To assess the promotion of life saving behaviors and determine the sustainability of nudge message effects, this paper examines nudges that promote evacuation during heavy rainfall, preventative COVID-19 infection behaviors, and COVID-19 vaccination. The results showed that altruistic gain messages may have more sustained effects than others in promoting both evacuation during heavy rainfall and contact reduction behaviors as a measure against COVID-19 infection. Specifically, social influence nudges that use a gain frame to convey that a person’s behavior promotes the behavior of others are effective for both heavy rainfall evacuations and encouraging COVID-19 vaccination. Torrential rain disasters have become an annual occurrence in Japan and other countries worldwide, and many people lose their lives, because they are unable to evacuate before the disaster strikes. To promote evacuation, disaster prevention education has traditionally been used to educate residents on evacuation sites and routes among other aspects. However, even if disaster prevention knowledge increases, many people do not evacuate in the event of an actual disaster. In this context, it is difficult to make evacuation compulsory, because governments cannot fully grasp the location of the residents and it is not realistic to prescribe penalties. Thus, there is a need for policy interventions that can bridge the gap between knowledge and action.A similar thing is happening in the field of infectious disease control. In 2020, COVID-19 caused many infections worldwide and the behavioral restrictions put in place for infection control had a massive negative impact on the global economy. The requirements involved getting people to avoid going to places with a high risk of infection in addition to basic infection control measures, such as hand washing and wearing masks. In some countries, masks were made compulsory and fines were levied for people who did not wear them, especially when restrictions were in place during severe COVID-19 spreading. Similarly, many countries also imposed restrictions on the operation of restaurants. However, in Japan, even if a state of emergency is declared, based on the Influenza Special Measures Law, businesses can only be requested to close and the general public can only be urged to take infection control measures. Therefore, in this context, it is necessary to have policies that encourage people to take preventive actions against infection in addition to providing knowledge on infection control measures. In other words, if we can create policies that increase the number of people who take desirable actions in situations where direct regulations are not available, such as during disasters or the spread of infectious diseases, we will be able to save people’s lives.As a potential solution, nudges can bring about behavioral changes in situations where regulations and financial incentives are not available. The application of behavioral economics to public policy is done through these nudges, which Thaler and Sunstein  defined In particular, Thaler and Sunstein , and ThaIn another field RCT, conducted in one municipality, Fukuyoshi  examinedMoreover, Sunstein  presenteHowever, Sunstein  also addThus, based on Sunstein , we can In the case of infectious diseases, people may consider the risk of their own infection, but they do not completely consider the risk of infecting others through their actions. Similarly, during a disaster, one’s own evacuation behavior influences the actions of the people around them , and only evacuate when the benefits are greater than costs. However, one of the major benefits of evacuation that should be emphasized is avoiding damages from disasters. On the one hand, when deciding to evacuate, people are uncertain that evacuation actions will produce benefits or that damages will occur with evacuation, because whether or not the disaster will actually happen is not certain. On the other hand, evacuation will certainly incur financial and non-financial costs, such as the hassle of traveling to and the inconvenience of living at the evacuation site, and the difficulty of maintaining privacy. As such decisions include making choices through times of uncertainty, behavioral economics biases may inhibit evacuation behaviors.The following three behavioral economic factors are considered to inhibit evacuation behavior. The first factor is the present bias effect: the time discount rate from the present to the future is smaller than the time discount rate from the future to the further futureThe second factor is the loss aversion effect. When comparing the same gains and losses in absolute value, the magnitude of the change in welfare from the reference point is greater in the case of lossThe third factor is diminishing sensitivity: the marginal impact of a gain or loss on the value function declines as the absolute amount of a gain or loss increases. This characteristic leads to asymmetry in the risk aversion of gains and losses. Specifically, uncertain losses are preferred to certain losses (risk-loving), while certain gains are preferred to uncertain gains (risk-averse)Accordingly, evacuation behavior is inhibited, due to loss aversion or asymmetry in risk aversion, when evacuation is perceived as a loss. Whether the same factor is perceived as a loss or gain depends on the reference point. In this case, messages that change the point of reference, emphasize the gain of going to a shelter, or highlight the loss of not going to a shelter may change people’s behavior. Furthermore, bottlenecks that inhibit evacuation behavior may involve the way the information is provided and the surrounding people’s behaviors. For example, Kakimoto et al.  showed tUrata and Hato  developeMany studies have used social norms as messages to promote behavioral changes . Providing information that one’s evacuation behavior will promote that of others will encourage evacuation.Hypothesis 2 (Loss aversion). Messages that emphasize loss will promote evacuation behavior more, compared to those that emphasize gain.Hypothesis 3 (Diminishing sensitivity). Setting the reference point to the situation of maximum damage and expressing evacuation in terms of gains, rather than losses, will promote evacuation behavior as a safety measure.Based on these hypotheses, in Ohtake et al. , we creaMessages A and B are based on the social norms and altruism of Hypothesis 1. They promote evacuation by increasing people’s awareness of the externality that their own evacuation behavior triggers that of others and by appealing to their altruism. In other words, the message provides information on the social influence of one's actions. By comparing the effects of the two messages (A and B), we can test Hypothesis 2 (loss aversion). Message A promotes evacuation behavior by making the respondent aware of the altruistic benefits of evacuation, and that evacuation will encourage others to evacuate and save their lives. However, message B is framed differently, making the respondent aware that not evacuating will endanger the lives of others and highlighting the loss that may occur by not evacuating.Although the meanings of the A and B messages are essentially the same, message B is expected to have a stronger influence on evacuation intentions, because of loss aversionMessages D and E are also expected to be effective in promoting evacuation. For example, Kakimoto et al.  showed tIn this context, the purpose of our assessment is to examine whether messages A through E are more effective in increasing evacuation intentions in the short and long term, compared to message F that the Hiroshima Prefecture used to promote evacuation. We also aim to determine which message has the greatest effect and whether the effects of all messages are heterogeneous across targets. Their effects on evacuation intentions are shown in Fig. The percentage of those who indicated their intention to evacuate to a shelter also varied greatly among the messages. In the F message, 23.2% responded that they would evacuate to a shelter under the evacuation advisory, but in other messages, the number of people was much higher. The message with the highest number of respondents who would evacuate to a shelter was B (39.5%), followed by A (35.7%). Message E that emphasizes the loss of not going to the evacuation site and message D that highlights the gain of going to the evacuation site was effective for 33.6 and 32.6% of the respondents, respectively. Message C, “wear something that can help identify you,” encouraged 31.3% of the respondents to evacuate to a shelter. In other words, messages A through E, being more statistically significant at the 1% level, are more effective for raising one’s intention to evacuate to a shelter than the control message F.Table Next to message B, message A was the most effective, increasing the percentage of people willing to evacuate by about 11 percentage points. Messages D and E were less effective, but they did increase the probability of evacuation by 7.5 percentage points and 10 percentage points, respectively. Based on A, B, D, and E, it appears that people respond more strongly to messages that make them aware of the loss phase. Although omitted from the table, we obtained similar results when analyzing which messages increased the number of people who had the intention to evacuate, regardless of where they evacuated to when an advisory was issued. Specifically, messages A, B, C, and E increased the probability that people would evacuate, while the most effective message was again B.In order to effectively use awareness-raising messages for disaster prevention, these messages must bring about long-term changes in awareness and behavior, and it is necessary to determine which ones have such an effect. As a result, we conducted a follow-up survey in November 2019, using the mail method, with the same 5,598 respondents from the first March 2019 survey. The number of respondents in the follow-up survey was 4,254 (76% collection rate). This follow-up survey asked respondents about their impressions on the multiple messages used in the first survey , their disaster evacuation and evacuation preparation behaviors, and their evacuation awareness since the first survey.Specifically, the respondents were asked to respond to “want to evacuate,” “feel a sense of responsibility,” “have room for improvement,” “don’t understand the meaning,” “feel peer pressure,” and “feel repulsion” on a four-point scale . Of these, statistically significant differences in the distribution of responses were found between messages A and B for “feeling peer pressure” and “feeling repulsion.” The percentage of respondents who answered “I feel peer pressure” was 8% for message A, 17% for message B, and 12% for message C. The percentage of those who answered “I feel repulsion” was 3% for message A, 11% for message B, and 9% for message C. In all cases, the difference in means between the messages was statistically significant at the 1% level (t-test). In other words, while message B promotes evacuation behavior more than message A, it also makes people more aware of peer pressure and is more likely to make them feel repulsed.Table The first variable was “increased evacuation awareness.” The first question was “Has your awareness of evacuation increased since the issuance and announcement of evacuation information using alert levels in June 2019?” Of the responses to this question, 1 was assigned to those who answered “increased” or “increased slightly,” and 0 to those who answered “neither,” “not very much,” or “not at all.” The mean value of this variable was 0.60. Overall, those who received message A had the highest increased awareness of evacuation among each message group.The second variable was “intention to act when an evacuation order is issued.” This was based on the same question as in the first survey: “If an evacuation order was issued in your area, do you think you would evacuate?” The results are shown in column (3), where “very much” and “somewhat” were counted as 1, and “not much” or “not at all” were counted as 0. The evacuation awareness among those who received message A in the first survey was high (75.0%). The descriptive statistics of the responses to this question, with “very much" as 1 and other responses as 0, are shown in column (4). The third variable was “evacuation timing,” an indicator of commitment to evacuation behavior. Column (5) shows the percentage of respondents who answered that they had decided on some kind of timing. Overall, the percentage of individuals who decided on timing was higher for those who received messages A and B in the first survey.The fourth variable was “food and water reserves.” This was based on the responses to the question, “Do you currently stockpile at least three days’ worth of food and drinking water?”, where “I stockpile enough” and “I stockpile quite a bit” were set to 1, and “I do not stockpile” or “I stockpile a little” were set to 0. Overall, those who received message A in the first survey tended to stockpile more than those who received control F  and (4), message A increased evacuation awareness, compared to message F, by about 3.9 to 4.9 percentage points even when controlling for attributes and residence information (significance level: 5%). In addition, message D increased evacuation awareness more than message F by about 4.9 percentage points when controlling for the same factors (significance level: 5%). Columns (5) and (6) show that message A increased the intention to evacuate by about 4.1 ~ 4.3 percentage points compared to message F, even when the evacuation advisory was issued (significance level: 5 or 10%). These results indicate that messages A and D have a positive effect on long-term evacuation awareness and intention to evacuate.Finally, we analyzed the message’s long-term impact on specific disaster prevention behaviors. Table These results indicate that message A had a significantly positive effect on disaster prevention behavior compared to message F. Therefore, messages that make people aware of gains and disaster prevention are effective in promoting long-term disaster prevention behavior. However, the number of people who actually evacuated in advance, before the disaster that occurred after June, was small. Although not shown in the table, 1882 out of the 4214 respondents (approximately 65%) received an alert level of 3 or higher since June, but only 101 evacuated their homes in advance (approximately 2.4%). There was no difference in pre-evacuation behavior among the messages distributed in the March survey. This may be due to the fact that there were no major disasters, such as the July 2018 torrential rains in Hiroshima Prefecture, during the period from June 2019 to November 2019, when the follow-up survey was conducted, and that there were few evacuation notices issued.Many experimental studies have been conducted on nudge messages to promote infection prevention behaviors. For instance, Lunn et al.  found thIn one of my previous publications, Sasaki et al. , we condWe tested the effectiveness of six nudge messages, including a control group:SKO1 (Control): to prevent infection, reducing contact with others, avoiding the “3 Cs” , practicing proper hand washing, and wearing a mask are effective.SKO2 : by refraining from going out, avoiding the “3 Cs,” washing your hands, and wearing a mask, you can protect the lives of people close to you.SKO3 : by going out, not avoiding the “3 Cs,” and not washing your hands or wearing a mask, you will put the lives of people close to you at risk.SKO4 (Selfish message): by refraining from going out, avoiding the “3 Cs,” washing your hands, and wearing a mask, you can protect your own life.SKO5 (Altruistic and selfish message): by refraining from going out, avoiding the “3 Cs,” washing your hands, and wearing a mask, you can protect your life and the lives of people close to you.SKO6 (Simple message): stay home. You can protect the lives of people close to you.The nudge messages from SKO2 to SKO6 were presented to survey respondents in addition to informational messages about the infection prevention measures used in the control message (SKO1). Prior to presenting the four messages, we measured the extent of avoiding human contact, such as frequency of going to a restaurant or bar, going to work, or traveling, for the week prior to the survey with 10 questions. We also measured the extent of infection prevention behaviors, such as wearing a mask, washing hands, and using a delivery service, with 15 questions. Each question was answered on an eight-point scale, ranging from 0 (never) to 7 . We divided the total score for each human contact and infection prevention behaviors by the number of questions (10 and 15) to obtain a behavioral index. After presenting the nudge message, the participants were asked about their intention to take each action. Again, for contact behavior and infection prevention measures, they answered on an eight-point scale, with 0 indicating no intention to stop the behavior and 7 indicating intention to stop definitely. In this case, we also used the mean of the intention related to contact and infection-prevention behaviors as an index.For contact avoidance behaviors, only the gain-framed altruistic messages had an effect on behavioral suppression in the second survey, but not in the third and fourth surveys. This effect was observed in people who previously had a lot of contact with others. For them, the altruistic gain-framed message had a positive effect on the intention to reduce contact with people every time. Moreover, nudge messages had no effect on promoting infection prevention behaviors. Rather, the gain-framed altruistic message had a negative effect on those who were taking infection prevention behaviors. The loss-framed altruistic message also did not have a statistically significant effect on contact avoidance behaviors, although a larger effect than the gain frame was predicted from loss aversion. However, in the group that did not engage in contact avoidance behaviors, the loss frame did have an effect on raising the intention to engage in these behaviors during the third and fourth surveys. The possible causes for the gain-framed altruistic message’s effect on contact avoidance behaviors in the second survey, but not in the third and fourth are as follows. First, it is possible that presenting the same message repeatedly caused habituation and lost its effect. In particular, the fact that the government, including the expert panel, repeatedly used similar messages may have affected the message. Second, as the second survey was conducted one week after the first survey, it captured the fact that behavioral changes had occurred under the influence of the message. However, there was a month between the second and third surveys, and more than a month between the third and fourth surveys, indicating that the message’s effect only lasted about a week.In terms of changes in motivation immediately after the message’s presentation, the gain-framed altruistic message had a positive effect on the group that had relatively no contact avoidance behavior until then, both times. Thus, it is possible that a behavioral change occurs for about a week after the message is presented, but that beyond that time, it decreases or disappears. In this case, repeating the message would be effective in maintaining behavioral changes. The loss-framed altruistic message was expected to influence behavioral changes with loss aversion, but as it is difficult to perceive benefits from the message itself, it may not be suitable for repeated behavioral changes and may not have long-term effects in disaster prevention behavior. Nonetheless, this does not mean that loss messages are ineffective for changing behaviors. For instance, Moriwaki et al.  examinedCOVID-19 has a negative externality: it infects the infected person as well as others and worsens their health. In this sense, it is justifiable to use nudges to promote infection prevention behaviors and vaccinations that are effective in preventing the onset of disease and infection. Particularly in the case of vaccinations, due to the risk of adverse reactions, it is necessary to establish a policy that raises vaccination rates, while ensuring individual’s freedoms to not get vaccinated. What kind of nudge message would be effective in increasing the willingness to obtain a vaccine? In this regard, Larkin et al.  found thIn Japan, Tanaka et al.  also conFor younger, less prosocial individuals, the motivation to get vaccinated was low, because the selfish benefits of vaccination are very small. Therefore, it is natural that communicating the scientific rationale for vaccination to this group would not be effective. Altruistic messages may increase the motivation to get vaccinated in groups with a high prosocial nature, but cannot be expected to have an effect on those who are not. Even in the case of low prosocial nature, social norm messages may increase motivation to get vaccinated, because they also affect one’s social image, but the effect of nudge messages on younger people remains very small.Finally, I will discuss two previous studies that I conducted with colleagues, Sasaki, Saito, and Ohtake , 2021b. These studies used two online questionnaires to measure willingness to pay (WTP) for the vaccine when provided with related information. The first questionnaire survey was conducted over a five-day period from Jan 18 to 22, 2021 and the second over a three-day period from Mar 16 to 18, 2021, both among registered monitors of an internet survey company. A hypothetical experimental question was used to measure the WTP for a vaccine to prevent the onset of COVID-19. WTP referred to the maximum amount that one is willing to pay for vaccination. In the first survey, we collected the data by assigning it to match the population distribution of the basic resident register in terms of gender, age, and residence area. In the second survey, we focused on the elderly (65–74-years old), who would be eligible for vaccination at an early stage, and the young sample (25–34-years old), who would be eligible for vaccination later. This data collection process ensured that the number of samples would be evenly distributed in terms of gender and age.We measured the presence or absence of vaccination intention and the amount individuals who were willing to pay or who were willing to receive vaccination in case they were paid for receiving it when the opportunity for vaccination was available, without setting any particular situation. We asked the same respondents about their vaccination intentions in each of the following situations: randomly adding conditions related to “newly infected status” and “vaccination progress.” For the status of new infections, there were two settings: “The number of new infections is decreasing and is at a low level” and “the number of new infections is increasing and is at a high level.” Regarding vaccination progress, there were also two settings: “One out of 10 people of your age living in Japan have already received this vaccine” and “five out of 10 people of your age living in Japan have already received this vaccine.” The respondents were asked to indicate their willingness to be vaccinated in a total of five different situations: no situation setting, two different situations each for infection status and vaccination progress. In addition, the survey was conducted in two settings: (1) the vaccine only has a preventive effect on the onset of infectious diseases and (2) the vaccine also has a preventive effect on infection.The main results are as follows. The average WTP for the vaccine to prevent the onset of illness among the elderly was ¥2016.5. In this population, 76.4% (seven to eight out of 10) were willing to receive the vaccine if it was offered free of charge. Although the strength of the willingness to get vaccinated varied depending on the situation, most elderly respondents were willing to obtain the vaccine in any situation. Specifically, the intention to obtain the vaccine among the elderly decreased when the number of newly infected people was decreasing and the infection situation calmed, or when the vaccination of people in the same age group had not yet progressed.The “proportion who will be vaccinated when offered free of charge” and “WTP” factors in the situation where both conditions overlap were the lowest compared to the baseline and other situations where these conditions did not match. Conversely, the willingness to get vaccinated rose in the phase where the number of newly infected people increased or the proportion of vaccinated people in the same age group increased. The latter result supports the possibility that vaccination behavior may have a positive peer effect, encouraging others to get vaccinated. These results were almost the same in both settings, where the vaccine had a preventive effect on disease onset and on infection.During the first survey, we also examined nudge messages that emphasized selfish and altruistic benefits. Specifically, the nudge message emphasizing selfish benefits was “vaccination protects you from becoming seriously ill” for vaccines with a preventive effect and “vaccination protects you from infection” for vaccines that also prevent infection. To emphasize the altruistic benefits, we used “vaccination helps save lives by freeing up hospital beds” for vaccines with a preventive effect and “vaccination helps control infectious outbreaks and save many lives” for vaccines with infection-preventing effects. However, these messages had no effect on either the intention to get vaccinated or the amount the population was willing to pay.Based on the fact that progress in vaccination status was affected in the first survey, the second survey used the results of the first to examine the effects of social norm messages on vaccination intention and WTP. The three types of messages were as follows:SSO1 (Comparison nudge): seven to eight out of 10 people in your age group answered that they would receive this vaccine.SSO2 (Influence-gain nudge): the more people receive this vaccine, the more people have the intention to do so. Your vaccination behavior can encourage the vaccination behaviors of those around you.SSO3 (Influence-loss nudge): the more people receive this vaccine, the more people have the intention to do so. If you do not receive the vaccine, the people around you may also not do so.At the baseline, 84.4% of the elderly wanted to be vaccinated and the average WTP was 427.1. The increase in willingness to get vaccinated, compared to the first survey, can be attributed to the fact that the vaccination of healthcare workers had started and vaccine uncertainty had been reduced. However, the average WTP was much lower than in the first survey, potentially because the people whose WTP was originally negative had a desire to get the vaccine and the possibility for adverse reactions was clearly stated in the message. The effects of the nudge messages were as follows. First, “your vaccination will encourage others to be vaccinated” (gain-frame message) strengthened the vaccination intentions of older respondents, who previously had no intention of being vaccinated, and increased the number of those who wished to be vaccinated. Second, “if you do not get vaccinated, others around you will not get vaccinated” (loss message) and “seven to eight out of 10 people in the same age group said they will get vaccinated”  further strengthened the intentions of older respondents, who originally intended to get vaccinated. The results simultaneously suggested that the loss message may place an emotional burden on people and that the social comparison message may weaken the intentions of older respondents who did not intend to be vaccinated. Third, these nudge messages did not have a statistically significant facilitative effect on vaccination intentions among young people.This research examines nudges that promote evacuation during heavy rainfall, behaviors for preventing COVID-19 infections, and vaccinations against novel coronaviruses. All nudges promote life-saving behaviors and all three evaluated situations involve externalities in which people's actions affect the actions and health of others. Social norm nudges that emphasize majority behaviors are known to be highly effective, but only when socially desirable behaviors are applied by the majority. When the desirable behavior is in the minority, nudges that turn it into the social norm are also necessary. Overall, this study’s greatest contribution lies in the finding that social influence nudges, in which a gain frame conveys the fact that a person’s behaviors promote those of others, are effective for both evacuation during heavy rains and vaccination against COVID-19.Furthermore, we examined the persistence of nudge message effects, a common issue in this field. The results suggest that altruistic gain-framed messages may have more sustained effects than others, both in promoting evacuation during heavy rainfall and contact reduction behaviors as a measure against COVID-19. Behavioral economics often emphasize loss messages, because of their loss-aversion properties. However, there is a possibility that the gain frame’s effect is sustained when the message is repeatedly presented, requiring a change in habits rather than a one-time behavioral change.When using nudges for public policy, multiple nudge messages are possible, based on the theoretical predictions of behavioral economics. However, the average effect and heterogeneity of the target are often unknown until they are actually tested and some messages may be psychologically taxing. Thus, it is important for governments to pretest messages for effectiveness and psychological burden levels before using them.


Most qualitative research on breastfeeding the preterm or low-birthweight (LBW) infant has focused on negative insights; there are no comprehensive insights into how, when and why mothers experience positive breastfeeding experiences. We aimed to address this knowledge gap by exploring what characterizes and facilitates a positive breastfeeding experience in mothers of preterm and/or LBW infants.A systematic review using meta-ethnographic methods was conducted. Search strategies involved a comprehensive search strategy on six bibliographic databases, citation tracking and reference checking. The analysis involved a reciprocal level of translation and a line of argument synthesis.Trusting the body and what it can do’, concerned how attuned breastfeeding was facilitated through understanding the bodily responses and capacity and feeling comfortable with holding the infant and to breastfeed. ‘Being emotionally present – in the here and now’ described the importance of feeling relaxed and reassured. ‘Experiencing mutual positive responses’, illuminated how attunement was related to feelings of mutuality - when the mother recognises the infant’s cues, responds to these signals and receives a positive response from the infant. The key factors to facilitate attuned breastfeeding were opportunities for prolonged close physical contact with the infant, positive relationships with and support from staff and peers, and being facilitated to breastfeed when the infant showed feeding cues.Searches identified 1774 hits and 17 articles from 14 studies were included, representing the views of 697 mothers. A positive breastfeeding experience was identified as being ‘attuned’. Three themes and eight sub-themes were developed to describe what characterizes attuned breastfeeding. ‘This study provides new insights into what characterizes a positive breastfeeding experience and how staff can facilitate and enable mothers to achieve attuned breastfeeding. Improvements in units’ design, such as for rooming-in and having prolonged skin-to-skin contact, and care provided by knowledgeable, supportive and encouraging staff and peers, are crucial. The mother’s physical and emotional states and the infant’s behavioural responses and physiological signals should guide the process towards positive breastfeeding practices. Over the last few decades, much attention has been paid to the intake of breast milk in preterm  and low-birthweight infants < 2500 g, LBW); breast milk provides nutritional, immunological, and neurological advantages compared to breast milk substitutes . It has 00 g, LBWOne of the major obstacles for breastfeeding  the preterm infant is the infant’s breastfeeding behaviour. Preterm infants’ ability to breastfeed is a maturational process and until the infant can be breastfed exclusively, mothers who want to breastfeed need to express their breast milk by pumping. In many settings, a range of non-evidence-based guidelines and care routines dictate that the infant should be of a certain gestational age when breastfeeding is initiated  or that A few reviews have been conducted on parents’ experiences of breast milk feeding their preterm infants: parents’ experiences on factors that help or hinder breast milk supply ; factorsWe undertook a systematic review and used meta-ethnographic methods of Noblit and Hare to extract and analyse the findings . A meta-Search terms were identified using the PEO  structure. The terms were developed following scoping exercises and were agreed in collaboration with librarians at Karolinska Institutet, Sweden. An overview of the search string, according to the PEO structure, the inclusion and exclusion criteria and additional selection criteria  is presented in Table Any study that described mothers’ experiences of breastfeeding their preterm  or LBW (< 2500 g) infant were included. A broad definition of breastfeeding was used  where alA comprehensive search strategy was used on six bibliographic databases: Medline (Ovid), Embase, Web of Science, PsycInfo (Ovid), CINAHL (Ebsco), and Global Index Medicus. Citation tracking and reference checking was also performed. Two librarians at Karolinska Institute University Library search consultation group undertook the database searches. All included papers from the searches were downloaded to an EndNote file and duplicates were removed.All abstracts were screened by at least two members of the review team against inclusion/exclusion criteria and papers were subsequently identified for full text review. All full text reviews were divided up across all members of the review team, and each paper was read in full by two reviewers. Agreements for inclusion were made by consensus, and any disagreements regarding inclusion were discussed with a third reviewer. The initial database searches were undertaken in October 2018, and again in June 2020.All articles were quality appraised using the instrument developed by Walsh and Downe , 29. TheKey data were extracted into a pre-designed template that included study aims/research question, methodology, sample size, participant characteristics, data collection methods, key findings/themes, and the quality appraisal rating Table . Each paAn inductive and interpretative meta-ethnography approach was used. This approach distinguishes first, second and third order data , 25. FirIn the original search, 1.644 hits were retrieved from the database searches and a further 130 during the updated search. No papers were identified via additional search methods. A total of 995 abstracts were screened against inclusion/exclusion criteria, 73 were reviewed as full-texts and 17 included in the final review  . And you have to feel comfortable with it." , it’s a bit noisy and people are coming and going. She seems to have a better go if it’s quieter and I am relaxed.”  is different since he’s not in that sleepy mode. Before I don’t even know if I saw it more as, like, nurturing. I’m just like, ‘This is just what I’m to do. He just needs to be held.’ He was supposed to still be inside of me, so of course I loved holding him then, but now I feel like it’s more of like a bonding . . . ." . But when they’re like this [in front of her] I can see them. Then it’s easier to see their signs of them being hungry. I try not to breastfeed less than every other hour. Sometimes they want to eat every hour. And sometimes, when I have put them down, they start to squirm and then I breastfeed again,”  a lot. (F3)” [Breastfeeding is definitely one of the best things I have ever done. Both I and my baby enjoy and we will continue for a long time [at 3 months]. Breastfeeding is wonderful. The longer we breastfeed, the more pleasant it becomes. There is a special bond between me and my baby because of breastfeeding, and I wouldn’t change it for anything in the world [at 6 months]. It still is very comfortable, the baby enjoys as well [at 12 months]” [“months]” .With time, mothers’ and infants’ abilities to respond to each other was enhanced. A mother in Holdren et al.’s study stated: “t. (F3)” . A motheWith some arrangement with pillows and so on it started to work. My son started to look for the nipple and suck. Even though it was not for a long time I was at that moment thinking 'Yes he knows what to do'. And then the nervousness disappeared." ["peared." .The third facet of mutuality was the infant’s positive response. When this mutuality occurred, breastfeeding was perceived to be an enjoyable experience for both the mother and her infant –42, 44. efficiently” [“. .. and umm, and I feel like she was really enjoying it even though she didn’t get much out of it yet (F3)” [Mothers described a positive infant response during breastfeeding as being calm, alert, active, and that the infant sucked and swallowed , 40, 44 ciently” , 42. A mciently” , 40, 41.et (F3)” .attuned’. Data was synthesized into three themes, ‘trusting the body and what it can do’, concerns how attuned breastfeeding is facilitated through understanding the bodily responses and capacity to produce breast milk, having faith and trust in the power of milk, and feeling comfortable with holding the infant and to breastfeed. The second theme, ‘being emotionally present – in the here and now’ describes the importance of feeling relaxed and reassured through closeness, privacy, the support from staff, peers, and others for feeling emotionally present. The third theme, ‘experiencing mutual positive responses’, concerns how a feeling of mutuality arises when the mother recognises and interprets her infant’s cues, when she is enabled to respond to those signals and when she receives a positive response from her infant. In the following sections we first discuss attuned feeding drawing on key insights from the three themes, followed by a discussion on the three major facilitators for attuned feeding.This systematic review and meta-ethnography aimed to define what characterizes and facilitates a positive breastfeeding experience in mothers of preterm and/or LBW infants. Insights into positive breastfeeding experiences were derived from 14 studies conducted in six countries. By using reciprocal translation, we identified characteristics of what constitutes a positive breastfeeding experience, an experience that we described as being ‘The phenomenon of attunement has been studied extensively, where the primary focus has been on behavioural, emotional and biological synchrony or mutuality between the mother and infant –50. Our The quality of parent-infant interaction and communication is an ongoing process that affects and contributes to the neurobiological regulation of the other , 52. BreMother’s ability to see, interpret and respond to infant’s cues have mainly been explored in mothers of term infants. Biologically pre-programmed behaviours have been described by Widström and colleagues  and Mattbeing in closeness; holding the infant or having the infant skin-to-skin enabled mothers to trust their bodies, become relaxed, and to see and respond to their infant’s signals. Montirossi and McGlone describe in their review [Across the papers, three major facilitative factors were identified to enable attuned breastfeeding. First, r review , that thr review .staff’s support and interpersonal relationship with the mother. Schmied et al.’s findings from their meta-synthesis of women’s experiences of breastfeeding support [The second major facilitator was the  support , showed  support . As nurs support , it is i support . Unlike  support  and to e support . Further support . Within  support ; this is support . However support , 71.being enabled to breastfeed when their infant signalled. By changing neonatal designs to include more private spaces and single-family rooms, the opportunities for mothers to support the infants’ resources and capacities  unfolds. In line with the values from family centred care [The third major facilitator for attuned breastfeeding was red care , an indired care –78, respred care , 79 and red care –82, are The strengths of this review are the comprehensive search strategy, and a minimum of two reviewers being involved in each stage to enhance the rigour and trustworthiness. An evident limitation is that most studies were conducted in the Nordic countries. There are several potential reasons for this; the Nordic countries having a history of being pro-breastfeeding cultures and also that the progression towards family centred care has potentially moved faster than in other countries. Another limitation is that few papers have been published on positive experiences. Although a broad definition of breastfeeding was used during the literature search and selection of papers, positive experiences of feeding the infant were only described when the mother breastfed at breast in all papers. One reason for this could be that in many settings the norm and goal is to feed the infant directly at breast , 8. WhenThis systematic review and meta-ethnographic methods identified positive breastfeeding experiences as being ‘attuned’. Attuned breastfeeding occurred when the mother trusted her body and what it could produce, when she could be emotionally and physical present in the here and now and when she experienced mutual positive responses with her infant. The most prominent facilitating factors for experiencing attuned breastfeeding were being in close physical proximity with the infant, meaningful and sensitive staff support and positive staff-mother interpersonal relationships, and being enabled to breastfeed when the infant signalled. This study offers new insights into how staff and gatekeepers in neonatal units can facilitate and enable mothers to achieve more positive breastfeeding experiences with a more prominent focus on the relational aspects of breastfeeding. Positive breastfeeding support requires a favourable environment which enhances mother-infant dyads closeness and trust in the mother’s and infant’s capacities.


Around 30,000 children living in Shenzhen, Mainland China cross the border to Hong Kong to attend school every day. This paper focuses on the school as a key meso-level organisation that mediates macro-level policies and micro-level everyday life experiences among these children and their families. We advocate a relational, spatial perspective, conceptualising schools as webs of intersecting physical, social and digital spaces, where differences between the “locals” and “others” are played out, negotiated and (re)produced, and in turn giving rise to specific (and understudied) geographies of in/exclusion. Drawing on our qualitative research, we offer a close reading of three exemplary school spaces: (i) the physical classroom and school grounds, (ii) the digital classroom, and (iii) at the school gate. Our findings demonstrate the complex and at times contradictory ways in which “the school” is a place of both inclusion and exclusion. It is a dynamic and power-traversed space where social differences between the “locals” and the “others” are played out, contested and redefined continuously. This distinct spatio-temporality intensifies the role of the border, the state and the journey produced and contested and in/exclusion is entrenched  position in the broader international educational context have motivated mobility of a diverse nature. Children and young people move across the border for education and training at different levels  and Mainland Chinese (predominantly women) have increased substantially with the rise of economic integration and social interactions between Hong Kong and Mainland China since 1970s Chee, . To migrCross-border families are not a homogenous group. They come, for example, from a mix of socio-economic backgrounds. Among “double not” families, many were originally from middle class backgrounds. However, as the market in birth tourism developed, more families from working-class and rural backgrounds have alsosought  Hong Kong residency for the children  such as Mandarin, Hakka or Teochew. Compared to Hong Kong where the education system still exhibits markers of British colonialism, English knowledge is more limited in Mainland China especially among lower-income families.The vast majority of CBS attend Hong Kong public schools in the North District close to the border Fig. . DependiOver the years, there have been numerous  media reports and a relatively small body of academic literature  that highlight the challenges these long-term and long-distance commutes pose to the children and their families, who are commonly seen as “trapped” in mobilities Chee, , 2017. MOur analysis is based on qualitative research that examines parents’ motivations and experiences in sending their children to Hong Kong for school. In addition, perspectives of teachers and social workers who have worked directly with these children were also collected. Physical fieldwork in Shenzhen, Hong Kong and at the border was conducted in 2018 and 2019, supplemented with follow-up interviews, policy and media analyses to track the first impact of the COVID-19 pandemic on CBS, their families, schools and teachers.The majority of our field data are derived from interviews and observation. Potential interviewees were approached through WeChat, the Chinese messaging, social media and mobile payment app (with the parents) and personal contacts . In total, we interviewed—in some cases with follow-ups—12 families (17 mothers and fathers), a university student (early 20 s), a high-school teenager (16 years-old) and two 6th-graders (12 years-old) who had crossed the border for school/university for years, a grandfather of CBS, a former school principal, five teachers, one school social worker, one government officer working at Shenzhen Customs and one staff member at a tutoring centre near one of the main border crossings. While most of the interviews were face-to-face, some of the conversations were conducted over WeChat or by phone. We also conducted observation at the border crossings and followed along the school journeys of these children and visited related social service centres in Shenzhen. In addition, we conducted an in-depth content analysis of relevant policies, news and social media coverage of the phenomenon. We followed the discussion on two WeChat groups dedicated to cross-border families. Each of the groups had around 400 members at the time of our research. The online groups provided valuable insights into parents’ perceptions, concerns and experiences. Approval for this research was granted by the University of Oxford Central University EthicsCommittee.Confirming previous studies  system that identifies a person as a permanent resident of a particular location in China. Hukou is the defining factor for social rights entitlements including state-funded education. According to the Chinese law, individuals cannot simultaneously possess a hukou in Mainland China and right of abode in Hong Kong. The Hong Kong school is, therefore, the only option for those unable  to pay a hefty fine charged by the state for violating the one-child, and late two-child, policy  or expensive school fees charged by private or international schools.It is important to note that this decision is not only driven by a hukou and those who live in the districts where their targeted schools are located. According to a survey conducted in 2017, only 9% of the 1077 participating Shenzhen-based parents considered transferring their Hong Kong-born children to Mainland public schools .My daughter went to a “Hong Kong class” in a kindergarten here in Shenzhen. It has a Hong Kong owner. Here in the neighbourhood, there are about a thousand of these Hong Kong children. So these “Hong Kong classes” are catered for them. They use teaching materials from Hong Kong, but the teachers are local [Mainland Chinese]… I noticed some differences. The Hong Kong education model was indeed very good, but because the staff was local, the “taste” changed. In Hong Kong, teachers teach with their heart. Here, it’s more like, teachers show their love in front of the parents, but once they are gone, the teachers change their face. I know that because I went there often. I observed the teachers, how they had ice-cold faces when parents were not around. I think it is a matter of “human quality”  provided us with her list of comparisons:I could write a book about it. Advantages: first, it is cheap in Hong Kong. I spent around 2,000 HKD one semester [210 Euro]. In Shenzhen, it normally takes RMB 3,000 per month [380 Euro]. Second, in Hong Kong, I think the teachers won’t beat my son. In Shenzhen, I worry that my kid might be beaten (by teachers). Third, Hong Kong has many English-native speakers, and it is good for him to learn English.SY also shared with us her vague plan to send her son to study overseas. She considered that a Hong Kong passport, English proficiency and an international outlook—all expected to come with the “better” Hong Kong education—would make her dream more reachable. In parents’ imaginaries, therefore, the Hong Kong school is superior because of its organisational culture , lower costs and also its relative position in the global education system. The Hong Kong school is seen as a “promising place” for their children’s futures, which is worth the pain that transborder schooling entails. The paradox  illustrates the power of social imaginary. As conceptualised by Taylor  pupils can join the Hong Kong Secondary School Places Allocation System and be allocated subsidised secondary school places in Hong Kong. These schools are, however, private schools that charge higher fees than Chinese public schools. We have also found that for many parents who are able to pay these fees, cross-border schooling is the preferred option, as it enables their children to gain the “real” Hong Kong schooling experience. We asked our interviewees about this. Their responses are characterised by calculative comparisons between the two school systems that are fused with stereotypes and display a distinct hierarchy. LF  shared her “calculation”:y Taylor , social in need of students. Due to persistent below-replacement birth rates in Hong Kong and the reluctance of the government to invest in small-class education, kindergartens, primary and more recently secondary schools are increasingly facing the risk of closure. For kindergartens and schools located close to the border, CBS are attractive “clients”. In order to attract pupils, schools actively produce the aspirations and practices associated with this transborder education field, both materially and discursively. Embedded in a dynamic mobility industry, schools work side by side and sometimes in collaboration with other service providers such as bus companies, daycare and tutoring and boarding house services in accommodating the needs of CBS  support and extra-curricular activities are made particular “selling points”. Some schools provide free shuttle services from and to the border. Catering for families who have tight budgets, some schools offer free-of-charge lending services for school books, uniforms and computers. A few kindergartens have opened extra-curricular activity centres in Shenzhen to serve their pupils on the weekends. These centres provide courses in English language, music instruments, drawing etc., which are common after-school or weekend activities for Hong Kong children, delivered in a “Hong Kong style”. Since CBS hurry to return home after school, it is very difficult to squeeze in time for these extra-curricular activities on weekdays whilst commuting to and from Hong Kong. By locating these offers on the Mainland, schools help satisfy, and (re)produce, the desire of CBS parents to replicate an all-round Hong Kong education for their children. While it is not (yet) a common practice for kindergartens and schools to run their own extra-curricular activity centres in Shenzhen, numerous commercial “Hong Kong style” tutoring centres have been providing similar services. As such, a kind of integration is being pursued in a re-territorialised, transborder manner. In a paradoxical way, by learning and playing in an exclusive bubble (away from their peers in Hong Kong and other children in Shenzhen), CBS are being raised, distinctively and separately, as a kind of “Hong Kong children” in transborder space.In the following, we will take a closer look at the schools in Hong Kong. By charting the processes on the ground, we bring forth the role of the school in mediating macro-level institutional policy directives and micro-level lived experiences among the students, parents and school staff. Our close-up analysis helps to map out “the school” as an intersecting physical, social and digital space where differences are (re)produced and in/exclusion is negotiated  emphasises ‘diversity’ and ‘internationalism’ , it does show how contestations of differences and processes of in/exclusion at school are embedded in a broader and changing institutional landscape.Language plays an important role in in/exclusive processes in this transborder education field  elements of this transborder education field, e.g. the “Hong Kong school”, its “values”, “good teachers” and the “students” are (re)produced and redefined.Schools are not only spaces of classroom learning. Because of the long-time commute, many CBS cannot take part in extra-curricular activities (such as joining a school sports team). Teacher B, who serves as one of the core staff members for organising extra-curriculum activities in his school, regrets the difficulty in engaging CBS in team sports fully:E-learning plays an important role at school in Hong Kong and China. Children are exposed to e-learning early on. Most primary schools and even kindergarten integrate digital technology in their curriculum. This does not, however, mean that all children are equally equipped to access and take part in these digital classrooms. Globally, technology has not enhanced educational equality Kim, . InequalYes, the internet has always been an issue. Sometimes our CBS students and their parents cannot access the school homepage and are therefore not informed. Depending on the schools and class levels, there are also homework to be done that requires the internet. Websites that we use in Hong Kong commonly like Googleare not accessible. That is a problem. … Now with the lockdown [since late January 2020] when we put everything online, it is even more problematic. Some CBS have been completely out of touch even since the border was closed. It is a big problem.Understandably, many CBS parents are worried about their children being ‘left behind’ and excluded, as we observed in parents’ chatrooms and news media. The lockdown has excluded their children from attending school, both physically and digitally. The Hong Kong Government has been urged by the city’s legislators and social critics to address the widening digital divide  shares her experience of prejudice at the school gate, and on the bus:Some Hong Kong locals reject us…. When they [local Hong Kong parents at the school gate] hear that we speak Mandarin, they discriminate against us … Even some (Hong Kong) bus-drivers, they have different attitudes toward Mainlanders.In the digital era, a “school gate” also takes forms online as parent forums or chatrooms. Parents come together to share information and experiences, and to seek and give mutual support. SY continues to tell us about her lack of belonging also in the digital space:I don’t feel belonged. Even in the school chatrooms, we talk about different things. We are just different.Our interviewees’ sharing makes clear how the school is a dynamic and power-traversed space where social differences between the “locals” and the “others” are played out, most intensely along class and language lines. CBS parents are, however, not passive victims in these contestations. They organise their own resource networks, making use of common social media in the Mainland, to tackle issues that concern them in particular. Hence, they have built their own ‘school gates’ in the digital space. We conducted observation on two WeChat groups, one initiated by a CBS parent and another by a social service organisation. These digital “school gates” are exclusive space. In many ways, they serve as a safe, third space for CBS parents. The purpose of this exclusive space is, however, to facilitate their children’s integration into the “Hong Kong education” that they highly value. Here again, we see how the process of inclusion and exclusion should not be seen as simply opposites. On the contrary, they are relational, reproduce and redefine each other in dynamic ways.While such high-level contestations at the school gate have been rare, identity politics are played out in more or less subtle manner on a daily basis. SY  underlines her feeling of not belonging , at the school gate:Focusing on the cross-border education phenomenon along the Shenzhen–Hong Kong border, our paper has substantiated our understanding of the role the school in migration and inclusion as a meso-level organisation, mediating macro-level institutional politics and micro-level lived experiences. Using a relational, spatial perspective, we analysed the role of school in (co)producing geographies of in/exclusion for Mainland resident children in Hong Kong.In order to make sense of Hong Kong schools’ agendas when it comes to CBS, and the challenges faced and actions taken by schools and teachers in their work with these children, it is necessary to go beyond the immediate school and education field. Drawing on our different data sets, we have shown how the school is embedded horizontally in a dynamic education mobility industry, and vertically linking macro-level politics and policy fields  and micro-level life experiences.We underline the importance of spatialities in understand the role of the school in (re)producing socio-cultural differences and mediating social in/exclusion. Zooming in on three sets of spaces at school, namely (i) the  classroom and school grounds, (ii) the digital classroom, and (iii) the school gate, we brought forth the lived experiences of our interviewees. Their narratives show how the school, as a web of intersecting physical, social and digital spaces, (co)produces and gives meaning to translocal social imageries and practices. Through our close-up examination of these spaces, we show that differences—and the aim of integration through education—are in a fluid and dialectic relationship rather than opposites. Paradoxical as it might seem, by deviating from the assimilationist approach and condoning students’ use of Mandarin in the classroom within their “social bubble” on the school grounds, teachers and the schools engender a more welcoming learning and social environment that facilitates (or at least does not hinder) longer-term integration.While centering on the school, we do not treat it as a coherent and spatially bound organisation Waters, . We haveThe situation in Hong Kong and Mainland China is, of course, dynamic. We have here provided some first insights into the impact of the COVID-19 pandemic on CBS. Due to border closure and the restrictions in access to specific websites, CBS have been disadvantaged compared to their local peers. Parallel to the pandemic, Hong Kong has also faced immense socio-political challenges and changes (and unrest) in recent years. Consequently, some CBS parents have voiced their intention to bring their children back to the Mainland for school Quinn,  (confirm


Due to their frontline position to fight the coronavirus disease 2019 (COVID-19), the professional and personal life of nurses was severely disrupted. To understand and describe their lived experiences and perceptions during the pandemic’s first wave in France, we interviewed 49 nurses, including 16 nursing students, and 48 of their family members from June to July 2020. Using a purposeful sampling, the semi-structured interviews were scripted according to Abric’s method with probing questions. The interview analysis led to the identification of six paradoxical perceptions concerning the pandemic’s consequences: the Silence Paradox, the Hero Paradox, the Workforce Paradox, the Learning Paradox, the Symbolic Exchange Paradox, and the Uncertainty Paradox. However, despite different experiences, the nurses perceived their frontline position both as a burden jeopardizing their safety and well-being and as a spotlight of nurses’ tough working conditions. Indeed, because they were in the frontline position, nurses and nursing students were psychologically vulnerable, even more so when they felt alone and inadequately protected. Besides, their families were vulnerable too, as they were also exposed to the consequences of the nurses’ frontline engagement. Thus, to preserve their safety and well-being, institutions should also provide them with better organizational support and inclusive leadership, without neglecting their families. Since its inception, as of 4 May 2021, the new coronavirus disease (COVID-19) has affected worldwide 153,187,889 persons, including 3,209,109 deaths reported to the World Health Organization (WHO)  were vulnerable so I wondered if I was doing something stupid on the way to work. Afterwards, I thought yes I was more at risk, but that is my job after all.”CRNA-PACUMost of the nurses did not consider themselves as heroes because they worked during the outbreak. They considered it as their duty. However, they were proud of what they did, as they kept working despite their fears and their medical conditions :“Through this crisis, you discover yourself as a professional with knowledge and skills. A feeling of pride in everything I’ve accomplished, reassured to see that I could do things that I thought were insurmountable, pride in myself, pride in a profession where people have unlimited self-sacrifice.”CRNA-ICUNurses’ pride also came from their awareness of their professional skills’ efficiency, as some of them faced unusual care:“Afterwards, this outbreak showed me even more how bad things are at hospital: all the problems nurses usually experience have been multiplied tenfold.”RN-M (f)Meanwhile, nurses’ relatives considered nurses and nursing students as heroes and were proud of them because they put their life at stake in caring for others despite their exhaustion and their difficult working conditions.“We were angry, we don’t even talk about money: we just talk about a thank you, it would have been nice if the management had simply thanked us.”NM-ICUHowever, nurses and their relatives were disappointed and angry by the public authorities’ lack of recognition for nurses’ engagement despite their heroisation:“For me, nurses are not recognized for their commitment, their efforts, their daily risks. In my opinion, it is not a medal on July 14th that will give them the recognition they deserve. They must have the salaries they need…There are years of studies. We have to give them the means to work well. It’s their lives they are putting at stake.”RN-PS (f)“We were considered a bit pestiferous, people were afraid of us, afraid that we might contaminate them, afraid that we might be contagious.”NS-MThus, they considered this crisis as an opportunity to raise society’s awareness about the French healthcare system’s failures and to promote a better recognition of the nursing profession. However, some nurses were quite skeptical about the heroization effects on society, as they and their families were confronted with stigmatization.Nurses reported that their working conditions were better if they worked in acute services as they were overstaffed, whereas nurses from other departments were confronted by a nursing shortfall.“I think the hospital is as sick as its patients… We are asked to take upon ourselves. It can be exhausting. It is true that sometimes when you are in a department with very few staff, you can talk about suffering.”RN-GS“My colleagues were very worried about the virus. Actually, many of them, who considered themselves to be at risk, refused to work. A lot of nursing assistants refused to enter rooms, for example to give breakfast to patients in the COVID-ward, obliging me, my fellow trainees, and other nurses to do this work for them, which added to the workload.”NS-GSIndeed, nurses who worked in geriatrics or nursing homes suffered from a usual lack of personnel but it worsened during the crisis, and they had to work overtime, even when sick. Moreover, some nurses feared becoming infected and refused to take care of COVID-19 patients, which led to increased workload for the remained colleagues. Thus, nurses were angry about these working conditions, and considered they resulted from cost saving healthcare policies.“There was a very good atmosphere between colleagues. There was a kind of working cohesion where everyone helped each other. I was able to rediscover a working atmosphere that I had known a long time ago and which had disappeared with the budget cuts. It gave me the strength to tell myself that I wasn’t alone.”CRNA-ICUOn the opposite side, COVID-19 units were often overstaffed, which contributed to improve the quality of care by enabling nurses to organize better. Moreover, some nurses reported that they were really supportive of each other, which improved teamwork and the cohesion between team members. This collective power helped them to face the adverse events occurring during this crisis. Because of this, some ICU nurses were reluctant to have work breaks, even enjoying working during this period.Because of the massive influx of patients related to the pandemic, nursing students, in initial or continuing training, were requisitioned to strengthen frontline teams. This training break was perceived and experienced differently by the students, as to whether they felt useful or not during this period.“My fellow nursing students were like me, not very reassured, as their position was unclear. We didn’t know if we were considered as a nursing student or as a nurse assistant.”NS-GSIndeed, most students wanted to be useful but they were also anxious about the skills expected from them:“I had the impression that the students were taken hostage and were unable to follow their training. And that is the collateral effects of COVID because they experienced it very badly and me too because it was necessary to support them, to accompany them, and it was complicated to manage.”NM-ICUThus, when nursing students felt poorly tutored and integrated with the staff, as if they were more used than useful, some of them could be considered as collateral victims of the virus, as one nursing teacher reported it:“It was an opportunity for me to work under such conditions. And as a student, the fact of being positioned both as a support for the team and as a student was formative and helped me getting new skills: autonomy, taking initiatives.”NS-ICUHowever, some students considered this experience a professional opportunity, as they could deepen their nursing skills and also obtain new ones. Thus, these nursing students estimated that their training had not been altered by this period:“It was an opportunity for me to work under such conditions. It helped me getting new skills.”NS-ICUThis period was also valuable for some certified nurses, who learnt new skills from colleagues, and wished to extend them further by obtaining new degrees.As nurses and nursing students were engaged frontline, they experienced sacrifices as they were robbed of a part of their personal and professional life. However, in exchange, this position induced some gains, as they felt fully supported by their family and society.“Some residents died, they were completely suffocating and nothing could be done: it was difficult…These images chased me for a while.”RN-NHConcerning their professional life, nurses and nursing students felt powerless and frustrated as they considered that COVID-19 had stolen essential features of their job, especially the ones related to end of life care:“The care was different because of the protective outfits we had to put on. It’s a different approach of care, as everything that has to do with touch or even smiling, we didn’t have that anymore or at least we limited it.”NS-GSIndeed, some of them pointed out that the nurse-patient relationship was deeply disrupted by the protective measures  and their consequences :Moreover, nurses found the ban of patients’ visits a bad experience.“The families could not see the people who had died, but in addition there were no religious rites and they were only washed with water.”RN-MThus, nurses also considered that patients families’ grieving process was robbed by the virus, as they were not allowed to see their relative’s body:“It was extremely violent to apply Do Not Resuscitate choices for people in their 70s, without risk factors. It’s complicated to tell them that there is no place in ICU for them.”NP-MBesides, nurses experienced in a bad way the disruption of their professional values through the ethical dilemma induced by patients’ prioritisation, concerning mostly the elderly. Some nurses found this process difficult to accept, because they considered it as loss of chance for the excluded patients:“I was infected three months ago and I still have symptoms of COVID. Total exhaustion with asthma-like respiratory discomfort, muscular pain: I currently have a post-COVID syndrome, which is disabling. I can’t do a lot of activities, because otherwise I have to sleep and I’m exhausted. I’m angry because I was sent to work, even when I was sick. And now I’m paying the price.”RN-NHMeanwhile, some nurses reported that the COVID-19 had also stolen their health, as they had to work regardless of their exhaustion and of their health conditions, which made them angry, especially in nursing homes:“For two months we didn’t live for the family, we lived around COVID.”CRNA-PACU“I still had a feeling of guilt because even if you come home, you’re not too available to do anything else. Helping the children in their homework, even on days off, I couldn’t do it.”CRNA-ICUConcerning nurses’ family life, this was disturbed by their increased job engagement, which made it difficult for them to keep the balance between their family and professional life, causing them to feel guilty and angry. However, nurses were grateful for their spouses’ support, as they were more involved in their household life management, even though it was harder when a nurse’s spouse was also an HCW:“When I came home, the children didn’t want to come near me, they even gave me the name Mummy COVID and said: ‘No kisses Mummy because you’re COVID!’ So there was this distance between my family and me because I had to protect them.”NS-NHMoreover, as they feared spreading the virus, nurses had limited physical contact with their relatives, even leaving their home. Thus, this period was emotionally tough for all participants, especially when children were involved. Some spouses felt deprived of the nurses’ presence at home because of their work’s engagement, and their relationship was affected:“We felt supported during this whole period by the outside, by the people who clapped every night, by the people who delivered meals, by the drawings. This multiple support carried us, as perhaps unconsciously, it has helped us to better overcome this crisis, to get through it. There was a real surge of solidarity.”RN-GSHowever, despite all these negative effects, the outbreak was also a period of donations and gains. Indeed, nurses and their families took advantage of the lockdown to question their priorities and to strengthen ties, as they enjoyed spending time together . They were also deeply grateful for their friends and other family members’ support through this tough period. Besides, nurses appreciated the gifts coming from the entire society to support them:Overall, participants perceived their own vulnerability, which they expressed through the certainties and uncertainties acquired through the pandemic management.“I was stressed to bring the virus home. So, I tried to set a strategy to avoid that…I’ve had patients who got sick because their spouse is a healthcare worker, one of them died and I didn’t want that to happen to me.”CRNA-ICUConcerning their family life, nurses and nursing students were deeply uncertain and anxious about how to avoid spreading the virus, when they came back home from work. Indeed, nurses and nursing students were deeply uncertain about their protection equipment’s effectiveness and use. It led them to become anxious and fearful of spreading the virus to their family members, because they were uncertain of the required measures to avoid spreading it, as they came back home from work:“We couldn’t protect ourselves as we should have. As if we were thrown into the lion’s den. Because in the beginning, the protocol was to put on masks only if patients coughed. Then afterwards, there were some who didn’t cough but who got COVID, so we were told to put on surgical masks, and then if they tested positive, to put on N95 masks and glasses…We didn’t feel protected by the protocols.”NS-MBesides, nurses also experienced uncertainties about their practices, as they were confronted to hygienic changing protocols, drugs and ventilator shortages and the doctors’ doubts about the medical treatment. Because of these elements, nurses and nursing students felt insecure and confused, which emphasized their fears and anxiety:“Nurses in non-acute services did not feel they were treated in the same way as those working in COVID units. They lived this situation very badly and felt forgotten by the management.”RN-ICUHowever, through this crisis, nurses also acquired some certainties through the poor PPE shortages management, which, for them and their families, was related to hospitals’ unpreparedness. Besides, some nurses, especially in nursing homes, felt devalued as they noticed COVID-19 units had more PPE than other units. This imbalance between services angered them, as they would have wished for more safety and better working conditions:“I’m thinking of changing my profession to go towards what is human, such as sophrology and relaxation, because I have the impression that there is no longer any humanity, either with the patients or the staff.”RN-NHThus, some nurses were certain that they wanted to quit their job after the crisis, while others gained confidence and wanted to keep working as a nurse. Indeed, of the 55 nurses interviewed (including relatives): four nurses (7%) expressed their desire to leave the nursing profession, four other nurses (7%) would have left the nursing profession if they had not already been engaged in a career evolution and five nurses (9%) are considering leaving their establishment following this health crisis. Thus, nearly a quarter of the nurses (23%) admit that they are considering a change of career path. However, this might be an underestimation, as other nurses complained about the poor management they had experienced.Since the coronavirus disease’s onset, nurses have been at the forefront, taking care of infected patients in tough circumstances, at their own physical  and psychological risks . Thus, their family and social life have been deeply disrupted. With this study, we aimed to understand and describe frontline nurses, nursing students, and their family members’ lived experiences and perceptions of the COVID-19 pandemic. The qualitative design of this phenomenological research enabled nurses and their relatives to express their paradoxical experiences and perceptions related to the COVID-19 first wave and its consequences on their personal, professional, and social life. However, our findings also highlight that both of them were collateral victims of the pandemic because of nurses’ frontline position.Despite their heroization and the militaristic language used by society and public authorities to describe their actions during this health crisis, our findings suggest that nurses did not consider themselves either heroes or soldiers.Indeed, they experienced psychological vulnerability, as they felt strained physically and emotionally by their relentless exposure to the virus consequences. Thus, as in previous studies , nurses Thus, being in the frontline position deeply undermined nurses’ professional self, which led most of them to be more likely to demonstrate self-sacrifice  . A previTheir families, who also endured psychological vulnerability, shared this anger. Indeed, our study stated that being related to a frontline nurse was a cause of fears and anxiety, as their families were afraid that nurses became infected being more exposed to the virus. Thus, through their perceptions , nurses’ families shared their vulnerability to infodemic , an “oveThus, families should also be supported because frontline status could induce parenting troubles and stigma, as reported in previous studies ,35.Our findings also suggest that, in the opposite position of another research , some ofThus, in our study, the more nurses felt alone and unprotected by their institution, the more they wanted to quit their jobs; almost a quarter of nurses (23%) are considering leaving their hospital or profession after this crisis. In previous studies, nurses expressed the same or opposite feelings ,26.As in previous research, our findings confirm that, as they worked frontline during the COVID-19 outbreak, nurses were physically and emotionally drained and vulnerable . Thus, tOne of the strengths of our study is the fact that it focused on frontline nurses and their families. Another strength of our work is that we recruited frontline nurses, including nursing students, from different settings and services with varying sociodemographic characteristics  despite the COVID-19 pandemic.Therefore, we were able to establish a broad picture of the consequences of the nurses’ frontline position on them and their families in France, which has not been studied yet through qualitative research. Indeed, despite the qualitative design of this study, the sample size was large enough to explore and understand nurses’ and their families’ perceptions. A limitation of this study was that all the interviews were conducted through video-conferencing after the first wave, thus the feelings and perceptions of the respondents could have been lowered. Yet, some nurses were emotional, as this study dealt with sensitive issues. Thus, it was clearly stated that they could stop the interview at any moment. Another limitation of our study may be seen in the study design, which can compromise the results’ transferability and generalization. Further research is needed in other countries, to grasp the lived experiences of other nurses and their families.World Health Organization (WHO) declared 2020 the “Year of the Nurse and Midwife”. It should have been a time to celebrate nursing profession but because of the COVID-19 pandemic’s hardship, nurses had to show their professional strengths and meanwhile healthcare systems were undermined.However, as nurses are the most important healthcare workforces, their increased frontline engagement impacted them in their personal, professional, and social life. Thus, our findings provide useful insights in describing and exploring the experiences and perceptions of nurses, nursing students, and their families during this period in France. The frontline position appears mostly as a factor of suffering, as nurses and nursing students were emotionally and physically strained. Their vulnerability was reinforced when they felt abandoned and inadequately supported by the top managers. After one year of pandemic pressure, these findings remain accurate, as nurses’ working conditions worldwide are perceived to be unsatisfactory to some of them, who still feel poorly rewarded and supported. Therefore, institutions should address their specific concerns  to preserve nurses’ job engagement and resilience. However, our findings highlighted that their families should also have been supported, as they were exposed to the consequences of the nurses’ frontline engagement .Through this pandemic, participants’ perceptions about the nursing profession have been questioned, despite their heroization. After one year of pandemic pressure, our findings remain accurate, as nurses’ working conditions worldwide are perceived to be unsatisfactory by some of them, who still felt poorly rewarded and supported by their institutions.