drivedebate. The dominance of aggressive metaphors of war remains entrenched,particularly in the promotion of solutions to global health and conservationchallenges which also reflect opponents’ motivations to stop this technologyby arousing fears of its potentially catastrophic consequences. Yet, thesefamiliar ways of reporting are juxtaposed against a new focus onresponsibility where the language of controversy and war is muted by thelanguage of consensus, specifically by the use of buzzwords evoking thesocial responsibility of scientists and their commitment to shared values.As with lay publics, listening to their views and actingon them (This analysis reveals a new focus on responsibility in media reportingemanating from the gene drive community. Whether intentional or not, thisnew focus builds consensus around gene drive by emphasizing the moralauthority of the scientific community through the evocation of moralattributes, especially scientific responsibility, caution, transparency, andcommitment to democratic values. While in previous debates on emergingtechnologies, the authority of scientists centered on their knowledge andexpertise, a new “moral authority” has become increasingly visible in themedia through references to the values shared by scientists and society.This new focus suggests scientists are not seen as separate from a laysociety through their expertise but rather are part of society, workingon them . We have