Although I can see him still—The freckled man who goesTo a gray place on a hillIn gray Connemara clothesAt dawn to cast his flies—It’s long since I beganTo call up to the eyesThis wise and simple man.All day I’d looked in the faceWhat I had hoped it would beTo write for my own raceAnd the reality:The living men that I hate,The dead man that I loved,The craven man in his seat,The insolent unreproved—And no knave brought to bookWho has won a drunken cheer—The witty man and his jokeAimed at the commonest ear,The clever man who criesThe catch cries of the clown,The beating down of the wiseAnd great Art beaten down.Maybe a twelve-month sinceSuddenly I began,In scorn of this audience,Imagining a man,And his sun-freckled faceAnd gray Connemara cloth,Climbing up to a placeWhere stone is dark with froth,And the down turn of his wristWhen the flies drop in the stream—A man who does not exist,A man who is but a dream;And cried, “Before I am oldI shall have written him onePoem maybe as coldAnd passionate as dawn.”William Butler YeatsPoetry Magazine, Vol.7, No. 5, February 1916Poetry Foundationhttps://www.poetryfoundation.org/poetrymagazine/poems/13324/the-fishermanThis poem is in the public domain. Poet’s Pen was chosen to honor Dr. Craig M. Pratt, who sadly passed away this year. As many know, Craig was a passionate fisherman—particularly of trout, and generally in the many lakes of the Northern and Eastern Sierra Nevada slopes and wild rivers of California, Colorado, and Utah. Not so much a fly fisherman, as reflected in Yeats’ great poem, “The Fisherman,” Craig instead focused on bait and lures during my trips with him—most of the time catching lunch or dinner, which I could never do. Yeats’ poem is a fitting tribute to a man who had a deep love of nature and the stillness and equanimity it afforded.This edition of Fishing has long been a focus of the written arts, with generations of writers and poets celebrating the chance to escape into nature. Craig knew of Isaac Walton’s mid-17th-century classic “The Complete Angler” and also that Sir William Osler’s Coat of Arms and Crest (granted in 1911 when he was knighted) featured three Cornish pilchards (sardines) in tribute to his sea-going ancestors and son, Revere, also a passionate fisherman. “Aequanimitas” is, arguably, William Osler’s most famous essay. It originated from a valedictory address to University of Pennsylvania medical school graduates. The essay focused on imperturbability: “coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgement in moments of grave peril….” This was Craig, the master clinician educator, and Craig, the fisherman in the wilderness. He was, in all ways, resilient. Resilience is informed by equanimity and born of “stillness” that can calm and even heal. Stillness can be found in many ways, but trout fishing with Craig in Thousand Island Lake at 10,000 feet  was indeed “still” and healing for me. Escaping the sometimes painful travail of our profession is important and even essential at times.Using the allegorical picture painted in Yeats’ poem makes sense to recognize Craig’s contributions to Houston Methodist Hospital, the Texas Medical Center (his adopted hometown), the NIH, FDA, his patients, colleagues, friends, and family. Think of Craig as Yeats’ idealistic fisherman. It may be a literal interpretation, but for me it directly connects to Craig’s efforts to improve healthcare practices and medical education over his 45-year career in Houston while seeking equanimity and stillness. It is something we all should be mindful of.“The Fisherman” was published in 1916. It came after a tumultuous period in Yeats’ life, both politically and artistically. Yeats knew the sport, and he juxtaposed life’s frustrating events with more tranquil days spent fishing as a youth. We might think of Yeats casting gently from a water’s rocky outcropping to an inviting pool with hopes of a hit. That is the way I think of Craig and other avid trout fishermen: creating peace and tranquility in a hurly burly world with a flick of the rod, surrounded by nature’s wonder during dogged pursuit of an often-returned prize. “The Fisherman” was Yeats’ attempt to create the picture of a perfect man. Thus, the poetic image of the freckled man who goes to a gray place on the hill at dawn to cast his flies, which Yeats can still see.As we emerge from the year’s challenges, we should seek stillness, peace, and tranquility in our own ways. Perhaps some “will climb up to a place where stone is dark with froth, and the down turn of [the] wrist when the flies drop in the stream” can be seen. Remembering how Dr. Pratt reveled in the stillness of those moments makes me smile as I reflect on his life and contributions.


Findings: A total of 1070 patients were observed, amounting to a median prevalence of PR use of 19.11% (min: 0%–max: 44.44%). The differences observed between ICUs could be explained by a difference in restraint conceptualization. The various actors involved jointly build up a health care culture and a conceptualization of the terms “safety-risk”, which determine decision-making about the use of restraints at each ICU. These shared meanings are the germ of beliefs, values, and rituals which, in this case, determine the greater or lesser use of restraints. There were different profiles of PR use among the units studied: preventive restraints versus “Zero” restraints. The differences corresponded to aspects such as: systematic use of tools for assessment of PAD; interpretation of patient behavior; the decision-making process, the significance attributed to patient safety and restraints; and the feelings generated by PR use. The restraint–free model requires an approach to safety from a holistic perspective, with the involvement of all team members and the family.Aim: The general aim of this study was to explore the decision-making process followed by Intensive Care Unit (ICU) health professionals with respect to physical restraint (PR) administration and management, along with the factors that influence it. Method: A qual-quant multimethod design was sequenced in two stages: an initial stage following a qualitative methodology; and second, quantitative with a predominant descriptive approach. The multicenter study was undertaken at 17 ICUs belonging to 11 public hospitals in the Madrid region (Spain) across the period 2015 through 2019. The qualitative stage was performed from an interpretative phenomenological perspective. A total of eight discussion groups (DG) were held, with the participation of 23 nurses, 12 patient care nursing assistants, and seven physicians. Intentional purposive sampling was carried out. DG were tape-recorded and transcribed. A thematic analysis of the latent content was performed. In the quantitative stage, we maintained a 96-h observation period at each ICU. Variables pertaining to general descriptive elements of each ICU, institutional pain-agitation/sedation-delirium (PAD) monitoring policies and elements linked to quality of PR use were recorded. A descriptive analysis was performed, and the relationship between the variables was analyzed. The level of significance was set at  With regard to the Hippocratic maxim, “first do no harm”, nowadays, the need to implement policies that promote safety, quality, excellence, humanized treatment of others, and compliance with ethical aspects in health care settings would seem to be indisputable. In this respect, minimizing the use of physical restraint (PR), and in the event of such use being necessary, judicious application governed by quality standards as well as reducing the risks related with their use, well described in the literature at both a physical and psychosocial level ,3,4,5,6,lex artis), construed as a concept that is constantly evolving in response to scientific-technical and social advances.Recent years have witnessed a clear shift on the part of leading consultative/advisory bodies and scientific societies toward a reflexive, judicious, and informed use of restraints, especially since the measure is regarded as being of dubious effectiveness in many cases ,11,12,13The literature shows a disparity in prevalence figures among countries, partly accounted for by differences in the criteria considered in the respective studies ,17,18,19In the case of critical patients, concern in national and international spheres about the use of PRs is a very recent phenomenon. There are hardly any studies on the topic or reports of positions taken by intensive care units (ICU), and the difference between practice and guidelines seems to be even greater than in other settings; some authors even regard ICU as the “last frontier” of PR use ,26,27,28In general, health professionals advocate for the need for the use of PRs, seeking justification in individual safety (safety of the patients themselves) or collective safety (safety of third parties), with the latter being almost entirely restricted to mental health ,33,34. IWhat appears to be evident at the present time is that systematic PR use is becoming increasingly difficult to justify. Despite this, however, the situation persists, and progress must therefore be made in an issue viewed as being highly complex ,38. In tAs noted above, when it comes to making decisions about the placement of PRs, these generally focus on causes that compromise the safety of the patient ,34,42. HTraditionally, nurses have been the main actors in PR administration  and management  ,46,49,50In this respect, although nurses play this central role in PR management, it is reasonable to assume that they are not the only ones involved in decision-making: physicians and patient care nursing assistants (PCNA) could well exert a constant and powerful  influence. Acknowledgment of this interdisciplinarity in terms of PR management would be in line with recognition of the complexity of the phenomenon and the existence of individual, group, and legislative factors  ,40,41. IRegardless of who the health professionals tasked with making decisions about PR use might be, the setting in which this might take place, or the elements that might exert an influence, decision-making in clinical practice should include the following five elements: (1) awareness and definition of the problem; (2) determination of the goal; (3) assessment of alternatives; (4) implementation; and (5) evaluation . A numbeEverything said so far indicates that reflection on the decision-making process for PR use is essential. The inherent complexity of the study of PR, coupled with the difficulties posed by the design of studies that address decision-making, calls for approaches that are reflexive rather than reductionist, and capable of tackling complicated and intricate issues .It should be made clear at this point that, for the purposes of this study, PR was defined as “…any action or procedure that prevents a person’s free body movement to a position of choice and/or normal access to his/her body by the use of any method, attached or adjacent to a person’s body that he/she cannot control or remove easily.” . In lineThe general aim of this study was to explore the decision-making process surrounding PR use and the factors that influence it among the various professionals comprising the ICU health care team .The study hypothesis was formulated under the conceptual proposal of the “Iceberg Theory” ,38. ObseUnder this conceptual premise, the specific research goals for each of the proposed stages are set out in detail in The methodology adopted responds to the need to examine a little explored phenomenon that is also rather complex. Indeed, it was in response to the sheer range of nuanced outcomes envisaged by the specific goals that we chose to adopt a qual-quant multimethod design ,58,59,60A multicenter study was thus undertaken at 11 public hospitals in the Madrid Region (Spain) that accounted for a total of 17 ICUs, with the Puerta de Hierro Majadahonda University Teaching Hospital acting as the coordinating hub.The study covered 17 ICUs belonging to 11 public hospitals in the Madrid region. Although all hospitals participated in the clinical audit, not all did so in qualitative stages I and II, since the respondents were selected on the basis of their suitability and willingness to take part.Based on the data initially furnished by the hospitals, the nurse:patient ratios of the ICUs involved ranged from 1:2 through to 1:4, according to work shift.All the health professionals participated in the study voluntarily and were asked to sign the informed consent (IC) form. Confidentiality of information was guaranteed throughout. Once the texts had been transcribed, all the tape recordings were destroyed and the data were anonymized.ICU data were collected anonymously in the form of aggregate data, with the consent of the directors of the respective ICU being previously obtained for this purpose. The study received the formal approval of all the clinical research ethics committees of the participating hospitals.We conducted a qualitative interpretative phenomenological study  as propoData were collected from December 2013 through January 2015, and generally included health professionals drawn from eight public hospitals and 14 of the ICUs included in the study. Nurse:patient ratios at the ICUs involved ranged from 1:2 to 1:3, according to work shift.We carried out intentional purposive sampling ,65. The Given the absence of prevalence data at the date of undertaking this stage of the study, the different ICUs were classified by the principal investigator (PI) and research assistants as “systematic or frequent use” (FU), “individualized or occasional use” (OU), or “mixed use” (MU), in line with the frequency and criteria of PR use yielded by a purpose-designed questionnaire  see . Access A total of five DGs were held . In thesThe DGs were tape-recorded and transcribed for subsequent analysis.All DGs were moderated by the PI, accompanied by some member of the team of qualitative research experts. Initially, use of the same script was envisaged for all the DGs, employing a strategy of nondirective moderation with open and general questions , but sub7-step method for data-analysis  use restraints as little as possible […] and in full awareness […]. Well... I don’t get the idea of preventive (restraint). That’s to say, if we’re already saying that the fact of applying therapeutic immobilization is a complicated matter, if we apply it preventively...What do we do? Do we restrain everyone before waking them up?”DG PCNA OU: “See what you’ve done? I told you that you had to have him restrained”, and that starts creating a dynamic […] it’s a question of the overall dynamic of people, that’s to say the feeling of thinking that one shouldn’t do it […] other than in specific cases and specific moments, it has to be a collective thing because if there’s somebody less inclined to do so, how do you put him on the right track with the idea, “See what you’ve done?”DG mixed physicians: Furthermore, the concept of safety and professional risk is approached from a different perspective. Hence, at an ICU with OU, both physicians and PCNA see the risk of undesirable events as something intrinsic to professional practice, even though resources and advances in knowledge mean that these are less frequent and that safety in the workplace is far greater.“When it comes to really inevitable risks [...] there are very few; what happens is that, with current state of knowledge, there are things that, as of now, we are unable to prevent, but if you analyze all the factors that influence the famous Emmental cheese with all those holes, if you start covering those holes, there’ll come a day when it’ll be very difficult for those errors and those mistakes to occur”.DG mixed physicians: Thus, they do not perceive PR use as a means to prevent incidents that might reveal or highlight personal error in professional praxis: what they see instead is that the real solution to the occurrence of undesirable events is a feeling of group responsibility.“…it’s the fear of feeling guilty, and that they might blame you for something which you think could be a personal error, when really it’s the same old story, we’re going to look for someone to blame and we’re not going to look for solutions and the reasons why things happen […] working together with the whole team and not trying to find scapegoats …but solutions”.DG mixed physicians: “Anyway, things have changed a little since safety protocols were established, like now everybody’s more aware that, instead of going around blaming people all the time, looking for someone to blame, it’s necessary to look for a solution to this type of problem. I feel that this whole concept is gradually changing”.DG-5-Nurses: In this context, the concept of safety acquires a more humanistic perspective, focused on the patient’s subjective experience and care from a holistic stance.“Being cared for, […] being accompanied, not feeling isolated. The fact of knowing that he’s being taken care of, monitored, protected. That he’s in the hands of good health professionals […] that he has trust in the professionals”.DG PCNA OU: . With respect to this notion of health care quality and patient safety, in the clinical audit, an inverse correlation was found with overall PR prevalence and PR prevalence in patients with ETT of −43.15% and −52.14%, respectively : in otheIn relation with the above, there is an evident need for a cultural change, a conclusion and at the same time, a demand, that other authors have also contemplated ,94,95,96The qualitative findings yielded by examining the experience of ICU nurses showed that in units with FU of PR, the presence of artificial airways or the initiation of the process of weaning patients off mechanical ventilation is used to justify the practice as a way of preventing self-removal of life-sustaining devices, without there being any assessment of the need for their use. Accordingly, PR use could not be attributed to a decision-making process for the management of restraints: a clinical judgment of this nature would not appear to exist.“See what you’ve done? I told you that you had to have him restrained”, and that starts creating a dynamic that the patient is about to arrive, and the assistant says, “Do I restrain him?” What are you talking about, restrain him? He’s just come in, and you’ve got no idea of how he’s going to behave, he’s hardly in the room and you’re already restraining him. That’s why I say that it’s a question of the overall dynamic of people”.DG mixed physicians: This would be in line with the results of the clinical audit, which concluded that in 33.68% of cases, PRs are applied as a matter of ICU policy  .While this reality might differ in an ICU with an OU of PR, where the health professionals acknowledge that such a decision-making process does indeed exist, they nonetheless experience difficulties when it comes to consciously putting it into words.“…in each nurse’s judgment [...]. On what do you base yourselves in order to take the decision? […] if I see, well, that during these mornings the patient is calm, I take advantage of the situation, I unfasten him [...] quietly observing him to see how he reacts […]. I continue to keep an eye on him. [...] Don’t you use anything on which to base your decision, a RASS score, a delirium scale, some element that would enable you to decide? […] If he’s clearly agitated, we restrain him, then there’s no turning back […], in a calm patient who answers you by nodding his head, well I don’t know, you just keep on watching…”.DG5 OU-nurses: In this connection, attention should be drawn to the differences found in the influence exerted by interpretation of the patient’s behavior on the indication for PR use or use of tools for assessment and management of the causes of agitation.As can be seen in An ICU with OU of PR highlights the importance of the systematic use of validated tools for the assessment of pain, agitation/sedation, and delirium, with the use of these instruments being assumed to determine optimal use of pharmacological tools for the control of agitation. At an ICU with FU of PR, however, there is acknowledgment of the under-use of such tools and mismanagement of some causes of agitation such as pain see .With respect to the above, the clinical audit found that, when it came to the monitoring of pain, 64.71% of ICU did so appropriately in communicative patients and 35.29% did so in noncommunicative patients. Whereas 88.24% of ICU monitored sedation in accordance with the guidelines, only 11.76% did so in the case of delirium.p < 0.001). With regard to the association with the monitoring of delirium, no conclusions can be drawn, given the negligible number of ICUs that monitored delirium appropriately.We analyzed the relationship between compliance with the standard and variables of PAD monitoring as well as the use of protocols and training of health professionals . Lower pIn our results, the most frequent indications for use were agitation, attempted removal of AAs and other devices, which might be related with pain or delirium ,29,97,98In the participants’ discourse, it was possible to identify a large variety of elements that influence use/non-use of PR and respond to the conceptual framework of the “Iceberg Theory”, the theoretical reference framework adopted as the point of departure.According to studies conducted in settings other than critical patients ,50,102, ; health professionals inflexibility when it comes to change ; and the interpretation put on patients’ behavior .With respect to the first of these, mention should be made of: fear of physicians’ reaction to self-extubations Noteworthy among the group factors are: nurses being blamed for patient-related extubations ; problems of communication between physicians and nurses ; pressure from the rest of the members of the group ; and mismanagement in the unit of causes of agitation and assessment tools , “....poor patient sedation ([…] he should be better sedated...” [DG5-nurses]). All of these are matters that could favor the use of restraints.the family only spends 20 min here during the morning...” [DG1-nurses]); nurse:patient ratios; the architectural distribution of the ICU ; and allocation of workloads .Finally, insofar as organizational factors are concerned, attention should be drawn to: restriction of family visiting hours . Hence, although this factor is considered relevant by nursing professionals, it may possibly not be quite so decisive in clinical practice ,39,45. TIn the discourse of health professionals drawn from ICU with both FU and OU of PR, the subtopic of “economy of feelings” surfaces, in which health professionals voice the absence of feelings generated by managing patients with PR.“...I don’t feel anything, good or bad...”, DG1-nurses: “...it’s part of your work, which you may or may not like to a certain extent [...] I don’t go home feeling any the worse…”.DG4-OU-nurses: .In line with the “economy of feelings”, related concepts emerge such as “nurse’s helplessness”, which appears as a stance with respect to problem-solving and decision-making so that nurses find themselves propelled toward the application of restraints when they perceive that they have been left without tools for managing the patient or have lost motivation and/or confidence in themselves and the resources at their disposal. In the same way, as postulated by the theory of learned helplessness  , nurses,Although “economy of feelings” is envisaged in both subtypes of ICU, significant differences can be seen in the cause of this emotional blunting in the face of an extreme measure such as physical restraint: at an ICU with FU, normalization of PR use could account for the suppression/minimization of feelings; at an ICU with OU of PR, however, this blunting of feelings might be related to the fact that restraints are only used when all alternative approaches have failed .While the “economy of feelings” referred to above might initially prove somewhat surprising, it is nevertheless in line with the data in the literature ,43,107 oThe idea of working under a “zero-restraints” paradigm appears naturally and credibly in the discourse between PCNA from ICU with OU of PR and physicians.“When is it going to be of interest to us? Well, when everyone admits that what’s being done is not altogether right; perhaps we won’t get to 0% restraint use, but we can bring it down for sure […] there has to be some kind of aim or plan”.DG mixed physicians: “I believe we can restrain less because I’ve experienced it. Of course, the fact is I’ve seen it, so zero restraints, and I mean zero, zero, because I don’t know whether you’d need to restrain the patient in some specific case, but what I am sure of is that you can use restraints a lot less because truth is I’ve been there. And at the start, it was like “wow”. And when you see that you really could do it, when we made the break and continued with the same routine of making less use of restraints, well yes, there were people who removed the tube, but it wasn’t like we had a whole lot of extubations, more than before”.DG-5 Nurses: This approach is based on the following four premises: patient- and family-centered care; well-being-comfort and self-determination as outcome criteria; clinical judgment and planning of consensus-based interdisciplinary health care interventions; and the provision of adequate human and material resources .Regarding the patient as the subject of care implies taking patient safety as the axis of care, placing clinicians in the role of advocacy, with this being construed as a role of preserving the patients’ safety and defending their rights and interests . From th“And then there’s another factor […] all these non-pharmacological and non-healthcare measures, such as family accompaniment for instance, that’s to say, many patients are much calmer if they have a person, a relative at their side, who helps them when they come round, to focus and, to…, that’s been demonstrated, there are many non-pharmacological actions that depend on the family or relatives, who help a lot to maintain these situations”.DG mixed physicians: “I think that another measure you were talking about before to try and reduce the number of restraints would be to also increase visits, I feel that this would also be a possible measure. What we ourselves do in the case of some patients is to increase visits for family relatives. Patients are much better off with their family”.DG-5 Nurses: Furthermore, correct analgosedation is essential to place patients in the best condition to maintain their self-control and consciously participate in their recovery process. Providing the patient and family with information about clinical status and training in care are indispensable for making decisions and participating in caregiving, thereby achieving a feeling of control and self-esteem.“[…] until a few year ago, it was thought that the intensive-care patient had to be sedated and not […] he has to be wide awake, collaborating and in no pain, and if you succeed in this, ok the intubation will cause a little discomfort, but well […]”.DG mixed physicians: “[…] if instead of applying therapeutic immobilization […] and a member of the family came in and sat there […] holding the man’s hand, the fact is he was quiet the whole afternoon […] there was no need to restrain him or anything”.DG PCNA OU: None of this is possible, however, without a consensus-based interdisciplinary approach based on in-depth knowledge of the patient and joint decision-making. A routine multicomponent assessment that envisaged PAD monitoring, the risk factors for its implementation, and the pertinence of the continuity of invasive devices, would be crucial in such a decision-making process. This integral and integrated interdisciplinary approach is reflected in the proposal of a “comprehensive restraints policy” and would imply the drawing up of joint-action protocols. In such a context, interpersonal communication  is fundamental, as is formal regulation of the prescription of PR, which, being ambiguous, generates invisibility and a dilution of responsibilities.“[…] we’re all colleagues. […] I’ve never had a problem with nurses when I’ve told them my opinion, but talking about it, you know? Not pejoratively, always ‘‘no, it’s just that the nurse’’, no, we also have our part”.DG PCNA OU: “[…] just as a nurse will say ‘‘listen, we’ve got blood sugar levels rising to 250 mg/dL, open me a line of insulin’’, she should tell you, ‘‘listen, look, with this patient there’s no way of keeping him calm, he scares me’’, and we assess it together […] it’s about expressing a joint problem. […] we’re not at the bedside 24 h a day […] its left to the nursing staff, nurses are competent, and many things that you’re not going to see in the 10 min you spend there on your rounds every shift or hour […] it’s very curious how even nursing assistants. […]. Maybe it’s a little about bringing the key element […] cohesion […] into the team, most of the problems begin right there, in the lack of a common goal and communication”.DG mixed physicians: With respect to human and material resources, different factors were identified that would foster the promotion of restraint-free ICUs . ExampleFinally, attention should be drawn to a key guiding factor cited in the health professionals’ discourses, namely, motivation. The motivation required here is the kind that would impel the team toward a change in organizational and health care culture, something that would imply, first, becoming fully aware of how one was working and what the aim of one’s work was, and second, planning a transition strategy endowed with resources that would favor a harmonious and integrating process based on communication, team work, shared leadership, and compassionate, empathetic, and committed care.“Right, and no-one stops to think that maybe patients shouldn’t be restrained, and maybe we’re doing the wrong thing […] it’s also very difficult to break the… […] I see it as a problem that’s being trivialized and is something cultural, so it has to be changed [...] This has to be re-addressed as a non-trivial, non-routine measure, something that’s exceptional”.DG mixed physicians: “flexible positioning (is necessary). We’re dealing with persons and this isn’t a mathematical science: 2 + 2. There are many variables. Training and positioning ”.DG-3 Nurses: All these elements, highlighted as crucial to progress toward the “zero-restraints” work paradigm in ICU, are shown in Returning to the basic premises, by virtue of which patient safety would be construed as a collective responsibility, and decisions  would be based on consensus reached by health care teams, these give rise to the need to think about the prescription of PR use.The findings show that physicians admit to trusting in the nurses’ judgment, considering them to have in-depth knowledge of the patients and their needs when it comes to guiding decision-making in the management of analgosedation and implementation of pharmacological measures (under nurse-driven protocols) as well as non-pharmacological measures. Furthermore, nurses are regarded by physicians and PCNA as the figure that centralizes information and serves as the manager of patient needs by coordinating therapeutic interventions. Furthermore, the nurse is acknowledged as being the professional carrying front-line responsibility for ensuring patient safety . In this respect, their judgment, far from being questioned, is trusted and relied upon.“If a nurse tells me that she’s going to apply restraints to a patient, even though I may not agree, I trust her judgment”.DG mixed physicians: “It’s just that I have doubts about the world of prescription because, for example, restraints are considered something that should be prescribed by a doctor, it’s the sort of thing they say, but on the other hand, restraints, at least in my hospital, have always been regarded as coming under the heading of safety, let’s say, and safety is part and parcel of nursing, so there’s never been any challenge or argument about who had to prescribe, and it’s always been the nurses who’ve done it on their own account. They can report it, there isn’t any kind of secretiveness, it’s simply that they’ve viewed it as their initiative, no-one’s ever mentioned it…”.DG mixed physicians: Notwithstanding the above, nurses demand support in decision-making, in that there are variables that influence and determine patient well-being and safety, and which depend on aspects of clinical and pharmacological management that come within the physicians’ scope of competence. The findings revealed opposing points of view, with feelings of empowerment on the one hand and vulnerability on the other.“In my unit, for instance, they’re never prescribed […] that’s surprising when physical restraints should actually be prescribed. And as I feel unsure, well you’re scared that one of these days something’s going to happen and you’re going have to face the music”.DG Nurse-FU: “It seems to me that there‘s no reason why restraints should come within the sphere of doctors, but (prescription) is a way of protecting ourselves legally and drawing up protocols […] I feel that what’s lacking is training in the management of restraints, PR use protocols that are really for the safety of the patient”.DG Nurse-FU: What also emerges from the nurses’ discourse is the concept of “moral suffering” in relation to decision-making about the application of PR ,41,110. “But I’d like to explain to you that there are sure to be other measures to take and not just restraints, that a doctor can’t force you to restrain a person, because in that case, let him come down and do it himself. […] No, no, force me, no; force, no […] No, but maybe if he was the one who had to restrain the patient, then he might not be so ready to tell you to apply the restraints […] Yes obviously it’s really easy to delegate the job of applying a restraint or whatever, and that’s exactly why they don’t want to talk about it, because what they really do is delegate the job to somebody else, and that’s the person who actually applies the restraints”.DG Nurse FU: interpersonal network as a forum for decision-making”.The current PR prescribing scenario at ICU around Spain seems to consist of the “nonexistence of medical prescription”, and the routinization and what one might call the “invisibilization” of decision-making ,8. In th“[Prescription] really is something that we’ve left in the hands of the nursing staff and we pretty much try not to become involved […] Has it got to be a medical prescription? Well, I feel it ought to be a joint or delegated prescription. Seeing as it’s the nurse who’s at the bedside 24 h a day, or the nursing assistants. They should be the ones participating in this prescription, just as they participate in many other aspects of care. At present, it’s not like that, so in difficult situations they also look for support in the fact that there is or isn’t a medical prescription. Well, an agreement will have to be reached, it’ll have to be reviewed”.DG mixed physicians: “This has to be re-addressed as a non-trivial, non-routine measure, something that’s exceptional, and that’s imbued with this exceptional nature because of its indications and joint prescription”.DG mixed physicians: As has already been noted, on discussing the process of taking judicious and consensus-based decisions, anxiety, agitation, and rest-sleep feature prominently as fundamental pillars of pain assessment. Integrated multidimensional information leads to planning of health care interventions at a pharmacological and non-pharmacological level, which in turn implies impeccable coordination among the various professional figures. Having come thus far, it is necessary to introduce another actor with a say in matters and operational capacity, namely, the family, which may exert a major influence. Taking Haines’ contributions  as a refIn addition, the role of mid- and high-level managers should also be kept in mind. With regard to the latter, health care professionals highlight the passivity of managers with respect to PR use . These r“...the truth is, it’s always been done, everyone knows it, but no-one cares… It’s something that’s always there… and when I say no-one cares, I mean no-one… neither physicians, nor us, nor even my boss, who’s never given it a second thought”.DG1-nurses: “...when there’s an extubation and they ask you if the patient was restrained… the physicians and the supervisor come to ask you why he wasn’t restrained…”DG2-nurses: Institutional positioning and involvement could be crucial in achieving changes in clinical practice, with the introduction of policies and strategic lines that would generate a culture of restraint-free care and provide the structural resources  and necessary knowledge to implement it .This multimethod project was conducted throughout from a pragmatic and translational stance, and has sought to provide a broad overview of a complex reality. Indeed, acquiring in-depth knowledge of the reality surrounding PR and the factors associated with their use, opens up the possibility of reflexive management of restraints, which would in turn translate as a real reduction in clinical practice. In this respect, one of the undeniable strengths of the study is the use of multimethod strategies to minimize the specific limitations of each of the methodologies used. Even so, there are some limitations in each of the stages that warrant consideration.In both stages of the qualitative interpretative phenomenological component, a comparative analysis was made of the discourse of health professionals drawn from ICU with OU or FU of PR. At the time, however, there were no real prevalence data on PR use at the ICU included. Hence, in light of the absence, both in the literature and at the ICU involved, of reliable data on the real prevalence of PR use and the modulating factors of such use, the ICU were stratified on the basis of a purpose-designed questionnaire, which though unvalidated, was nonetheless agreed upon by the whole research team.Given the nature of the audit of the proposed clinical practice, a high number of cases were observed. Due, however, to the characteristics of this data-collection , this inevitably gave rise to other related limitations such as the fact that the data were collected on an aggregate basis.The set of optimal use criteria proposed is a model created by the authors, based on a review of the literature and knowledge of the study topic, but has not undergone validation, and must therefore be approached with caution and reviewed from a more up-to-date perspective, by, for instance, replacing concepts such as the fact that the patient is sedated by quantification with validated instruments .excessively benevolent image of PR use in this country.The fact that only ICUs that voluntarily wished to do so participated in the study may influence the findings and exhibit an The study included health professionals from a single region in Spain, and as a result, the conclusions must be contextualized and can only be extrapolated to cultural contexts with similar ethical conceptualizations such as other regions of this country or countries in the Mediterranean Basin.The chronological order of the study and the time elapsed between the different stages may have amounted to a limitation in light of the changing nature of reality. Moreover, as observed in the Introduction, recent years have witnessed growing concern in ICUs about the management of critical patients’ behavior and, in a far more tentative manner, about PR use, with changes having taken place in recent years in the pharmacological and non-pharmacological strategies used for PAD management. Although the difference between theoretical advances and the translation of results to clinical practice is undeniable, with this being a long, and costly process, it is nonetheless likely that, across the years covered by this study, small changes may have occurred in the ICUs involved, with the result that, as of the date of writing, the reality recorded during the initial years may have undergone certain modifications. Finally, it is important to highlight the influence of the research process itself on the ICU/professionals involved, inasmuch as participation in the study may well have given pause for thought and, by extension, led to a change in these same units/professional participants.The multimethod strategy has shown itself to be of great utility. Initially, the qualitative approach made it possible to gain greater insights into a complex and multifactorial phenomenon to then be able to validate some of the emerging hypotheses via the quantitative approach.The various actors involved jointly build up a health care culture and a conceptualization of the terms “safety-risk”, which determine decision-making on the use of restraints at each of the intensive/critical care units.The qualitative findings appear to confirm the “Iceberg Theory”: based on the discourses, a notion of risk and safety is identified that is constructed, transmitted, and interiorized in the context of a sociocultural group. These shared meanings are the germ of beliefs, values, and rituals which, in this case, determine the greater or lesser use of restraints.This study revealed a reality of use that might be similar to that of other countries with frequent use of restraints.Different profiles of PR use among the units studied were identified. The differences corresponded to aspects such as systematic use of tools for the assessment of pain/agitation-sedation/delirium, interpretation of patient behavior, the decision-making process, the significance attributed to patient safety and restraints, and the feelings generated by their use.The restraint–free model requires an approach to safety from a holistic perspective, with the involvement of all team members and the family. Interventions such as interdisciplinary rounds, in which the nurse would act as the central reference figure, or the establishment of a model with quality standards for the application of restraints, may prove useful.


We compared an increase in the number of papers from PubMed with search interest expressed in Google Trends. Collected Google Trends data is from the same period, covering fifteen months starting January 2020 and were searched with the use of three search topics: coronavirus, lockdown and social distancing. The geographic setting for search engine users was worldwide. We propose a hypothesis that after increased interest in searches during the pandemic's initial months came an increased number of published papers on topics such as infoveillance, infodemiology and Google Trends.We noticed an increase in the relative number of published papers on topics such as infoveillance, infodemiology and Google Trends. Collected PubMed data are from the period of January 2020 to March 2021 and were searched with the use of five keywords: infoveillance, infodemiology, Google Trends, diabetes and  •Google Trends data underline the importance and duration of the COVID-19 effects.•PubMed data reveal an increase in the number of papers in infoveillance, infodemiology and Google Trends•Current restrictions such as lockdown and social distancing are reflected in the number of internet searches The search period was from January 2020 to March 2021. We used series of queries with changing keyword and period. Following is an example of one query:As a result of the first step, we have received a number of published papers containing the selected keyword in the title or abstract in the monthly resolution. In addition, we have also established a total number of published papers with identical conditions (keyword in title or abstract) before the year 2020. These numbers serve as starting point for further calculations.coronavirus”, “lockdown”, “social distancing”. Searching for topics, instead of searching for particular search terms, helps cover the same topic in different countries and languages. Search topics cover all the keywords which are under the same topic. Setting the region worldwide allows seeing the same search topic's interest in all countries covered by Google search engine.In the second step, we have collected data with the following settings in Google Trends. We have set a time span since 2004 and used monthly data resolution for the years 2020 and 2021. We have selected the region worldwide and set all categories. The search was conducted using the index from Web Search. We have used three search topics: “Coronavirus” represents all keywords related to information about the disease [Lockdown” covers all keywords related to closing borders, economy, schools, and malls [Social distancing” refers to all keywords related to the use of personal protection measures, especially to keep the distance between two persons and using face masks [We have selected these search topics as the most discussed and presented in news and media. “ disease . “Lockdond malls . “Socialce masks .3infodemiology”, “infoveillance” and also high values for the term “Google Trends” in the title and abstract for scientific publications starting April 2020 compared to previous months (infodemiology” is noticed in August 2020, for “infoveillance” in October 2020, and for “Google Trends” in June 2020. During this investigation period, the relative increase in publications with the much broader term “in silico” and the increase in publications on the comparison term “diabetes” remained relatively constant.The relative increase in the number of publications compared to the previous month was examined using the PubMed database for the fifteen months starting January 2020. Our study with the PubMed database has shown a noticeable increase in the terms “s months . The higinfodemiology” and “infoveillance” compared to the number of publications with “diabetes”, which are orders of magnitude larger, the observed increase is nevertheless apparent.Apart from the influence of the smaller number of publications with the terms “lockdown” and “social distancing” (This trend in PubMed follows the peaks of search interest in Google Trends in March and April, which are based on the worldwide COVID-19-related requirement of the population for “tancing” . First, tancing” . The hig4Google Trends data are widely used for current research work on coronavirus disease. It delivers up-to-date relative search volumes for almost every country where COVID-19 was reported. For the past decade, data from Google Trends served as a source to conduct research on seasonality in infectious diseases, mental health, other diseases, and general population behaviour [The main finding of this study is confirmation of the increase in the number of papers on infodemiology and infoveillance with the use of PubMed data during COVID-19 pandemic time. As presented results showed, in the period from January 2020 to March 2021, there is a relative increase in the number of published papers in the PubMed database. Our hypothesis that after increased interest in searches during the pandemic's initial months came an increased number of published papers on topics such as infoveillance, infodemiology and Google Trends is supported.e.g., interest in various other coronavirus symptoms, like loss of taste and smell, before these symptoms were identified as typical for infection [e.g. personal protection measures like protection masks, hand washing, social distancing and mobility restrictions [Data from Google Trends are used for different study fields. Here are only a few identified in previous studies regarding COVID-19 disease and its consequences. First, data from GT are used to predict COVID-19 incidences or to communicate risks . An incrnfection . Third, rictions ,27.Fourth, it is used to assess current psychological effects and mental health on lockdowns and overall well-being. There is a reported increased number of searches like boredom, loneliness, worry and sadness . Fifth, prediction area. There are several studies where authors argue that Google Trends data can predict infections and the development of the disease [A further literature review may identify several other fields. The most exciting field seems to be the  disease . On the  disease . The curdiabetes” for search through PubMed, we may have overlooked more suitable terms introduced through literature.This study has some limitations. First, Google's popularity varies globally. For example, the search engine is not very popular in Russia, China, Japan, and South Korea. In the rest of the world, Google has more than half of the search market share. Therefore, for regions where Google has a higher market share, the results may be more representative. Second, by selecting the keyword “in silico.In a One Health approach, in addition to focusing on the health effects of the human population, it is also important to consider implications for and interactions with nature and the environment. In particular, the various corona viruses with their zoonotic origins teach us not to neglect veterinary public health issues ,24. As  describeThe authors declare no conflicts of interest.


In Romania, one in four children has excess weight. Because childhood obesity is a sensitive topic, many healthcare professionals find it difficult to discuss children's excess weight with parents. This study aims to identify barriers and facilitators in childhood obesity-related communication, as perceived by healthcare professionals in Romania. As part of the STOP project, healthcare professionals  who treat children with excess weight were invited to a telephone interview. The semi-structured questions were translated from a questionnaire previously used at the Swedish study site of the STOP project. Interviews were transcribed and then used for thematic analysis. Fifteen doctors and three dieticians , with average 18.2 ± 10.1 years of experience, were interviewed. Four main themes were identified. Professionals reported that when children began experiencing obesity-related stigma or comorbidities, this became the tipping point of weight excess, where parents felt motivated to begin treatment. Barriers in communication were part of several layers of distrust, recognized as tension between professionals and caregivers due to conflicting beliefs about excess weight, as well as lack of trust in medical studies. Most respondents felt confident using models of good practice, consisting of a gentle approach and patient-centered care. Nonetheless, professionals noted systemic barriers due to a referral system and allocation of clinical time that hinder obesity treatment. They suggested that lack of specialized centers and inadequate education of healthcare professional conveys the system does not prioritize obesity treatment and prevention. The interviewed Romanian doctors and dieticians identified patient-centered care as key to treating children with obesity and building trust with their caregivers. Howevertheir efforts are hindered by healthcare system barriers, including the lack of specialized centers, training, and a referral system. The findings therefore suggest that, to improve childhood obesity prevention and treatment, systemic barriers should be addressed.Trial Registration:ClinicalTrials.gov, NCT03800823; 11 Jan 2019. Excess weight in children is prevalent worldwide. Although plateauing trends were observed in many high-income countries in Europe, in medium and low-income countries childhood obesity prevalence has increased in the last decade . In RomaChildhood obesity is recognized as a significant concern in the 2014–2020 Romanian National Health Strategy  and efforts have been made to implement policies supporting healthy food and activities in the school setting. Additionally, media campaigns were coordinated to promote a healthy lifestyle. The Health Ministry's strategy did not formally name the healthcare professionals who should treat childhood obesity; however, family physicians, general, and specialist pediatricians , together with dieticians, are key to childhood obesity treatment.Communicating with children and families about excess weight represents a crucial clinical skill for healthcare professionals in the prevention and management of childhood obesity . FocusinThe success of childhood obesity treatment depends on improving healthcare professionals' education, attitudes, and practices related to communication about obesity, as well as coordinated efforts to reduce weight stigma on the community level , 11. A rThis study presents the first analysis of barriers and facilitators Romanian healthcare professionals face when communicating with and treating families of children with excess weight. Through this, we aim to develop an in-depth understanding of the locally-specific conditions healthcare professionals face, and thereby contribute to the improvement of childhood obesity treatment in Romania.Healthcare professionals  who treat children with excess weight were recruited for the study. Doctors were identified through a public registry of 242 family physicians and 54 pediatricians. A formal list of pediatric dieticians was not available, therefore, a sample of the author's professional contacts were invited to participate. All healthcare professionals were recruited in Timisoara, a metropolitan area in western Romania. Timisoara's metropolitan area is home to almost half a million inhabitants and is one of Romania's economic hubs, as shown by gross domestic product per region . PotentiThe present study is part of the EU funded project “Science and Technology in childhood Obesity Policy” (STOP) (Grant Agreement No. 774548). We used the questionnaire and interview guide developed by Sjunnestrand et al.  at the SThe interviews were conducted one-on-one by a female researcher (SP), with professional experience in medicine and dietetics  and teaching experience of 26 years. She asked all respondents the same set of core questions, as well as individualized follow-up questions based on the responses, using think-aloud and verbal probing techniques . Both teThe interview transcripts were analyzed in Romanian, using thematic analysis. The transcribed interviews were read, re-read and then coded by ACE and CLS, using an inductive approach (data driven), rather than being limited to a pre-existing coding frame stipulated by the initial hypothesis . Thus, iThe study received ethics approval from the Scientific Research Ethics Committee Board of the “Victor Babes” University of Medicine and Pharmacy Timisoara (no.06/02.03.2020). Participant confidentiality is maintained throughout the manuscript. Each quote is labeled to indicate the position of each respondent and the interview number, as follows: (1) gender , (2) number within group, (3) group: primary care (PC) represented by family physicians and general pediatricians; secondary care (SC) represented by specialist pediatricians ; tertiary care (TC) represented by pediatric specialists designated for obesity healthcare  and dieticians; (4) years of experience. The COnsolidated criteria for REporting Qualitative research (COREQ) checklist  was usedInitially, 21 participants agreed to be interviewed; however, three of them were not available to schedule an interview in the proposed timeframe due to time constraints (2 persons) and health issues (1 person). The final analysis included interviews with 18 respondents, all of whom verbally expressed informed consent and provided answers to all questions.In total, 18 physicians and dieticians , with average 18.2 ± 10.1 years of experience (range 5–35 years), were included in the analysis. Physicians in primary care  had on average 17.75 ± 10.4 years of experience. Physicians in secondary care  had on average 21.2 ± 9.0 years of experience. Healthcare professionals in tertiary care  had on average 15.2 ± 12.0 years of experience. The average interview time was 26 min (range 14–49 min). Four main themes and eight sub-themes were identified  and emerging comorbidities (second subtheme).Although some physicians described excess weight discussions as routine, the majority felt that children's excess weight was a sensitive subject for caregivers. This was especially the case for physicians who were the first to raise the topic. On the contrary, dieticians did not consider excess weight as a particularly sensitive topic, as they saw families after they had been self-referred or referred by a physician, and were therefore already prepared for discussions of excess weight.Most healthcare professionals deliberately used non-offensive words in raising the issue of childhood excess weight:I try to be very careful, I don't use the words obesity or fat, I may say that he/she weighs a few extra kilograms and that he/she should take some measures to prevent worse situations, (…) I try an approach with kid gloves, more gentle, to see how parents react” (F5PC30).“Practitioners were aware of the effects obesity stigma can have on families, and actively tried to avoid connotations of stigma when speaking to patients and parents:trying to keep a balance between avoiding stigma for the patient and explaining that excess weight is a problem,. it is not about aesthetics or trying to fit into a body ideal, it is about the health consequences of obesity (.) To stigmatize is not in our interest, as we try to obtain the patient's compliance” (F3TC33).“However, children and families often encountered stigma before meeting the physician. Parent and family awareness was sometimes triggered by a shocking event in a social context or a school setting, such as an incident of bullying. For example, one physician said:I think there is a context, in school, or somewhere else, a situation that triggers this, and all of a sudden the parent understands -.Ooo! my child is…- even though in the last years the child was chubby and nothing happened”(F2TC6).“Older children, girls, are generally bothered by being overweight because they have problems at school. They are bullied (…)” (F2TC6). In school, stigmatization by peers was worse in sports contexts, where physical capabilities and endurance were evaluated: “the child cannot integrate in the sports class because he cannot cope and his peers laugh or the teacher points out the difference in performance” (F2TC6). According to most respondents, stigmatization at school was a key tipping point that urged children and parents to seek help. For example, one physician spoke about a patient who said “that she really wants to lose weight because she gets tired too easily and is ashamed during sport classes and in school” (F4PC9). Another respondent also mentioned: “When children are socially discriminated against, the parents are starting to feel that something is wrong and want to make a change” (F1TC12).Stigma burden in the school setting was reported in almost all interviews. “Never with small excess (weight), always when the excess outruns some threshold, when they feel it's beyond their control (.) in most, when the excess is moderate to severe” (F5TC23). In many cases, families contacted physicians due to comorbidities of excess weight rather than due to the excess weight itself:Respondents reported that some families approached healthcare practitioners only when the child's excess weight became moderate or severe: “Most do not contact us due to being overweight, rather (.) for other (causes). asthma, hypertension or diabetes or something else, but do not come to the hospital due to obesity, do not come to ask for help in losing weight” (F7PC15).“In preschoolers, orthopedic complaints, gastroenterological issues, recurrent respiratory infections, and sleep disturbance were mentioned as drivers to seek medical care. As one respondent described:A very high percentage asks for help when other health problems arise, that can be felt. That is, concretely, the child feels ill, the child does not breathe well, the child snores, does not sleep at night, does not rest” (F2PC7).“Another respondent noted:They decide [to seek help] when their children have an orthopedic problem, they have joint pain, pain in their lower limbs or back or when they have respiratory infections, (…) more frequently compared to their friends” (F1PC30).“In adolescent patients, comorbidities usually found in adults, such as arterial hypertension, metabolic syndrome, and endocrine dysfunctions were reported.Physicians reported that, even after seeking help for a child's obesity-related illness, parents still did not recognize obesity as the underlying issue, and sometimes did not understand that excess weight could contribute to the condition for which they seek treatment:Most of them come for gastroenterology consultation, due to high levels of transaminase or irritable bowel syndrome or dyspepsia, which are clearly connected with obesity. But they (the caregivers) do not see obesity as a problem, they only see these symptoms and focus on them” (F4SC12).“They come for other pathologies - breathing problems, most often, and then, we take the opportunity to talk about obesity” (F2PC7).Nonetheless, physicians explained that, even when parents did not recognize obesity as a problem, they used the child's referral for another condition to initiate a conversation about obesity: “layers of distrust. This theme captures disagreements about excess weight and food practices in the family, alongside an intrafamilal “blame game.” It also captures conflicting views of obesity, as expressed by families and healthcare professionals, and families' lack of trust in the medical system. Two subthemes were identified: family in disagreement and tension between doctors and families.The second overarching theme identified in the interviews was (.) most unsuccessful outcomes are due to family disagreeing views” (F3PC10). According to the respondents, the presence of both parents in the clinical consultation increased the level of agreement and strengthened the chances of treatment success. When children were accompanied by one caregiver, usually the mother, she disclosed that other member(s) of the family did not agree with seeking help for the child's excess weight, usually because they felt excess weight was not urgently problematic. One respondent explained that “[m]ost of the time both parents agree that there is a problem, (but) the way they respond to the problems is different. At least one of them tends to neglect or minimize the importance of this problem” (M2SC18).Respondents noted that family members often disagreed about the meaning and severity of excess weight, and that this had implications for children's treatment. As one respondent said,“(.) the guilt is usually assigned to grandparents, or someone else than the person that accompanies the child. (.) Others are (accused of) secretly giving chocolate, snacks and potato chips” (F7PC15). When possible, a more complete picture of the familial situation was ascertained by conducting separate discussions with different caregivers involved in the child's care: “things are not exactly as the parents present them. When we talk to grandparents, we learn that the parents are also buying and eating unhealthy foods and then things are more complicated” (F3TC33).When children were accompanied by only one caregiver, absent family members were frequently blamed for the child's obesity: “[y]ou (the doctor) cannot tell me that something is wrong with my grandchild, that he is too fat. He is a child that eats well” (F1SC16). Another respondent described remarks such as: “- Ma'am, this is not a problem, I mean, I am also white, fat and beautiful”; this practitioner explained that “[t]his creates a communication barrier, that I felt that I will have no success, no matter how I approach it” (F2PC7).The gap between healthcare professionals' and families' understandings of childhood excess weight was another source of tension. Respondents said that communication barriers occurred more often in meetings with low-income families or with grandparents. Among poorer and older family members, the respondents explained, children's excess weight was associated with higher social status, health and beauty. For example, one respondent said a grandmother confronted her, saying “I don't know what it's like in other countries, but in Romania they don't like to be studied. They fear they will become a guinea pig. I think it's a matter of perception and I don't know how it could be changed” (F4SC12). Respondents suggested that families' concerns were driven by not understanding the benefits of research and the belief that no feedback will be provided, as well as low parental education level, the socio-cultural valuation of children's excess weight, and the additional effort that research participation involves: “The complexity of these studies and the fact that we ask parents and children make an extra effort, efforts that I do not think they are willing to make (…) Somewhere here is the barrier” (M2SC18). A potentially key reason for refusal to participate in studies was lack of trust in the healthcare system. One respondent reported that she encountered similar refusal to participate in studies on diabetes and obesity across Romania:Respondents noted that families often refused to participate in studies concerning excess weight. A recurrent opinion was that parents worried their children would be treated as “guinea pigs” in clinical studies: “Because there is a general distrust in the medical staff in Romania (.). Distrust is also showed by the refusal to vaccinate children (.) We did not experience this 10-12 years ago, instead, recently, for a study regarding diabetes, two years ago it was a mass refusal, and not only in Timisoara but also in other parts of the country. (…) In studies that require blood sampling, interventional studies or studies that include medication, there are already more reluctant. I can't say that these refusals are justified, but unfortunately I found refusals like that … without any a justification” (F3TC33).“Most respondents reported they use various models of good practice to ensure appropriate communication, aiming to empower patients and their families to start treatment. This theme consisted of the two subthemes: gentle approach and patient-centered care.Words, including gentle words, can have an impact. We must not be brutal in the way we communicate with the families, in any form” (F4PC9). Many practitioners reported using a probing interview approach to assess caregivers' awareness of excess weight: “after I have taken care of the acute pathology that brings them to me, I ask questions like what age did the child start to gain weight, and so, I find out if it is a problem for them, because for many it is not a problem” (F6PC30). Other respondents reported using a direct approach without labeling the child obese. This was usually achieved by highlighting children's deviations from the normal growth curve: “based on measurements, we show them exactly the situation of their child versus normal growth line for age and gender (.). On a reference chart we can show the family (.) the healthy weight for the height of their children” (F3TC33).Respondents recognized the crucial role of language in the clinical encounter: “level of awareness, to be sure that they understand what I want to say to them, (.) that I am not talking about aesthetics, rather, thinking about possible risks that they undertake if they continue with increasing weight” (F5TC23).When approaching families who were not aware of the risks associated with excess weight, respondents described using a gentle approach that included seeking a “I think, foremost, you have to earn their cooperation and trust and then recommendations can be enacted progressively, but with their consent. First they must understand and then they will accept” (F5TC23). Respondents also frequently reported focusing on what could be done and achieved, using positive language. For example, one physician describes speaking to families as follows:Healthcare professionals recognized that trust could be built step-by-step only when a channel of communication had been opened, with recommendations delineated gradually: “you have to look at the positive side all the time: your child has a few extra kilograms, but let's look at the good side, he/she is in a growing period and it's much easier to do something now, as the child is much more physically active and then let's see how we can improve in the future (…) and that kind of works. So, I always tell them that it is much easier for the child to lose weight during periods of growth” (F7PC15).“To improve communication, respondents made efforts to empower patients and families. For example, one respondent said[i]t helps to communicate and listen to their problems actively. Many times, they just need to be listened to. When they feel understood, they have even more confidence; somehow, they feel that they can do it. They often need encouragement and self-confidence that they can make changes” (F1TC12).“I praise the child directly. I ask him if some things have improved (…), I ask how he feels, toward maintaining or losing weight” (F1PC30).Another respondent said she made sure to praise her patients: “I think it matters a lot to be perceived as an ally, as a person who wants what's best for them and not as an extremely authoritarian figure. As an ally who knows what she is talking about and who gives them informed advice, having experience in this field” (F2PC7). Respondents also said they adapted to the families' concerns by offering personalized advice, taking into account families' wishes and their financial and social needs. For example, a dietician trying to dismiss a family's perception that healthy food was expensive said:Respondents communicated to families that they were on their side: “I gave them information about the price of foods a child can eat. To prove that it is not so expensive for a child to eat healthy (.) I give them options and examples - Look, instead, he can eat something that is four times cheaper and healthier. I even give them variants of shopping lists, including stores where to do grocery shopping. (.) From the moment I explain the cost , that it's not so expensive, they have less preconceptions” (F2TC6).“[i]n a subsequent conversation we invite the grandparents, (.) and then the grandparents have to support the treatment plan by sharing the same meals as the grandchildren” (F3TC33).According to the respondents, good practice entailed the successful involvement of the family in providing supportive environment for the child. They encouraged family members to share home cooked meals and act as role models of healthy eating. When grandparents were in charge of cooking for the child, the respondents invited them to the clinic to attend discussions regarding healthy food choices. For example, one respondent noted, “[t]hey  understand more than we think” (F4SC12). If the children were older, respondents said that compliance and outcomes were improved if the child was engaged in the treatment plan. Indeed, one respondent noted that “doctors can sometimes work better with the child than with the parent” (F7PC15). Some practitioners reported using an age-and gender-specific approach:Almost all respondents agreed that children's presence in clinical visits was beneficial, except if the children were too young to join the discussions. However, even if young children were kept busy with other activities during the visit, the respondents thought it was good for them to be present and to hear the discussion, as one physician pointed out “If the child is small, I do not approach the child, I approach the parent. If the child is a female preadolescent, I try to approach it differently. I tell the parent very clearly that if she does not control her excess weight at this age, she is at risk to have distorted body image perception that might lead to eating disorders in adolescence. In boys, I mainly focus on sports and mention that social success with the group of young people is also related to the physical aspect” (M3SC25).“Although most respondents felt confident using models of good practice, they noted systemic barriers to good practice, specifically a referral system, and time constraints that did not accommodate obesity treatment, showing that obesity does not fit the system. Additionally, respondents suggested that lack of specialized centers and poor education of healthcare professionals indicated the system doesn't prioritize obesity treatment and prevention.You have to have a lot of time for explanations with these families, (…) you gain their trust this way (.) however doctor's consultation time is shorter than I would need (.) honestly with a patient with obesity, I consume time for 3 consultations”(F5TC23). Another respondent explained: “One cannot do a consultation for obesity in 15 or 20 minutes, as for acute pathologies” (F3TC33).Respondents frequently noted that clinical consultations should empower families. For this to be achieved, patients needed time to build trust, and healthcare practitioners needed time to adapt to each family's needs; however, time constraints sometimes hindered this. As one respondent described: “Healthcare settings and processes were also cited as barriers. One respondent noted that a barrier in seeking treatment for the child's excess weight might be related to the hospital setting:It is a cultural fear of being in a physician's office or in hospital. Parents say: “I don't want to take my child to the hospital because he gets a disease there." Perhaps, de-medicalization of the subject would be a solution, in the sense of not being addressed in a clinical setting as a medical treatment, rather as a behavioral treatment” (F1TC12).“we lose them there because when they turn 18, they no longer have a trusting vote with us (pediatricians) …. They see themselves as adults and as an adult they do not respect what they are told.unfortunately.” (F3TC33).Some respondents worried that adolescents with risk for morbid obesity were lost in the transition to adult care: “Obesity is not seen as a medical condition, it is not seen as a condition that needs treatment. That's why the  system works poorly here” (M2SC18). Respondents mentioned lack of training as one example of the deprioritizing of obesity. One pediatrician said: “I am not very convinced that we, the physicians, are properly educated to understand that obesity is a disease.” (F2PC7). Another aspect of the deprioritizing of obesity was the delay in referrals, with specialist doctors saying that general practitioners did not address childhood obesity in time:Several respondents noted that, as opposed to diabetes or cardiovascular diseases, the Romanian medical system does not consider obesity prevention or treatment a priority. As one respondent said: “(.) the family physician, or the physicians in schools should have observed that the child has excess weight and they should have addressed it, and get in contact with specialists to receive adequate monitoring. Practically, the system  does not exist” (M2SC18).“Respondents suggested that multiple professionals should be involved in obesity care, including dieticians, psychologists and social services, as needed. However, consultations could rarely be scheduled in 1 day and respondents cited multiple visits as a contributor to families' reduced treatment participation. To increase coordination amongst multiple professionals, respondents underlined the need for specialized centers for childhood obesity treatment, as one respondent noted:Medical barriers are organizational. (.) all consultations should be scheduled and well-coordinated. I'm talking about a consultation with the medical team, followed by a meeting with the dietician and with the psychologist, so that all this can be performed conveniently during one morning. Then the child does not have to miss school once for the doctor appointment, once for the dietician, once for the psychologist” (F3TC33).“All respondents underlined the need for a systemic approach, with childhood obesity prevention and intervention promoted by government policies, media, kindergartens and schools, family physicians, and general pediatricians.This is the first study in Romania and in Central/Eastern Europe to investigate the barriers and facilitators healthcare professionals face when communicating with and treating families of children with obesity. The analysis shows that healthcare professionals identified the burden of stigma and the presence of comorbidities as the “tipping points” that lead families to seek help. However, they found that disagreements between family members about the seriousness of obesity, alongside families' distrust of the healthcare system, posed barriers to treatment. To build trust and engage families in treatment, the participating healthcare professionals followed models of good practice, consisting of a gentle approach and patient-centered care. Yet the respondents argued that treatment was often limited due to systematic barriers, including the referral system and time constraints, as well as the lack of specialized centers and poor education of healthcare professional. These were cited as examples of the healthcare system's deprioritizing of childhood obesity treatment and prevention.The respondents' observation that children's experiences of weight stigma were the main motivation for treatment seeking suggests that treatment was initiated too late, and that children starting treatment had already experienced emotional and social hurt related to obesity. Children and adolescents with obesity who experience stigma suffer from psychological, physical, and behavioral difficulties that increase the risk of social isolation and weight gain . In addiThe respondents characterized childhood obesity an “invisible disease,” with family members seeking treatment only after observing comorbid conditions. Delayed treatment seeking, until childhood obesity becomes severe or complicated by other diseases, has been observed in other studies –28. MoreTo make the “invisible” nature of excess weight concrete, the healthcare professionals in our study reported that they used growth charts to objectively compare the child's weight status to with a healthy weight reference population. Growth charts are useful and acceptable tools that professionals commonly use to improve counseling and facilitate behavior change . TherefoSeveral layers of distrust within the family and between the family and the medical practitioners were noted in the interviews. Within the family, respondents said that often only one parent or some family members recognized the excess weight, while others did not, leading to disagreements on how to help the child. Similar findings were reported in an Australian interview study by Jackson et al. , who fouIn our study, tension between families and healthcare professionals created barriers in communication. This is in line with a meta-synthesis of qualitative studies showing that different perceptions of excess weight between families and doctors are common barriers . These bModels of good practice reported by the respondents also included a patient centered care approach. Practitioners adapted treatment recommendations to the possibilities and needs of patients and families. Promotion of informed choice as part of the patient centered care approach has been emphasized in different medical fields , 42. It A key finding was that respondents identified changes in the healthcare system as crucial to improving capacity for childhood obesity interventions. They noted that primary care physicians were often slow to refer families, and that families initiated treatment in secondary and tertiary care, only after comorbidities were observed. If obesity treatment were promoted in primary care, excess weight could be addressed earlier, with benefits to both patients and the healthcare system, as shown by a recent guideline issued by World Health Organization . InteresThis is the first study to investigate Romanian healthcare professionals' perspectives on communicating with families about childhood obesity. The study used the interview guide developed by Sjunnestrand et al. , who intWhile this study has focused on healthcare professionals' perceptions of communicating about and treating childhood obesity, it would be important to understand families' experiences, as well. We plan to investigate the experiences of parents and children as part of the More and Less Study Europe . The stuThe interviewed doctors and dieticians in Romania identified patient-centered care as key to treating children with obesity and building trust with their caregivers. However, their efforts are hindered by healthcare system barriers, including the lack of specialized centers, training and a referral system. The findings therefore suggest that, to improve childhood obesity prevention and treatment, systematic barriers should be addressed.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Scientific Research Ethics Committee Board of the Victor Babes University of Medicine and Pharmacy Timisoara (no.06/02.03.2020). The patients/participants provided their written informed consent to participate in this study.AC-E, PN, and AE developed the interview guide. SP conducted the interviews. AC-E and CLS wrote the first draft of the manuscript under supervision of PN. KE contributed to the analysis and to the writing of the manuscript. All authors contributed to final editing of the document and approved of the last version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.