Even though a lot of scholars have been looking at outpatient education lately because it has become more popular and they want to know about its successes, failures, and problems, we have not been able to find a complete study. Therefore, our study aims to gain a deeper understanding of the various aspects of outpatient education based on the actual experiences of medical students, faculty, and residents.Face-to-face and semi-structured interviews were used to collect data for this qualitative study. Until data saturation was reached, the interviews continued. A total of 21 participants from Shiraz University of Medical Sciences, including medical students, residents, and teachers, were enrolled. The Guba and Lincoln-first written standards for scientific accuracy in qualitative research were used to figure out how reliable the data were.Fourteen categories were extracted from four main themes. The results show that four categories: “physical space and equipment,” “prerequisites related to the curriculum,” “teaching skills development,” and “near-peer teachers” should be considered for outpatient education preparation. Theme 2, “implementation requirements,” included “student dimension,” “faculty’s commitment to planning,” and “program supervision.” Theme 3, “challenges of outpatient education,” was described by five related categories, including “curriculum implementation challenges,” “student challenges,” “faculty challenges,” “system-related challenges,” and “patient-related challenges.” Finally, two categories emerged about facilitators of outpatient education: internal and external facilitators.Outpatient clinics represent a crucial aspect of medical practice. To effectively leverage this resource, preliminary planning, considering all the prerequisites, paying attention to the implementation requirements, getting to know the challenges, and trying to solve them, especially with incentives, are essential. Academic lectures, ward rotations, and outpatient education comprise the majority of clinical medical education. Outpatient education has become increasingly popular in recent decades for two reasons. Firstly, they are more effective in improving medical students’ learning; secondly, teaching rounds of inpatients are no longer as effective as they used to be , 2.In the past decade, numerous adjustments have been made to the healthcare system. One of the greatest changes has been moving away from traditional inpatient care and toward ambulatory care , 3–5. InThis has prompted numerous professional societies, such as the “American College of Physicians (ACP),” the “Society of General Internal Medicine (SGIM),” and the “American Association of Medical Colleges,” as well as accrediting bodies, such as the “Liaison Committee on Medical Education and the Higher Learning Commission,” to advocate for the expansion and further development of ambulatory education , 12, 13.Outpatient education, despite its importance and benefits, faces many challenges and is sometimes criticized as a dying art. Recent research has highlighted many difficulties in ambulatory care clinics that can significantly impair the educational experiences of both medical students and faculty members .Question 1: What are the prior conditions for establishing and implementing outpatient education based on participants’ viewpoints?Question 2: What are the implementation aspects of outpatient education based on stakeholders’ viewpoints?Many scholars have recently focused on outpatient education due to its increased prominence and subsequent curiosity about its achievements, failures, and obstacles. These studies have primarily been carried out in the context of program evaluation via assessing learning  or from This study used a qualitative approach and conventional content analysis to describe a phenomenon. By resolving “how” and “why” research questions, this type of study can yield rich and varied insights into individual experiences . The quaParticipants were medical school faculty members with teaching responsibilities in the university-affiliated clinics. In addition, students and residents with experience in outpatient education were chosen from a range of clinical levels. As clinical education for medical students takes place in the final three years and at different levels, we aimed to maximize variation in our sample by including clinical semester students from different admission years. Exclusion criteria consisted of participants’ refusal to continue cooperating.Purposeful sampling was employed, and sampling continued until data saturation, at which point no additional information was gathered regarding the concept.A total of 21 medical students, residents, and faculty members of Shiraz University of Medical Sciences were enrolled and then interviewed  were arranged with participants who agreed to participate.A general question was initially posed during the interview, and as the interview progressed, the questions were steered toward the research objective. The interview started with a general, open-ended question: “Please describe a day from your most recent outpatient education experience.” Based on the responses, we asked participants the following in-depth questions to gain a deeper understanding of the concept under investigation: “What are a faculty member’s duties and responsibilities in a clinic with students’ attendance?” “How is learning assessed in this setting?” and “What are the most challenging issues?” In-depth questions were also posed, such as “Can you clarify further?” “Describe more,” and “You said that … please explain?” At the end of every interview, I asked questions such as, “Do you have any ideas or comments?” “Do you think there is a question that has not been addressed?” and “Would you like to question me?”.All interviews were recorded with the participant’s permission. The first researcher with the requisite training for conducting qualitative studies, conducted and transcribed interviews. Only the first researcher knew the participants’ identities, while other researchers received interview transcripts that had been anonymized. The mean duration of the interviews was 42.24 min, ranging between 25 and 80 min, based on the circumstances of the interviewees and their assent.Graneheim and Lundman’s qualitative content analysis method was used to analyze the data by identifying meaning units, codes, subcategories, categories, and themes . During Two researchers (MB and EB) then read each text line by line, identified meaning units, and assigned codes to each meaning unit. MB and EB read the preliminary codes multiple times and then contrasted them to identify similarities and distinctions. In the event of disagreement, a third researcher (AF) was involved. Next, codes were assigned to subcategories based on their similarities and differences. Similar subcategories formed categories, and then themes emerged (representing the text’s hidden meaning).To assess the trustworthiness of the collected data, the Guba and Lincoln-first published standards for scientific accuracy in qualitative research were applied: credibility, confirmability, dependability, and transferability . For creAn independent observer’s opinion was sought to assess the dependability of the findings. The external observer was a researcher with experience in both qualitative research techniques and outpatient education who was not a part of the research team. The consistency of the results was validated by this external review.To ascertain the dependability, an external observer’s opinion was solicited. A researcher with experience in outpatient education and qualitative research techniques served as an external observer who was not a part of the research team. The consistency of the results was validated by this outside review.A thorough explanation of the study’s concepts, participants, content, data collection, analysis methods, and limitations confirmed the data’s transferability. This will allow other researchers to replicate the study’s procedures.Qualitative research relies on translation to accurately convey participants’ meanings across languages, maintaining its trustworthiness. The literature suggests back-translation, consultation, collaboration, and piloting to solve translation problems. Each method has pros, cons, and costs.Consultation is a practical approach to addressing the risk of losing meaning.In the ideal translation process, it is essential to recognize that translation should not be viewed as a single, completed task upon receiving the translated materials from the translator. Consultation entails discussions between a researcher proficient in research methods and a translator knowledgeable in language and culture . In thisThe ethical approval for the study was acquired from the Research Ethics Committee of Shiraz University of Medical Sciences (IR.SUMS.REC.1400.456). All methods were carried out in accordance with relevant guidelines and regulations or the Declaration of Helsinki. Participants were given detailed information about the study’s goals before interviews were conducted, and their signed informed consent was obtained before any interviews were recorded. The anonymity of the participants, their responses, and the use of aliases or codes in quotations were guaranteed. Participation in the research was entirely voluntary and would not interfere with their academic progress, and they were given the option to drop out at any time. The interview and encoding data were encrypted before being saved to a personal hard drive for long-term storage. We promised to do so if a participant wanted to see the findings as a group.Out of 21 participants, seven were faculty members, nine were medical students, and the remaining were residents. The experiences and perceptions of participants were extracted and analyzed. Based on the results of the analysis, 14 categories were extracted within four main themes after coding and comparing the codes based on similarities and differences: “preparation for outpatient education” Table , “challeThe theme “preparation for outpatient education” refers to what should be considered and what preliminary planning should be done before implementing an outpatient education program. Based on the participants’ experiences, this concept pertains to the four basic components: physical space and equipment, prerequisites related to the curriculum, teaching skills, and near-peer clinical teachers Table .This indicates that in designing a successful educational clinic, we should pay attention to the number of rooms, the connection of rooms, the quantity and quality of examination equipment, the number of examination beds and chairs.“It seems that three rooms are necessary for each clinic; a clinic that is large or includes several departments has enough space for students to move between the rooms, see examinations, and even rest.” [S7].Before implementing a curriculum, it is important to consider several factors based on the participant’s experiences to organize the program efficiently. These factors, as subcategories, are listed below.The clinical elective course can be a valuable, highly regarded experience with benefits in providing better learning and academic success and gaining clear insight into their future postgraduate specialty. According to interviewee perceptions, some specialized and sub-specialized clinics can be considered locations for elective programs.It happened to me that I went to the ophthalmology clinic and saw the patients next to the teacher, and I thought this field was very interesting, but because my attendance was optional, not mandatory.” [S1].“Learning outcomes and expected skills must be defined to devise a program that makes the most of the learning opportunities for the students. According to the participants’ perceptions, student learning opportunities in outpatient clinics usually focus on history-taking, physical examination, pharmacology, drug prescription, clinical approach, interpretation of paraclinical data, counseling the patient’s family, patient education, and professionalism.The faculties insist, and it is true in my opinion, that the student takes a history first; usually, the students do a clinical examination after the history taking.” [R2].““In my opinion, drug prescription is very important. Because, when we graduate, we must prescribe these drugs ourselves. In the clinic, the teacher’s approach to the patient is very important. That is, how does he diagnose, how does he manage, and how does he follow up?” [S3].Besides, learning objectives should genuinely prepare students for the demands of professional practice.“In fact, I do a needs assessment based on what skills my students will need when they become a doctor.” [F3].A program needs to have an efficient and dynamic set of teaching tools to be effective. According to the experiences of participants, a variety of strategies can be applied: a brief overview of the disease shortly before the patient enters, structured observation, active and gradual student participation, content delivery from simple to complex, consideration of differences in the knowledge level of learners, supervision and feedback, practical teaching, lecturing, conferences, and debriefing.Always, in the clinic, before a patient comes in, I talk to the students about that patient for 5–10 min and overview the disease.” [F4].““In my teaching sessions, I first determine my audience. If they are students, interns, residents, or fellows, I tailor my goals, vision, and educational content accordingly.” [F5].“Sometimes, teachers provide us with conferences that feature common clinical cases.” [S2].“We review the patient’s history with the teacher, who provides additional explanations as needed. I keep track of feedback to address any issues.” [S3].Experience has shown that readily available additional resources or instructional aids can be used to enhance learning. These resources, based on interviewees' experiences, include a summary of the cases of that day, laboratory reports and radiographs of patients, and internet-based resources.“As part of our course, I instruct students to access dermatology atlases online.” [F2].Learning in clinical settings heavily relies on patients as a valuable resource. Participants believed that an ideal volume of patient encounters, pertinent to learning objectives and expected qualifications of a doctor, is important.“During the week, if I have patients suitable for learning, I postpone their appointments to a day when my clinic is educational.” [F1].“In the tumor clinic, only tumor cases are visited, and if I, as a GP, am going to see a few tumor patients, this does not truly help me.” [S9].“In clinic A, the number of admitted patients was low, and we could easily communicate with the patient and receive training.” [S2].The appropriateness of the number of patients compared to the number of students in a clinic was also highlighted.“In a certain clinic, the number of interns and students was small, allowing us to examine each patient for at least 20 min.” [S4].A variety of different models for organizing student, patient, and teacher interactions in outpatient clinics have been described, according to the participants.“I use different models. Sometimes, we visit the patient together, and the student observes. Sometimes, the students visit the patient alone, and then they present the important points of the patient to me.” [F1].To achieve competence in teaching, faculty members must acquire knowledge and skills in educational principles. Participants’ experiences reflected the view that the teaching competencies of faculty members can be achieved through their experience over time or through formal teacher training programs.“A teacher gains appropriate experiences over time, which improve his/her teaching skills.” [F7].“Training can help faculty members be better teachers.” [F4].It is known that residents play an important role in teaching undergraduate medical students, and based on the experiences of most participants, the resident performs his/her teaching role better if this role is defined as a duty and commitment in the educational system.“If residents understand their teaching roles from the beginning and take responsibility for educating, it will improve our education.” [S3].Based on the participants’ experiences, the concepts of implementation requirements refer to the three basic components. The first two relate to the students’ and faculty’s commitment to planning, and the last is program supervision Table .Actions related to students must be taken while present in the clinic for effective learning. This includes familiarization and assessment.According to the participants’ statements, a briefing session on the initial day of each clinic is indispensable.“From the very first day of the course, our teachers informed us about the topics that would be taught, the conferences that would be held, and the presenters who would be delivering the lectures. This helped us immensely.” [S5].Students’ readiness for apprenticeships or internships was affected by how clearly their duties and expectations were outlined.What I wanted to say is that it should be clear what they want from me, that is, when I come in the morning, I should know what I should do to be in the norm and what I should not do. Well, this increases productivity, in my opinion.” [S1].“According to participants’ experiences, a continuous assessment of students’ clinical skills is important for switching from a static to a dynamic education.“On-the-spot assessment can be more effective than evaluation at the end of a three-month internship. The teacher may not even remember who I was or what I did. In any case, I went to the clinic today and spent 2 or 3 h there, so how I performed should be considered.” [S6].Based on participants’ statements, it refers to allocating enough time to teaching and the teacher’s management skills.“Some teachers extended the training period to work with fewer patients, leading to more detailed examinations and benefiting both the patient and our learning.” [S7].“A faculty member in a clinic is not just a teacher but must manage her environment; for example, he or she should make sure that the clinic is not crowded, patients are visited on time, students are satisfied, have a scheduling secretary, and no one is late.” [F2].A list of supervisory considerations must be considered to minimize errors and resolve problems. These include teacher performance, student attendance, and patient quantity and quality.“In terms of the educational system, there should be a difference between a teacher who spends time teaching students and a teacher who does not.” [S4].“Sometimes, the student would leave the clinic or not participate without anyone noticing. This is not acceptable.” [S8].“Of course, it is necessary to give feedback to the teacher about his performance…” [F4].“Someone, somewhere, must specify that a clinic supposed to be educational only accepts up to 10 patients[S3].It refers to barriers that interfere with valuable and effective education in clinics. This theme can be described in five related categories, including curriculum implementation challenges, student challenges, faculty challenges, system-related challenges, and patient-related challenges.It refers to factors affecting curriculum delivery. Inappropriate implementation of near-peer clinical teaching was identified as one of the program's challenges. Participants defined turbulence as incompatible integration of trainees, lack of resident commitment to teaching due to lack of sleep and long shifts, and lack of knowledge and self-confidence to teach students.“When residents and fellows are present in the clinic simultaneously as students, we do not receive any teaching. The cases suitable for residents or fellows are boring for students.” [S8].“A resident is a person who hasn’t slept for 48 h, hasn’t drunk a drop of water, hasn’t eaten, and has been struggling for the past 12 h. How can such a person be expected to teach.” [S2].“My experience is that I should not trust what the resident says. I don’t know how much they read from reference books and how much is based on experience; their working time is long and, they don’t have time to update their knowledge.” [S5].One of the problems with designing and implementing the educational tool was the lack of involvement from all stakeholders, as well as the logbook being reduced to just a tool for roll calls.“We did not use a log book. On the last day of the rotation, we would go to one of the residents, get his stamp, and stamp all the activities, of course, if there was a log book.” [S9].“In most departments, only one person creates the logbooks by copying and pasting from other sources.” [F3].Reducing students’ educational duties to the level of secretarial work, prioritizing the health system over education, and the small share of outpatient education in total clinical education were other stated challenges emphasized by most participants.“We and sometimes residents are responsible for filling out forms and recording documentation without prior guidance.” [S7].“There were many times when I felt like the teacher was assigning us menial tasks instead of teaching.” [R2].“According to one of our clinical teachers, our top priority should be the health system and patient care. If time allows, we can also focus on medical education, which is secondary to our primary goal.” [S4].“Our clinical education mostly takes place in the hospital, with very limited outpatient education opportunities.” [S1].Several students also mentioned patients with specialized conditions as a noteworthy challenge.It refers to problems that students struggle with. One of the most critical obstacles raised by the participants in this category was related to unsystematic and irregular student assessment. These unsatisfactory experiences include lack of a plan or objective criteria for student assessment.“Outpatient education lacks a specific assessment program. Students are typically evaluated at the end of each department rotation.” [F3].“They only tell us that we will give you a score out of 20. It is not clear on what basis they give this score.” [S6].In turn, student assessment has been limited to students’ attendance.“During an evaluation, the clinic secretary asks attendees to raise their hands. This becomes their score at the end of the course.” [S9].The incongruity of the student assessment method with the educational program or content was another challenge stated by participants.“Most of our assessments are only theoretical, even though the internship training is practical, but they take a multiple-choice exam, with questions more related to teaching in the inpatient ward than in the clinic.” [S5].The students were unhappy that the resident assessed them without being involved in their teaching.“The score of the students’ exams is often in the hands of the residents, while the residents do not teach. Some students try to maintain their relationship with the resident to get a better score.” [S2].Other issues, such as lack of awareness of learning objectives, lengthy clinic duration, student fatigue, and neglect of student welfare, were declared along with the challenges of student assessment.“During the teaching session, we must be on our feet; we don’t have time to drink water or go to the bathroom. In terms of comfort, I would like to point out one simple thing: the presence of a chair. We must stand for at least three hours. In such cases, we do not pay attention to the learning. In the last clinic I went to, we were on our feet for four and a half hours; I could not feel my legs, and it did not have a learning aspect.” [S6].Eventually, the students complained about feeling invisible in clinics and uncertain about their future job prospects.The presence of supportive teachers can significantly improve trainees’ experiences in the clinic. However, outpatient clinician-educators face several challenges.The diversity and multiplicity of the roles of academic staff, a lack of motivation , and a lack of commitment to teaching were issues stated by all three participant groups.“A faculty member is expected to be a therapist, teacher, publisher, administrator, and make economic demands. This workload can reduce their motivation and make them feel like robots." [S4].Scant knowledge and skills and inadequate or low-quality teacher training programs in outpatient teaching were other challenges.“Many teachers taught us based on their experiences as students, and they did not know how to teach in a clinic.” [S7].“Faculty development programs are often in the form of lectures and are not taught very practically.” [F7].Based on some students’ views, little knowledge or not up-to-date or evidence-based knowledge of faculties in the specialized and professional field of medicine was a serious issue.“We felt that the teacher was not scientifically up-to-date, which was why he did not answer our question.” [S9].A lack of feedback and supervision on student performance was also highlighted.“We were taking the patient’s medical history, but the teacher was not paying attention. I may have made some errors in my history taking, and there was no one to provide feedback or guidance on improving.” [S1].Another challenge was the lack of skills to communicate safely and without anxiety with students and residents.“In certain fields, teachers humiliate residents and interns to the point where they cannot sleep due to fear.” [S6].Institutional policies fail to support outpatient education due to a lack of resources, incentives, and evaluation criteria for clinician educators.“The university (system) looks at students and us as cheap labor; practically, the burden of the system  is on our shoulders. If we want to go to the clinic to be taught, then who will do the work of the hospital?” [R5].“When the research activities of a faculty member are evaluated, an h-index is used. His/her therapeutic activities are based on the number of patients visited, operations performed, etc., so how are his teaching activities measured? or where are they included at all?” [S3].In this category, we describe two main issues related to patients as one of the main components of clinical education that can pose challenges. One of them is the difficulty of respecting the patient’s privacy.“In the clinic, there are typically ten students for every patient. It can be difficult for a patient to discuss personal problems, such as a perirectal abscess.” [S1].The other challenges are the excessive number of patients and their specialized conditions in most clinics.“One day, 80 patients were visited in a clinic within 5 h; we could not see or hear anything anymore.” [S8].“In the tumor clinic, only tumor cases are visited, and if I, as a GP, am going to see a few tumor patients, this does not really help me.” [S9].Two categories emerged regarding facilitators of outpatient education: internal and external facilitators. It refers to factors that can facilitate learning and teaching in outpatient education, improve effectiveness, and be associated with greater student and faculty satisfaction..The internal factors affecting outpatient education refer to the subjective preferences, contentment, and pleasure experienced by an individual. Individuals acquire or impart knowledge without expecting rewards such as grades or commendations. In expressing the participants’ experience, students’ personal interest in learning was one of the issues that emerged“My motivation to learn, even if the teacher isn’t willing to teach, drives me towards becoming a good doctor.” [S4].“In my opinion, a significant aspect of teaching is personal; a teacher must possess an intrinsic concern for education. Teachers devote enough time based on their conscience and personality.” [S3].Faculty members’ positive personality traits, such as compassion, friendliness, and humor, in their relationships with students and patients are among three factors that are related.“The teacher had a very intimate and warm relationship with the patient and us; he joked, which made us more interested and involved in the issues.” [S1].“She taught and listened not only to student criticisms and suggestions, but also to their stories, which greatly aided learning.” [R3].The faculty’s personal interest in teaching and desire for self-improvement were other components.“I believe the teaching profession should only be pursued by those with a positive attitude towards education. Otherwise, the prevailing mindset is to prioritize healthcare and treatment.” [F6].Participants in the current study identified external factors affecting outpatient education, including faculty salary support, clinician educator job promotion, bonuses, teacher training programs, and accommodations for patient volume.“Part of the difference in the quality of teachers’ teaching is related to the system. I mean, the amount of support the system gives to the faculty influences his or her quality of performance.” [R5].“Schools must manage the teacher’s teaching time in such a way that the financial loss of the teacher is compensated, for example, to give a special privilege to teaching, either financially or professionally.” [F2].This research aimed to identify all the facets of outpatient education. In addition, including three sets of stakeholders was a crucial part of the study’s methodology. The present research results revealed the difficulties and factors that might assist outpatient education, in addition to the concerns before and during its implementation.One of the prerequisites for the successful implementation of outpatient education is a clinic with adequate space and minimal necessary equipment . DespiteElectives, which can be taken in addition to the core curriculum, allow students to tailor their education to “their specific requirements and/or interests” and develop a comprehensive insight into their intended postgraduate field. Therefore, this issue should be given some consideration in the development of the curriculum.This study identified two fundamental steps in curriculum development approaches: clarifying objectives and related content and identifying educational strategies.Like some other studies, this study indicates that various patient management skills can be improved within the outpatient setting , 30–33.According to the findings of this study, various teaching techniques can be employed to enhance learning in outpatient settings. The decision about which methods to use is extremely complex and influenced by factors such as student knowledge level, learning objectives, as mentioned by our participants, teacher experiences, educational funding, facilities, and equipment , 35. UsiAlthough no conclusion about the optimal case mix for learning can be drawn from studies to maximize educational efficiency , approprThe choice of a contact organization model for students/patients depends on the number of faculties, available rooms, and present students. However, instructors should always emphasize the importance of students’ engagement in their learning .Clinical faculty members are expected to teach medical students without adequate training. Faculty members often improve their teaching abilities through personal experiences and observing skilled teachers , 39–41. Within the teaching interaction, it is essential to contemplate the role of the near-peer teacher. In several countries, including the United States, the United Kingdom, and Canada, all residents are expected to undergo training to teach. The potential benefits of training all residents at an institution are significant and emphasize the importance of a teaching position there .In this study, the outpatient education implementation requirements included three categories: student dimension, faculty commitment to the planning, and program supervision.As a “golden rule,” orientations were held at the onset of each clerkship rotation to review clerkship objectives, schedule activities, and establish performance expectations , 43, 44.This study found that formative assessment is as crucial as summative assessment in evaluating and improving student learning. During practical instruction, formative assessment can be conducted using a predefined evaluation grid , a log bAlthough the program’s effectiveness depends on the time commitment of faculty, clinic, and patients, time constraints are always a challenge , 12, 15.In the “program supervision” category, participants revealed that conducting a systematic investigation of various facets of the program is necessary. The Ambulatory Care Learning Education Environment Measure (ACLEEM) questionnaire has been suggested as a valid and reliable instrument to determine the efficacy of an ambulatory education program and identify areas for improvement , 48, 49.In curriculum delivery, problems such as inappropriate incorporation of various levels of trainees and difficulties with developing and implementing the logbook were revealed. Although logbook implementation in outpatient education has been mentioned in some studies, its use and efficacy have not been evaluated , 50–52. The assessment methodology employed in the clinic posed the most significant challenge for the students. Limited student engagement in the learning process and their passive (shadowing) role, resulting in fewer chances for independent learning, are additional hindrances confirmed by other studies , 15, 28.This study, like others, has identified various obstacles that outpatient clinician-educators encounter. Balancing their teaching responsibilities with other roles , 15, theThe challenges related to the system include a need for more support for clinician educators , 15, a sManaging patient volumes in clinics is never easy , 28, 53.Based on this study, faculty’s and student’s self-interest facilitated teaching and learning. In this study, internal and external motivational factors were positive personality traits of teachers, self-improvement or development through a formal faculty training program, and supporting clinician educators via salary and job promotion. Some of these factors have been considered influential in other studies , 28, 41.Although not directly mentioned in our study as a necessity for setting goals, curriculum planning, and curriculum delivery, social accountability must be considered in reviewing of the outpatient curriculum for relevance to cultural context as well as community, national, and regional priority health needs .This study has limitations, such as time-consuming research and difficulty scheduling interviews with busy faculty members. Because the study used purposive sampling, the research findings cannot be generalized to a larger population.Outpatient clinics represent a crucial aspect of contemporary medical practice. Given the growing prevalence of patients in this setting, medical education endeavors must cultivate educational prospects that effectively leverage this resource. Merely arranging for students to participate in this setting does not provide a comprehensive solution. Effective outpatient education begins with proper preparation and consideration of prerequisites before the students enter the field. During the implementation, supervision of various program aspects will help to improve it. At the same time, being aware of the potential challenges of the program and paying attention to external and internal motivators will increase the chances of its success and efficiency.


To analyze the relationship between leadership coaching and nurses’ resilience in hospital environments.BRASIL). Nursing technicians/assistants answered the Nursing Technician and Assistant Perception in Leadership Exercise Questionnaire (QUEPTAEEL). Student’s t test and Pearson’s correlation were used (p ≤ 0.05).This is a cross-sectional study, carried out with nurses, nursing assistants and technicians. Nurses answered the Nurse Self-Perception Questionnaire in Leadership Exercise Questionnaire (QUAPEEL) and the Connor-Davidson Scale for Brazil-25  and in the “Give and receive feedback” (p < 0.001), “Delegate power and exert influence” (p < 0.001) and “Support the team so that the organizational results are reached” (p = 0.020) domains. There was a statistically significant correlation between all the Nurse Self-Perception Questionnaire in Leadership Exercise Questionnaire Coaching and Resilience domains.Resilience was positively related to nurses’ self-perception of coaching leadership. The work process in health is a complex and dynamic phenomenon, constantly influenced by changes in socioeconomic, political and technological scenarios.The various changes experienced by current societies have reflected in workers’ daily lives, making them increasingly involved and charged by workplace demands and routines–3.On a daily basis, nurses and other health team professionals are exposed to stressors, which can trigger physical and mental health problems, turnover of work teams, decreased professional performance and negative repercussions on direct nursing care to patients, identified as constructively and positively influencing the results of nursing care.In this context, nurses, as leaders of their teams, need to create working conditions that minimize these problems. Thus, coaching leadership and resilience, objects of investigation in this study, are considered relevant and essential competences for achieving organizational goals–6. It is based on four domains: Communication; Give and receive feedback; Delegate power and exert influence; and Support the team so that the organizational results are reached organizational–7.Coaching leadership is considered an innovative model in the health field. It is based on the mutual commitment between leaders (coach) and followers to achieve goals. Coaching leadership began to be adopted more frequently based on changes in the job market, which made people seek to improve their performance in order to contribute more effectively to institutional results,9.The “Communication” domain is the process of understanding and sharing information in messages received and sent between leaders and followers, on an ongoing basis. Feedback is a tool used for developing work teams. The “Give and receive feedback” domain is a necessary skill for coaching leaders. Through it, the leader conveys information clearly to achieve professional goals. The “Delegate power and exert influence” domain consists of the power relationship that leaders exert over their followers in enabling them to achieve their goals and influencing their reactions. The “Supporting the team to achieve organizational results” domain is related to the alignment of organizational goals and individual expectations, taking into account their followers and the mutual trust between leader and follower.For coaching leadership exercise, it is important that leaders have a relationship of trust with their team, positively influencing their followers. Faced with this situation, this current and innovative model of leadership has proven to be an interesting alternative in the process of developing skills that are interrelated with leadership, such as the ability to relate, to work as a team, to communicate, to be resilient, among others. This mechanism of recovery and adaptation, in the face of adverse situations, has been recognized as an important aspect for mental health promotion and protection, reducing the intensity of stress and decreasing negative emotional signals, such as anxiety, depression and anger. It is a dynamic process in which the influences of the environment and individuals reciprocally interact, allowing it to adapt, despite the stressors.Resilience, which is also the object of investigation in this research, is defined as an individual’s ability to recover from adversity and adapt positively in situations of tension and stress. It is a concept widely used to explain the different effects that the same level of stress has on different individuals, while it can be considered an essential tool for nurses, even more so in the current context, in which changes and stressful situations have become constant, and knowing how to manage them is essential, due to their repercussions on professionals’ professional and personal lives.Faced with the adversities experienced by nurses while working in hospitals, it appears that resilience can be a valuable and fundamental resource in daily work, and can contribute to the exercise of leadership with greater efficiencyIn nursing, what is observed is that there is a shortage of studies, mainly that address nurses’ resilience and leadership, mainly in the national scenario, where the interface between resilience and leadership has still been approached in an incipient way, which corroborates the relevance of this study.It is observed that resilience and coaching leadership are important characteristics for these professionals’ daily work, especially in hospital environments, where stressors and occupational stress can be more intense, with repercussions on nurses’ performance and quality of care provided to patients. Furthermore, in the area of nursing, there is a shortage of studies that address the relationship between resilience and leadership among nurses, which justifies the development of this study.From the above, the following questions arose: what is the relationship between coaching leadership and nurses’ resilience in hospital environments? Is there a difference in these professionals regarding self and hetero-perception of coaching leadership exercise assessment? What is the nurse-leaders’ resilience score? Thus, the study aimed to analyze the relationship between coaching leadership and nurses’ resilience in hospital environments..This is a cross-sectional, correlational and observational study, guided by the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) recommendationsLarge hospital institution, characterized as an autonomous non-profit entity, with legal personality and own assets that serves public servants of the state of São Paulo, their dependents and associates, located in the municipality of São Paulo, SP, Brazil.The population consisted of nurses and nursing technicians/assistants who worked in Hospital Admission (COVID and Non-COVID Infirmary Units), Hemodialysis, Blood Bank, Adult Emergency Room, Child Emergency Room and Chemotherapy Units.Participants met the following inclusion criteria: working at the institution for at least six months; being directly subordinated to nursing management; and being present during the data collection period. Initially, nurses were approached, and, after collecting data from these nurses, nursing assistants and technicians who made up their team were approached. If they agreed to participate in the study, they were randomly selected by the researcher and carried out an assessment of nurses’ leadership. Data collection was carried out from January to April 2021.Exclusion criteria included: nursing professionals away from work during the data collection period due to vacation, leave  or on-duty staff hired only to cover shifts.For sample size planning, the Analysis of Variance (ANOVA) technique was used, with 1 factor and r = 4 levels. It was then suggested to use a sample of 144 nurses and 144 nursing assistants/technicians, totaling 288 professionals. A total of 230 professionals participated in the study, 115 nurses and 115 nursing assistants/technicians, as they agreed to participate and met the inclusion criteria.Questionário de Autopercepção do Enfermeiro no Exercício da Liderança, QUAPEEL) and the Connor-Davidson Scale for Brazil-25 (CD-RISC-25BRASIL). Nursing technicians/assistants answered the Nursing Technician and Assistant Perception in Leadership Exercise Questionnaire .Nurses answered the Nurse Self-Perception Questionnaire in Leadership Exercise Questionnaire  and leadership exercise assessment by nurses by nursing assistants and technicians; and the third part addresses the four domains of coaching leadership , arranged in 20 items in total, 4 items for each domain. The items were measured using a 5-point Likert-type scale, with a score from 0 to 100. Each question includes response options from “never” to “always”, with “never” = 0 points and “always” = 5 points, and the higher the score, the greater the coaching leadership competence that professional hasBRASIL is a widely used version of the CD-RISC questionnaire for measuring resilience. It is an adaptation and validity for Brazilian culture with an alpha coefficient of 0.93 and intraclass correlation of 0.84. It is a questionnaire with 25 questions, covering five domains, each with 5 items: Trust in one’s instincts and tolerance of negative affect; Positive acceptance of change; Control; Personal competence; and Spirituality. The answers are given in a Likert-type scale format, with 5 options to choose from: 0 = Not at all true; 1 = Rarely true; 2 = Sometimes true; 3 = Often true; and 4 = Almost always true. The score is based on the sum total of all items, whose scores range from 0 to 100, with higher scores demonstrating greater resilience scores.The CD-RISC-25® spreadsheets by the researcher herself. Then, the database was checked, revised and validated by another professional.After collection, the data were organized and entered into Microsoft Excel® and R, version 4.0.3. Means, standard deviations, medians, minimum and maximum scores of quantitative variables were used.Data were analyzed using descriptive statistics using IBM SPSS Statistics 26.0 for Microsoft Windows, considering: small: between |0,200| and |0.499|; medium: between |0.500| and |0.799|; and large: above |0.800|.In order to compare the scores obtained by nurses in their self-assessment in the exercise of leadership (QUAPEEL) and the hetero-assessment carried out by nursing assistants or technicians (QUEPTAEEL), Student’s t test was performed for independent samples, and the effect size was calculated using the d coefficientBRASIL), Pearson’s correlation test was performed for the total sample. The statistical significance value adopted was equal to 5% (p ≤ 0.05).To carry out the investigation of the presence of correlation between coaching leadership (QUAPEEL and QUEPTAEEL) and resilience scores .The study was approved by the Research Ethic Committees of the A total of 115 nurses aged between 35 and 55 years participated in the survey. The mean age was 42 years (SD = 8.6); 92 (80%) were female, with an average training time of 11 years (SD = 6.9) and an average time working at the institution of 8 years (SD = 6.8). As for the sector where nurses worked, 59 (51%) performed their activities in Non-COVID Inpatient, 22 (19%) COVID Inpatient, 22 (19%) Adult, Child and Hemodialysis Emergency, and 12 (10%) in Blood Bank and Chemotherapy Units.lato sensu graduate course. None of the participants had a stricto sensu master’s or doctoral degree. Only 13 nurses (11.3%) had a specialization course in nursing management; 3 nurses (3%) were certified in public management, 2 (2%) in health management and 8 (7%) in hospital administration. The other nurses were certified in other areas of knowledge, such as intensive care, pediatrics and neonatology, nephrology, cardiology, public health and other areas.With regard to the training of nurses, 86 (75%) had at least one Regarding nurses’ self-perception in exercise of coaching leadership, 112 (97%) acknowledged being leaders of their teams. When nurses were asked about the concept of leadership, 77 (67%) responded that it is the process of influencing people’s behavior to achieve goals in certain situations; 26 (23%) conceptualized leadership as the process of transforming an individual’s or an organization’s behavior; and 12 (10%) defined leadership in their own words. Regarding the leadership style exercised by nurses, it was found that the majority identified with people- and task-oriented leadership, depending on the situation in which they are involved.Considering the main skills related to the communication process between leaders and followers, nurses selected the best answers thinking about skills they thought were most important. Of the alternatives offered in the instrument used during the research , the alternative most chosen by nurses was the option that all skills are necessary for leaders . Some nurses  also chose two other joint responses, namely: Communication skills; and Ability to give and receive feedback. Last choice was the answer Ability to gain power and exert influence, selected by 34 (29.5%) professionals.Regarding the total score of the scores of coaching leadership domains, the minimum value was 49 and the maximum, 100 points, with an average of 84.41 (SD = 9.44), which demonstrates that there is a diversified degree of leadership coaching development for nurses in the institution.BRASIL was used. Regarding the sum of participants’ total resilience scores, the minimum value of the sum of the scores was 45 and the maximum value was 97, with an average of 77 (SD = 10.51).Part of the study consisted of assessing nurses’ resilience score in this institution. To this end, the CD-RISC-25During participation in the study, nursing technicians and assistants were asked about their knowledge of the concept of leadership and whether these professionals considered their immediate superiors as leaders. Most nursing technicians and assistants  considered nurses leaders, and only 14 (12%) of these professionals reported not considering their immediate superiors a reference in leadership. Regarding the total scores related to assessment of nurses’ coaching leadership, carried out by nursing technicians and assistants, it was found that the minimum value was 12 and the maximum value was 100 points, with an average of 77.61 (SD = 21.74), which demonstrates disagreement with the self-perception of the assessment carried out by nurses. . The others were considered small.The “Give and receive feedback” and “Power and exert influence” domains had effect sizes classified as medium according to the coefficient dBRASIL scores. For this analysis, the correlation coefficient and p-value were calculated, through Pearson’s correlation test for the total sample, since the sample presented “n” large enough for the direct use of parametric tests, due to the Central Limit Theorem.Most nurses recognized themselves as leaders of their teams, and believe that leading is exerting influence on people’s behavior to achieve goals in certain situations and transform the behavior of an individual or an organization.,15. This conception of leadership moves towards a contingency view, in which nurses analyze the various dimensions that permeate a situation, to guide their leadership style and make more assertive and coherent decisions with the scenario and the problem experienced.It is through leadership that nurses promote the quality of nursing care, as they motivate the team to accept new practices,17,18,19.In this context, the importance of leadership is emphasized as an indispensable and necessary competence for nurses’ practice, as leaders inspire and encourage their teams to accept innovation and transformation actions. It encourages the bond of trust between leader and follower, contributing to the quality of nursing care provided to patients, which reflects on job satisfaction. Moreover, it is necessary for leaders to adapt their behavior to the teams’ context and reality, as leadership influences the work environment. When there are coaching leadership characteristics in nurses, there is job satisfaction, demonstrated by mutual trust, continuous interaction between leaders and followers, and the search for professional and personal development,17, which reinforces the importance of investing in and encouraging the implementation of programs to develop these skills in nurses in hospital environments as a strategic objective viscerally in organizational culture.In a study on situational leadership styles adopted by nurses in a hospital area, it is mentioned that the influence of leadership styles is used to qualify care, and when it has high quality, it is full of trust, good communication, respect and reciprocitylato sensu graduate course, however, a scarce number related to the management area. Furthermore, it is also noteworthy that none of the participants had a stricto sensu master’s or doctoral degree. This finding alerts to the need for greater investment by the institution to enhance professional development, given that research carried out in the academy serves as subsidies for practices developed in hospital environments, impacting service quality. With regard to nurses’ self-perception (QUAPEEL) and assessment of nursing assistants’ and technicians’ perception in the exercise of nursing leadership coaching (QUEPTAEEL), in this study, divergences between the assessments (self and hetero-perceptions) were evidenced.The results indicated that most nurses had, at least, a –21. One of these studies mentions that this fact occurs because nurses are more aware of the exercise of their influence on their followers. It must be considered that there is evidence that the self-assessment performed by professionals is always more positive, which can be considered a bias.Nurses’ scores were higher when compared to the assessment that followers made about these professionals’ coaching leadership exercise. Such differences in assessment perception were also found in two other studies, in which coaching leadership was shown with higher scores in nurses’ self-perception (leaders) than in followers’ self-perception (nursing assistants/technicians)The domains that showed a statistically significant difference between the self- and hetero-assessment conditions in the study were “Give and receive feedback”, “Delegate power and exert influence” and “Support the team so that the organizational results are reached” and the total score. There was concordance of assessments in the “Communication” domains., aiming at identifying and comparing nurses’ self-perception and nursing assistants’ and technicians’ perception regarding coaching leadership practices, also showed divergence in the perception between these two categories. Similar to the findings of this study, the results of the study carried out in these hospitals showed that there was divergence in “Give and receive feedback”, “Delegate power and exert influence” and “Support the team so that the organizational results are reached” as well as the total coaching leadership score. There was agreement in the “Communication” domain between nursing teams in the two hospital units.A study carried out in two hospitals in São Paulo, the findings also showed that there was a statistically significant difference between leaders’ and followers’ perception. The same also occurred in a study carried out outside hospital units, in the Mobile Emergency Care Service, and in a study carried out with professionals in Primary Health Care.In another study, carried out in two university hospitals and two private hospitals,20–22, there is an agreement of self and hetero-perception of this characteristic in coaching leadership exercise.The “Communication” domain was recognized as a present characteristic and recognized by both categories (leaders and followers). In the cited studies–24. The study points to the importance of communication as a basic element of coaching leadership as well as the need to reduce noise and encourage employees’ active participation in decision-making processes.Communication is recognized as essential in nurses’ daily lives, as it can influence workers’ behavior and performance in achieving goals. It is also a working tool, since nurses often perform articulation functions between other teams and professionals for human careRegarding the resilience score of nurses participating in the study, it was found that most professionals had a score equal to or greater than 70 points, which can be considered resilient. Corroborating this finding, what is observed in practice are the presence and performance of dedicated professionals who, even going through difficulties that are particular to nurses’ work, they know how to deal with conflicts and manage the demands that arise in an optimistically and altruistically. Regarding the variables nurses’ resilience and self-perception regarding coaching leadership exercise (QUAPEEL), in this study, it was found that there is a statistically significant and directly proportional correlation, and the increase in one variable was associated with the increase in another, i.e., the higher the QUAPEEL score, the higher the leader coach resilience score.,25. International studies have shown extremely positive changes after adopting leadership coaching programs. In Australia, the program was associated with significant improvements in goal achievement, and employees became more solution-focused, increased self-awareness, resilience and tolerance. Study participants reported being able to use the lessons learned in coaching, having a better balance between work and personal life.Thus, investing in coaching leadership can be an interesting strategy for institutions, as coaching leaders prove to be resilient. In a context of health work, especially in the pandemic and post-pandemic reality imposed by COVID-19, this seems to be a strategic decision for managers, because, in this context, coach leaders naturally act as educators, work with the development of their teams, investigate and encourage everyone’s evolution, managing to deal with the adversities and stressors of everyday life.In a study carried out in London, with nursing managers, after adopting the coaching methodology, nurse managers became more resilient and confident, as well as acquired better mechanisms for coping with conflict situations. This allowed better management and team cohesion perception, leading to better quality of patient care.Likewise, in Spain, in a study carried out with executives from an automobile sector, similarly to what can happen in hospitals, a similar result was observed, whereas, after specialized intervention and leadership coaching program training, the results were positive and helped leaders to develop coaching skills, improve professionals’ well-being and performance in organizationsIn this regard, the relationship of the coaching leadership model associated with resilience was verified as an advance. Therefore, this model can be very interesting for people management in institutions, for offering greater robustness and scientificity in the development of leaders in nursing, with positive repercussions on qualification of care, professional satisfaction and organizational climate.As a limitation of this study, it is noteworthy that the analysis of the relationship between coaching leadership and nurses’ resilience in hospital environments occurs in a single context, characterizing a specific population’s perception. Thus, further studies on the subject are suggested to expand this knowledge and strengthen studies of management and leadership in nursing.From this study, it can be concluded that there is a difference between the self-perception of leaders in relation to the exercise of coaching leadership assessed by followers. Such differences in assessments were statistically significant in the total score of coaching leadership, in “Give and receive feedback”, “Delegate power and exert influence” and “Support the team to achieve results”.BRASIL), observing a statistically significant correlation. Such correlations occurred in the total QUAPEEL and CD-RISC-25BRASIL scores, with the domains: “Communication” and CD-RISC-25BRASIL; “Give and receive feedback” and CD-RISC-25BRASIL; and “Delegate power and exert influence” and CD-RISC-25BRASIL.With regard to resilience, according to the scores obtained by the nurses participating in the study, they can be considered resilient. Furthermore, resilience was shown to be present in leaders, with an increase in one variable (QUAPEL score) being associated with an increase in another variable (CD-RISC-25In this way, leadership coaching, as it is a model in which leaders seek to achieve results by encouraging the development of followers, is a valuable strategy for people management to be adopted by health institutions. Moreover, it can increase nurses’ resilience to overcome challenging situations experienced in hospital environments.


Based on the “2019 Living Time Survey” data conducted by the National Statistical Office, this study is aimed at comparing the time usage of single-parent families by classifying the occupation area based on the fourth edition of the occupational therapy practice framework (OTPF) and dividing time use according to weekdays and weekends and by gender. t-test was conducted to compare time usage on weekdays and weekends.  After extracting the subjects who were selected belonging to a single-parent family from the original data of the “2019 Living Time Survey,” 404 subjects who were single parents were selected, and the data were analysed. The sample consisted of 134 males and 270 females. The time usage by occupation area during weekdays and weekends and according to the gender of the subjects was checked. By using SPSS 25.0 version for data analysis, the general characteristics and time usage of subjects were presented as frequency analysis and technical statistics, and an independent sample  Subjects spent more time on “education” and “work” on weekdays, and on weekends, they spent more time on “activities of daily living,” “rest and sleep,” “leisure,” and “social participation.” After classifying the subjects by gender, men spent more time on “work” on weekdays, and on weekends, they spent more time on “activities of daily living,” “rest and sleep,” “leisure,” and “social participation.” Women spent more time on “education” and “work” on weekdays, and on weekends, they spent more time on “rest and sleep,” “leisure,” and “social participation.”  By examining the time usage of single-parent families according to the day of the week, we hope that it will be used as basic data to suggest in which areas they have difficulty managing time, depending on the day of the week, and to establish solutions to insufficient time use due to gender differences. Modern families are changing into various forms of families, such as dual-income families, childless families, and single-parent families. This is due to the increase in the number of nuclear families as a result of the development of industrialization, changes in gender equality, life views, and women's social advancement . Among tMeanwhile, time is limited to 24 hours a day, so if time is used in one activity, time spent on another activity is inevitably reduced . In ordeTherefore, studies were conducted on various subjects to determine the characteristics of time use according to the occupation area –18. FirsMeanwhile, there have been studies examining the use of time among single-parent families –21. FirsTherefore, this study is aimed at classifying time usage from the National Statistical Office's “2019 Living Time Survey” data, which was based on the fourth edition of the occupational therapy practice framework (OTPF), and to divide the time use of single-parent families on weekdays and weekends by gender.This study used the original data from the “2019 Living Time Survey” conducted by the National Statistical Office. In the data conducted on household members aged 10 or older within 12,435 sample households nationwide, subjects belonging to single-parent families in the category of ‘single parent-parent-grandchild households' were selected. Among them, data of a total of 404 parents in a single-parent family were classified into the day of the week, gender, age, marital status, education level, and economic activity. This study was carried out after the approval of the Kangwon National Institutional Review Board (KWUIRB-2021-07-002-001).This study used the time diary of the “2019 Living Time Survey” of the National Statistical Office, which began in 1999 and was conducted nationwide every five years with subjects aged 10 and older nationwide to understand how subjects use their 24 hours. The time diary was divided into weekdays and weekends (Saturday and Sunday), and respondents were asked to fill in the days of the week they responded to and to write about activities that continued for more than five minutes at 10-minute intervals.In the “2019 Living Time Survey” of the National Statistical Office, the behavior of the subjects was classified into “required time,” “duty time,” and “leisure time.” However, in this study, the subject's behavior was reclassified into eight occupation areas and used based on the 4th edition of the occupational therapy practice framework . Behaviot-test was conducted to compare time usage according to weekdays and weekends.The data collected in this study were analysed by using SPSS 25.0 version. The general characteristics and time usage of the study subjects were presented through frequency analysis and descriptive statistics. An independent sample The number of subjects was 404 in total, with 243 (60.1%) responding on weekdays and 161 (39.9%) responding on weekends. By gender, there were 134 males (33.2%) and 270 females (66.8%) %). In terms of age, 250 (61.9%) were in their 40s, and in terms of marital status, 336 (83.2%) were divorced, 64 (15.8%) were bereaved, and 4 were unmarried (1.0%). In terms of education level, high school graduates accounted for the highest number at 166 (41.1%), while elementary school graduates were the least with 4 (1.0%). As for economic activity, 320 (79.2%) were working. The detailed general characteristics of the study subjects are as follows .Comparing the amount of time used by single-parent family parents by occupation area and according to the classification of weekdays and weekends, it was found that they spend more time on “education” and “work” on weekdays than on weekends, and on weekends, they spend more time on “activities of daily living,” “rest and sleep,” “leisure,” and “social participation.”Subitems showed significantly higher time usage on weekdays in “out-of-school learning,” “paid work,” and “other work” than on weekends. On the other hand, “eating,” “home management,” “other instrumental activities of daily living,” “sleep,” “cultural and tourism activities,” “leisure activities using media,” and “relationship activities” showed significantly higher time usage on weekends than on weekdays .After comparing men's time usage by occupation area, more time was spent working on weekdays, and more time was spent on daily life activities, rest and sleep, leisure, and social participation on weekends .In the subitems, the amount of time used on weekdays was significantly higher only on paid days than on weekends. On the other hand, eating, home management, sleep, cultural and tourism activities, sports and leisure activities, and leisure activities using media significantly had higher time usage on weekends than on weekdays .After comparing women's time usage by occupation area, more time was spent on education and work on weekdays, and more time was spent on rest and sleep, leisure, and social participation on weekends .Subitems showed significantly higher time usage on weekdays in locomotion, out-of-school learning, paid work, and other work than on weekends. On the other hand, eating, home management, sleep, leisure activities using media, and relationship activities showed significantly higher time usage on weekends than on weekdays .This study attempted to determine the time use of single-parent family parents according to the classification of weekdays and weekends and by gender. To this end, the National Statistical Office's “2019 Living Time Survey” classified the work area based on the fourth edition of the occupational therapy practice framework (OTPF) and analysed the characteristics thereof. Focusing on the results analysed in this study, they are as follows.First, after examining the amount of time used by occupation area according to the classification of weekdays and weekends, 10.93 minutes were used more for “Activities of daily living” on weekends than on weekdays, and the time for “eating” on weekends increased by 13.64 minutes in the subitems. Usually, on weekdays, people must eat at work for a fixed time, but, on weekends, eating time seems to have increased because they enjoy leisure life such as talking or watching TV at home while eating with their family. These results are consistent with the results of using more meal time on holidays in previous studies, comparing Korean workers' meal time by dividing it into working days and holidays . MoreoveNext, after examining the amount of time used by men and women by occupation area according to the classification of weekdays and weekends, both men and women's “eating” increased in “activities of daily living”, but women's time use decreased on weekends compared to men in “personal maintenance.” These results are consistent with previous studies, showing that women usually spend time on “personal maintenance” such as putting on makeup to go out, but less time spent on weekends than on weekdays, such as going to work or leisure activities outdoors . FurtherAs such, it was found that single-parent families have difficulty balancing their time on weekdays and weekends because they are responsible for paid labor, housework, and child rearing alone, and face difficulties for different reasons, depending on gender. Previous studies have shown that women consistently spend more time on domestic work than men, regardless of whether they are employed or not . This hoThe limitations of this study are as follows. Because of the second analysis of the National Statistical Office's original data, it did not match the proportion of the number of people and gender surveyed on weekdays and weekends, the time usage of simultaneous behaviors, such as eating and watching TV at the same time, and the difference in time use compared to ordinary families. However, despite these limitations, the work area was divided based on the 4th edition of the occupational therapy practice framework, and the time usage of single-parent family parents according to the day of the week was also divided by gender. As a result, it is meaningful that it can be used as basic data to suggest in what areas parents of single-parent families have difficulty using time, depending on the day of the week. Furthermore, it can be divided into men and women to establish other solutions based on insufficient time use.Parents of single-parent families spent more time on education and work on weekdays than on weekends, and more time on activities of daily living, rest and sleep, leisure, and social participation on weekends.When looking at the amount of time spent by dividing the gender of single-parent families according to the day of the week, men spent more time working on weekdays, while, on weekends, they spent more time on activities of daily living, rest and sleep, leisure, and social participation. It was found that women spend more time on education and work on weekdays and more time on rest and sleep, leisure, and social participation on weekends.Based on these results, it was possible to determine the amount of time used by parents of single-parent families according to the day of the week and to point out the differences in time used between genders depending on the day of the week. Since parental time use can affect children's time use, it is suggested that future studies focus on the time use of children in single-parent households. Such research would hopefully lead to the development of effective solutions for the challenges faced by these families.


The incidence of type 1 diabetes (T1D) has increased by about 3% per year over the last two decades. Continuous Insulin Subcutaneous Therapy (CSII) is widely used in the pediatric population with diabetes; however, it requires more preparation by the treating team and a careful selection of its potential users. Prescriptive provisions vary from region to region, and the perspective of health workers in this regard remains an unexplored area. The aim of this research project is to explore the representations of a group of diabetologists and psychologists working in pediatric diabetology throughout the country, regarding their roles, functions, and activities as part of a multidisciplinary team; it also aims to investigate their views on the potential benefits of CSII and the types of individuals who apply for the use of this technology. A socio-anagraphic data sheet was administered, and two homogeneous focus groups were conducted, one for each profession, which were then audio recorded. The transcripts produced were analyzed using the Emotional Text Mining (ETM) methodology. Each of the two corpora generated three clusters and two factors. For diabetologists, a focus on patient care emerged at different levels, involving collaboration with other health professionals and engagement with the community, often incorporating technology in medical interventions. Similarly, psychologists’ representations highlighted interdisciplinary networking with a stronger emphasis on the psychological processes involved in managing the disease, from acceptance to the elaboration and integration of diabetes into the family narrative. Understanding the representations of health professionals working in pediatric diabetes with new technologies can contribute to the consolidation of a network of professionals through targeted work on possible critical issues that may arise. Type 1 diabetes (T1D) is one of the most common metabolic and endocrine conditions in childhood, with an incidence rate that has increased by 3% per year over the last two decades , the natContinuous subcutaneous insulin infusion (CSII), especially in the pediatric population with diabetes, is widely used to achieve better dosing accuracy and flexibility in insulin regulation . There hThe optimal organization of CSII therapy management should involve dedicated clinics and staff, a multidisciplinary team with expertise in the field, and the provision of 24-h contact with the patient through a dedicated telephone line .Therapeutic education should be conducted by a properly trained and multidisciplinary team capable of considering the specific needs of children and their families. Children with diabetes differ from adults in several aspects, including their insulin sensitivity during sexual maturation, their ability to practice self-management, the variability of their eating behaviors, and their physical activity. It is also crucial to pay attention to family dynamics, developmental stages, and psychological differences related to sexual maturity . TherefoIn Italy, there is currently no National Register in place, and only a minority of the surveyed facilities meet all these requirements. A significant number of facilities still lack a dedicated clinic for CSII therapy and do not have a multidisciplinary team that includes a diabetologist, nurse, dietitian, and, whenever possible, a psychologist. These services should aim to be safe, effective, patient-centered, accessible, and well-organized. They are intended to facilitate assistance and reduce healthcare costs associated with disease complications. The planning of work activities, combined with the workplace’s climate, organizational culture, and interpersonal relationships, contribute to a complex emotional context that healthcare workers are exposed to in their professional setting . In a stQualitative methods can be useful to explore topics on which the literature is limited  and/or iParticularly, focus groups enable researchers to quickly identify participants’ perspectives ,26. Due However, research related to the involvement of stakeholders in studying mental health in pediatric primary care is still lacking ,28. In IThe aim of this research project is to explore the representations of Italian diabetologists and psychologists regarding pediatric diabetes, technologies such as CSII, and the potential differences between these two professional groups.To investigate the functions and roles of Italian diabetologists and psychologists working with pediatric diabetes, a total of 53 Italian pediatric diabetes centers were invited via email. Specifically, critical recruitment criteria were applied for psychologists (PSY) and diabetologists (DIAB), which included having a minimum of one year of work experience with patients with T1D and being part of the same team.Out of the 53 centers, 37 did not respond, 4 did not meet the criteria, and 7 were unavailable. Five centers agreed to participate in the research, resulting in a total of 11 participants  and one for PSY (with a token count of 8391). To explore the emotional representation of these professional groups in the management of pediatric diabetes technology, we utilized the Emotional Text Mining (ETM) methodology . ETM is To assess the feasibility of applying ETM to the data, two lexical indicators were calculated for each corpus: the type-token ratio and the percentage of hapax. The results were as follows: DIAB: TTR = 0.234 and Hapax = 60.4%; PSY: TTR = 0.225 and Hapax = 57.0%. These findings align with the small size of the corpora . SubsequThe results of the analysis showed that the keywords selected allowed the classification of 99.05% (DIAB) and 97.02% (PSI) of the content units. The clustering validation measures showed that the optimal solution was three clusters and two factors for both groups of professionals.As shown in The first factor highlights the diabetologist’s “Taking Charge”. This emotional dimension is characterized by the Team (negative polarity), in which diabetologists are part of an healthcare facility from a teamwork perspective, and by Relationship (positive polarity), in which the therapeutic relationship is expressed through an operating mode. In the Team, the relationship with the patient is not mentioned, but emphasis is given to the team network, while in Relationship, the relationship is played by the lonely diabetologist who face the family and the decision to use new technologies.The second factor focused on “Healthcare”, highlighting two poles, Management and Care. On the one hand (Management) there is a dimension of coordination, a team that manages the diagnostic and therapeutic process, from which, however, some figures are excluded, those who have direct contact with the patient, or those who deal with Care.With regards to psychologists’ results , the PSYThe first factor of PSY highlights the Psychologist’s Work, which is characterized by the process (negative polarity) and its steps , and by the network (positive polarity) that includes all the actors and contexts that relate daily to the pathological reality of the patient.The second factor focused on Levels of intervention, with the negative pole, Processing the pathology, and the positive pole, Acceptance of the pathology. In the first one, the emotional component linked to the onset of the pathology emerges, and so do the changes that it involves in the patient’s life; the second one highlights the experiences linked to the path of care and the acceptance of the technology that are in the relationship between the psychologist and patient.Based on the results of the DIAB group , the firTo support the cluster analysis, we decided to insert quotes following the TF-IDF score of Salton , a measuScore (51.828): “In my opinion, having a dietitian present in the clinic, as my colleagues described in their experience, is crucial. While calling a dietitian during a visit, which you cannot dedicate more than 20 min to, you have to identify the problem and call the dietitian, who may be somewhere else dealing with metabolic diseases”.Original quote in Italian: “Secondo me la presenza in ambulatorio, come raccontavano le colleghe prima della loro realtà, di avere una dietista sempre presente è fondamentale. Mentre a chiamata, nel contesto della visita, alla quale poi non riesci a dedicare più di 20 minuti, devi cogliere il problema, chiamare la dietista, la dietista magari è da un’altra parte che fa le malattie metaboliche”.The second cluster, named Pathological reality (24% of U.C.), contains everything concerning the management of the disease by a predominantly medical team . The cluster makes us reflect globally on the degree of real or imaginary conjunction existing between the different professionals within an interdisciplinary work. In addition, a key figure, the patient, is not mentioned.Score (35.823): “I connect with what my colleague said: it is easy to work with those who are good, with those who accept technology, with good families—very easy to work with those. Once a colleague from xxx said, ‘save one of those that goes wrong’… That is your job, your satisfaction”.Original quote in Italian: “Mi riallaccio a quello che diceva il collega, è facile lavorare con quelli che vanno bene, con quelli che accettano la tecnologia, con le famiglie brave, facilissimo lavorare con quelli, una volta un collega di Modena disse: salvare uno di quelli che va male… quello è il tuo lavoro, la tua soddisfazione”.The third cluster, Family meets Technology, (38% of U.C.) underlines the meeting between the nucleus of the family and the technology (the pump), where the diabetologist is a spectator. There seems to be a request for help, as the professional seems to be frozen and passive in this scenario.Score (35.257): “So obviously the patient’s choice is essential, but there is a variety of attitudes from a technological perspective, like whether to use an insulin pump or not, with different preferences for the person, the child, and the family… Sometimes the family wants it but the child doesn’t, and vice versa”.Original quote in Italian: “Quindi ovviamente la scelta del paziente è essenziale però c’è una varietà di atteggiamento dal punto di vista della tecnologia, microinfusore si, microinfusore no, con tempi diversi della persona, del bambino, della famiglia… a volte c’è una famiglia che lo vuole e il bambino no e viceversa”.With regards to the three clusters of the PSY group , the firScore (34.554): “As my colleague from XXX said, the interface and balance between hospital and community care is always very delicate in a chronic condition that only comes to the hospital for a few days of admission and is mainly managed in the community. However, where we are, community intervention is mainly related to school-related activities”.Original quote in Italian: “Come diceva la collega di XXX è sempre molto delicata l’interfaccia, l’equilibrio ospedale/territorio in una patologia cronica che di fatto arriva in ospedale soltanto per i pochi giorni del ricovero e che si esplica, si vive tutta sul territorio, ma laddove qui da noi l’intervento del territorio è prevalentemente legato agli interventi di tipo scolastico”.The second cluster, Working with the patient (17% U.C.), refers to a more mature process of pathology management, including the acceptance of the disease and the feeling of impotence and the elaboration of the cure process.Score (53.277): “Then this episode, gestational diabetes regresses, puts at risk type 2 diabetes in the future; however, the sense of diversity, when they told me about this diversity and then the sense of impotence, I am trying to help the people who are fighting, because it is not a war—it cannot be a war”.Original quote in Italian: “Allora questo episodio, il diabete gestazionale regredisce, pone a rischio di diabete tipo 2 nel futuro però, il senso di diversità, quando mi parlavano di questa diversità e poi il senso di impotenza, di una lotta, tanto che adesso anche negli interventi cerco di aiutare le persone che lottano contro, perché non è una guerra, non può essere una guerra”.The third Psychologists cluster, Working with the family system (38% U.C.), alludes to the attention to the patient and his family: the work implies the attempt to integrate the event of diabetes within the family narrative.Score (32.719): “It’s as if a child is born, as if there is a new one, someone tells us about before and after the onset, as if before the onset was the year 0. The onset and from there we start again, there is a new life, everything has changed and time, their life stands out precisely on a before and after. This because it marks, is a moment that marks particularly.”Original quote in Italian: “È come se nascesse un bambino, come se ci fosse una nuova, qualcuno ci parla di prima e dopo dell’esordio, come se prima dell’esordio fosse l’anno 0. L’esordio e da lì si riparte, c’è una nuova vita, tutto è cambiato e il tempo, la loro vita si distingue proprio su un prima e il dopo. Questo perché segna, è un momento che segna particolarmente”.The aim of the present study was to identify the emotional representations surrounding the topic of pediatric diabetes and the use of related technologies in a specific group of professionals, namely diabetologists and psychologists. To achieve this goal, two profession-specific focus groups were conducted, and the transcripts were analyzed using the ETM methodology. Each group yielded three clusters and two factors that described the emotional dimensions and representations of each profession regarding the investigated topic. Diabetologists exhibited an emotional space characterized by two dimensions: Taking Charge (between the Team and Relationship) and Healthcare (between Management and Care). Psychologists, on the other hand, demonstrated dimensions of Psychologist’s Work (between the Process and the Network) and Levels of Interventions.It is interesting to note that the first factor in both groups focuses on the type of work performed for the patient. Psychologists describe a dimension of network and territory work, while diabetologists emphasize teamwork. Although the psychologist is present in the team represented by the diabetologist, this dimension does not emerge in the psychologists’ results themselves. These findings likely indicate a difficulty for psychological professionals to effectively integrate into work teams within this particular context. However, the presence of this representation within the diabetologists’ factors suggests a starting point for building a team where the competence and psychological expertise are effectively present and actively contribute to teamwork, rather than solely focusing on territorial aspects. Additionally, within the first factor of diabetologists, there is a relational dimension where the diabetologist is somewhat “excluded,” and the family’s decisions regarding new technologies appear as a challenging and impenetrable context for the diabetologist. This aspect could serve as a meeting point within the team where the psychologist can not only address the “need” but also emotionally support the diabetologist in understanding the patient and their family’s experiences.Furthermore, the second factor related to the Care component of the diabetologists is limited, suggesting a difficulty in adopting this dimensional perspective. A psychological component could support a vision of care that encompasses not only management but also actual care.Another significant finding is the importance, for both professionals, of working with the family rather than solely focusing on the individual. This applies to both accepting and managing the illness and incorporating new technologies. To ensure the success of a treatment involving the use of technologies, it is essential to consider the family system and provide support from preparation to ongoing assistance throughout the process. Teamwork and networking also play a crucial role in this context, indicating that the issue of pediatric diabetes and the use of related technologies should be approached from a network perspective involving not only individual professionals but also groups of experts or individuals who can impact the final outcomes. Meeting the needs, therefore, requires a team-based approach with a focus on comprehensive care and particular attention to the territorial network.To this end, establishing a network of professionals at the local level and providing specific training to practitioners who can adopt a family-oriented approach and collaborate with other professional figures appears crucial.The literature has demonstrated that focus groups serve as actual psychological interventions and have an impact through the re-elaboration of concepts and the exchange of different perspectives among participants ,39. TherThis research has several limitations. Firstly, there was a low response rate from the Italian Pediatric Diabetes Centers that were contacted, resulting in a small sample of participants. This is a common challenge in qualitative research, where participants are invited to play an active role in focus groups. For future studies, it is important to establish a strong network for participant recruitment and physically present the research in the centers to enhance engagement levels.Furthermore, it would be beneficial to further investigate the use of the same methodology (ETM) in exploring the emotional representations of patients and their families regarding pediatric diabetes and its technology. For instance, ETM could be valuable in exploring the various possible dimensions of diabetes in pediatric patients, allowing for focused interventions that consider the representations and attitudes of young patients towards diabetes management ,42. AddiAt last, this study aims to promote the future construction of intervention strategies involving the various community agencies of the pediatric diabetes patient management. Multi-sector partners, such as Academic, Public Health, Private Foundations and Associations could be set up to build shared national guidelines, reducing disparities in health service provision .