Many developed countries admit internationally educated physicians (IEPs) as highly skilled migrants. The majority of IEPs arrive with the intention of becoming licensed physicians to no avail, resulting in underemployment and underutilization of this highly skilled group of people. Alternative careers in the health and wellness sector provide IEPs opportunities to use their skills and reclaim their lost professional identity; however, this path also includes great challenges. In this study, we determined factors that affect IEPs’ decisions regarding their choice of alternative jobs. We conducted eight focus groups with 42 IEPs in Canada. Factors affecting IEPs’ career decisions were related to their individual situations and tangible aspects of career exploration, including resources and skills. A number of factors were associated with IEPs’ personal interests and goals, such as a passion for a particular career, which also varied across participants. Overall, IEPs interested in alternative careers took an adaptive approach, largely influenced by the need to earn a living in a foreign country and accommodate family needs and responsibilities. Internationally educated physicians (IEPs) are individuals who have graduated from medical schools located outside of Canada . They arThe low success rate of becoming a practicing physician in Canada causes frustration about life and career prospects in Canada, as well as financial strain leading, to being unable to bear family responsibilities ,11. ThisThe intent of an alternative career is not to start a career from scratch, but rather to find a position where IEPs can build on the education and training they already have. The non-recognition of all the qualifications and experiences of the IEPs and the lack of systemic support make the alternative career pursuit very challenging . Less thThe pathways to the professional integration of IEPs in Canada are already very complex, with multiple routes, requirements, and obstacles . LearninCanada continues to bring skilled migrants to health and other professional sectors to compensate for the aging population and low population growth . ExistinThe issue is more prominent for regulated jobs. Augustine  comparedThere is scarce literature regarding alternative career pathways for IEPs in the health and wellness sector ,27. As oHuman Capital Theory (HCT) has been the foundation of Canadian immigration policies in recent decades, which welcomes highly qualified migrant professionals based on their skill, education, and experience and intends to assimilate them back into their field of expertise following migration . During We also draw on intersectionality theory in understanding the alternative career decision-making factors among IEPs. Intersectionality allows the understanding of phenomena through multiple and overlapping lenses of intersecting identities such as gender, race, socioeconomic, and immigrant origins . The IEPAs this study focused on alternative career pathways for IEPs where there has been very little previous empirical work, we chose to adopt an exploratory qualitative descriptive approach to the methodology . This stAll of the selected IEPs were either already working in an alternative career or had expressed an interest in pursuing an alternative career and had similar backgrounds in terms of being an IEP and having experience of facing myriad barriers to their career pursuit, which for the purposes of our study constituted a homogenous group. The barriers were explored by a different research question in the same setting, which has been published elsewhere .Purposive sampling was used to recruit participants for our study. This is a non-probabilistic sampling where participants are selected by the researcher based on their knowledge, experience, and ability to expand on a certain topic, theme, or phenomenon . DespiteDespite the chance of selection bias, we chose this method to ensure that only the correct participants  were recruited. Ethical approval was granted by the Conjoint Health Research Ethics Board (CHREB) at the University of Calgary.Our study included a total of 42 participants across eight focus groups. Most participants were either Canadian citizens  or permanent residents, and only two were temporary residents . A totalEach of the eight focus groups comprised four to seven participants. The FGDs were facilitated using a semi-structured questionnaire that was developed by the research team and reviewed by two IEP citizen researchers. Each FGD was audio-recorded using Zoom recording options and transcribed verbatim. All FGDs were conducted in English. Each session lasted from one hour to one and a half hours.We adopted an inductive thematic analysis approach to analyze the data . We expoThe analysis of the focus group discussions revealed five themes regarding determining factors IEPs consider while exploring alternative career options. The first theme, “Qualification and experience requirement”, included the requirement of a certain number of hours of Canadian voluntary or paid work experience, certification, and certain undergraduate or postgraduate degrees/diplomas. The second theme was “Personal resource requirement for capacity building”, which entailed the time and cost required to be competitive for a particular job. The third theme, “Possibility of the utilization of transferable skills”, included factors related to the extent of transferability of the skills earned in medical schools and experience as physicians. The fourth theme, “Employment-related factors”, represented those factors that arise from being employed in alternative careers, such as financial compensation, opportunities for further growth within the job, and others. The final theme, “Personal factors”, addressed intangible factors arising from personal preferences and constraints.Participants indicated that one of the first things they would consider in choosing an alternative job was the qualifications required for that job.“Yeah, sure. I’m actually very, um, enthusiastic about learning. So I am doing the clinical research certificate and I want to work and I don’t mind going back to school. I really want to be settled here, so I don’t mind going back to school.”(FGD4P5), FGD: Focus Group Discussion; P5: Participant No. 5.However, their views differed regarding the need for the qualification requirement. While some were happy to take up further training/institutional education for an alternative career, others were not interested in further schooling. Some would consider additional training, but they would prefer programs that are quick and easy and that complement their backgrounds.“Uh, the thing that I am not open to is, as I mentioned before that I am at this point. Yeah. I’m not looking into going to school or going to upgrade myself. Uh, I think that it’s, it’s not in me. I lost that desire to do it. So I’m looking for something that can give me an opportunity to work now, instead of asking me to go back to school for one or two years, um, the otherwise I’m, I’m, uh, I can’t think of anything in particular. Uh, other than that.”(FGD4P2)A few participants also mentioned that they would look into whether an English language proficiency test ) and/or other credential evaluation tests (such as the Graduate Record Examinations (GRE)) was required as prerequisites to pursue further education for alternative careers.“So, so first off for the preparatory phase, I mean to say that certain courses require extensive qualification, uh, for example, um, like IELTS score GRE score experiences. Uh, so just to get into that course, I think that, yeah.”(FGD8P3).Participants also said that they tried to narrow down their career choices based on the probable importance of Canadian volunteer or paid work experience for that specific type of job. Many participants had the perception that employers preferred the Canadian experience and did not recognize their extensive experience from back home or in other countries.“You actually have the skills, you have the certification, but they still want you to have had the Canadian experience, which still makes it tedious. Even with this medical office administration. The fact that I even went to school here, they still want me to have had two years experience.”(FGD3P3).The time required to become prepared for a job by earning a degree, going through training, and accumulating volunteer experience was voiced by many participants. Participants were keen to develop and be eligible or competitive candidates for a career, either by taking short-term training  or enrolling in programs that were often two or more years in length.“I will think about the time factor. So I, um, I can take any program or any, uh, on any course for a short time period. Um, maybe up to a year or two years maximum, uh, until I finished my studying and exams on so much, but more than that, I think it.”(FGD4P6).Length of time varied according to their personal choices and interest and was influenced by their family responsibilities, financial circumstances, and career goals.Participants also recognized that certain career pathways might require them to undergo additional courses or retraining. The cost related to this capacity was also considered a factor in their decision of an alternative career.“…you know, first and foremost, what I think is, uh, what is the cost of that course? Have to do, if I have to do a course and, uh, if I need, you know.”(FGD1P1)However, the cost might be compared to the potential outcome of the job in terms of job certainty and financial outcome.“That’s not a problem for me, if it is needed, I’m also. Ready to invest for a course or whatever, but really the ever-changing Canadian and [muffled] landscape will be able to provide me with a job once I come out of it.”(FGD1P1)IEPs in general showed interest in finding an alternative job that would utilize their clinical skills and knowledge. IEPs looked for these jobs because they felt it would require less effort and fewer additional resources for them to obtain the required knowledge and skills for those alternative jobs that suited the medical field.“Third thing, uh, trying to select something, that near to the medical field. Okay. So that it will not take lots of money from the person who is trying, for example, to study or to prepare to get in that field. And it will not be time-consuming the same time.”(FGD8P4)Another purpose of participants looking for careers utilizing clinical skills and knowledge was to ensure continuous use of such skills, which would ultimately benefit participants when pursuing medical licensure in Canada in the long term, while pursuing alternative careers to meet immediate goals and needs. This was reiterated by those participants who had specialty training or additional qualifications such as a certification in Diagnostic Sonography. Participants intended to use these qualifications and experiences to guide their career search to a position where they could employ such experiences.“…since I have done the ARDMS . So, my first priority will be, when I think about the alternative career, it will be something related to this field. Like radiology or something, I know that’s really hard, but that will be my first priority and something related to patient.”(FGD2P6)Some participants pointed out that as a physician they also had experience with certain essential skills such as managing, interpersonal skills, communication skills, and administrative skills. They would also consider these when shortlisting their alternative career choices.“So I have been working with people, managing people, a part of work that I have done before. Also, it has given me those skills to work with. So. People rather than just dealing with patients.”(FGD4P2)The salary/wages of jobs were a crucial factor for the pursuit of alternative careers, which was a common theme that arose from the discussions.“So financial outcome. Yes, remuneration. Actually, what you’re going to get, it should be sufficient enough to maintain dignity as well as your life.”(FGD1P3)Most participants wanted a career that paid a decent amount; however, depending on other factors, such as growth opportunity, they might waive the priority of financial gain.“Yeah, top three for me would be one would be income, um, location and three would be, um, how close is it to my actual work? So income, location, and the third one, the closeness to my role as a doctor.”(FGD4P3)Many participants were concerned about the working hours for the job. It was often expressed as a surrogate for flexibility. Some participants were interested in part-time jobs to give more time to their families or have time to study for Canadian medical licensure and other long-term career options.“That I might hold some kind of job, which is not too hectic to have a family and, um, to, to, to give time to the husband, to the kids. And you know, it’s not like, uh, a difficult, you know, like, well, flexible hours relaxing, but it’s still some, you know, some kind of income, basic income.(FGD2P5)“…and I consider that is, working hours. Do I have to work on weekends? I have to do nights, or it’s just weekdays?”(FGD4P3)Another important employment-related factor was the opportunity for growth and career progression within an alternative career. Some participants expressed not wanting a job with no opportunity for promotion to higher positions accompanied by salary raises.“I needed to be in a, in a profession or something that I would like, can you going on and what I can grow and just continue and feel satisfied with it.”(FGD3P2).When asked to elaborate on how participants would know if the job had growth opportunities, participants mentioned they would explore to see whether the position had mentorship or job coaching programs, which may be indicated in the job description.“Yep. Um, so for the growth opportunity, I would say, you know, it might not be even again, a tangible thing that a lot of time actually come around with assistant development opportunities are provided or, you know, a mentorship is provided or coaching job coaching is private or something like that.”(FGD8P5).One participant, however, suggested that information on growth opportunities was not usually found to be documented, and participants had to communicate with individuals already employed by the organization to explore this aspect of the position.“Initially they said that there was no opportunity for growth, but then as I was in the job, I saw a lot of opportunities as I went through it. Cause like, um, I had the opportunity to be part of research studies as well as our medical lab technician. So I was in contact with a lot of physicians, like in Alberta Children’s Hospital. And then at the same time now at the South health campus, we do a lot of research studies. And then there’s also this opportunity for more of the administrative part, like knowing the ins and outs of the laboratory, how it works.”(FGD5P5).Participants reported that they often explored the market demand and long-term outlook of a career before pursuing it. This was especially the case when educational training was required, where participants were more concerned about the availability of jobs within and the sustainability of a career once they had invested their time, effort, and money to become qualified.“Cause whenever I want to train on something, I want to train it good, like a hundred percent perfection, but the money that is required to do the training, if it has to come from me and I would want to have some kind of, um, reassurance that I’m going to get a job at the end.”(FGD2P5).Some participants indicated that they would investigate whether there was a networking opportunity within an alternative career. To elaborate, participants mentioned that they would look to see whether there was an opportunity for collaborative work with other institutions or organizations so that the professional network could be widened.“Um, yeah, many of the research groups that I’ve known I’ve worked with or know about they work in collaborations. So there’s a lot of opportunity to work with different stakeholders and different collaborators, even though they are different than universities that are collaborating together on a project.”(FGD6P1).One participant mentioned that working in a team environment might be a good opportunity to widen their personal professional network.“So if you’re working in a team environment, you’re working with like, you know, 10 or 15 different peoples, you will get to know them. There is a networking opportunity, for sure.”(FGD8P2)However, participants did feel that the ability to successfully network was largely due to the personal competencies of the IEPs to build and maintain professional relationships.“Yeah. You can’t give it right. Like you can’t dictate it. Uh it’s because honestly, um, but from person to person, the networking ability differs.”(FGD8P1)When seeking jobs, participants prioritized workplaces that possessed a collaborative attitude, gave importance to stress management, had effective leadership from management, and had good staff benefits and support.(From the Zoom chat feature) “Collaborative work environment, amount of stress and what do the employer (do) to manage staffs’ stress. One of the proxy could be what proportion of people are working in the specific workplace for what duration. How much they appreciate their staffs for the work they do. Paid vacation, sick leaves, family leaves, paid holidays, etc.”(FGD8P5).Certain participants mentioned that the alternative career had to be something that was meaningful to them and satisfied them as an individual. Participants elaborated to say that careers should be something that involves patient engagement and care and decision-making capacity regarding patient care, something that is an important attribute in practicing physicians.“Like radiology, or something, I know that’s really hard, but that will be my first priority and something related to patient. Actually, since I, I worked solely through the clinical side. I don’t know. Is it possible or what, but if I got chance to work with the patient, uh, I will, I will definitely go through that, that being my first priority.”(FGD2P6)Some participants mentioned that the job must relate to their personal future goals, which varied among participants. For example, some IEPs who had the intention of pursuing Canadian medical licensure focused on careers that would ultimately benefit their chances of gaining residency spots when going through the licensure process.“…either that or that particular job is going to be a bridging job. Uh, or a position like a stepping stone, uh, for me to, uh, work for a little bit and then move on to something that is going to be my destination.”(FGD4P4).Our study’s findings indicate that IEPs interested in alternative careers took an adaptive approach in general, perhaps influenced by the need to earn in a foreign country and accommodate family needs and responsibilities. Many interrelated factors and barriers, from very individualized  to very general  to systemic , are associated with IEPs choosing alternative careers in combination with the resettlement challenges they face in Canada. The IEPs go through a critical process of finding a career that balances all these factors and constraints.Non-recognition of immigrants’ education and work experience has been well documented in the literature, and it results in limited access to opportunities IEPs can pursue with interest, passion, and dignity . These eA study that explored alternative careers for certain internationally trained professionals, including IEPs, concluded that IEPs are the driver in making the decision as to which alternative careers to pursue based on their backgrounds, which was reflected in this study . MoreoveThe results of this study also highlight the importance of both objective and subjective career success as important determinants of choosing alternative careers. Apart from IEPs utilizing their human capital, their personal feelings of self-accomplishment and pride, or subjective career success, are an important facet of transitioning into a successful contributing member of society . ParticiThis study presents an exploration of important factors in career exploration for IEPs and may assist in the development of a career decision-making tool specific to IEPs and assist them in finding alternative careers. Prior studies that discussed the career decision-making model match the findings of our study . ScholarThe moderator of the focus groups ensured that all participants contribute to each idea to reduce bias in our findings due to dominant participants. Despite the lack of interpersonal interactions, conducting focus groups online came out as rather beneficial for this study as the participants could express themselves more freely and could join from their homes anywhere in Canada . HoweverThis study extracted the thoughts and views of IEPs on alternative career choices, which can help inform future research and professional integration. The findings of the study can be used to develop a decision-support tool for IEPs who are considering alternative career options . The resThe integration of IEPs and other skilled immigrants into the Canadian economy is a major policy issue within Canada and can have a significant impact on local economies. Utilizing the human capital that IEPs bring to their host countries can have major implications not only for the career success of economies, but also for major workflows, policies, and labour shortages, especially during a time of globalization when economies welcome international expertise. As seen through this study, IEPs use a series of contextual and personal factors to determine alternative career choices, making them self-reliant and proactive in their career behaviours. This career self-management is an excellent opportunity for labour policymakers and employers to assist IEPs through supportive human resource policies that focus on development, training, teamwork, and experiential learning that can assist IEPs to transition successfully into the labour market. This type of career self-management should be supported by labour policy to increase both the objective and subjective career success IEPs may gain from their alternative careers.This qualitative study explored the decision-making process of IEPs pursuing alternative careers. A variety of influencing factors was identified that arise from educational qualification and professional experience, capacity-building resources, transferable skill utilization, employment, and individual-level concerns and priorities. These can be used to develop a decision-making support tool for IEPs considering alternative careers. Considering the difficult challenges IEPs encounter after moving to Canada and failing to succeed in their natural order of career—to become a physician—it is imperative to work toward supporting them to find and grow in suitable alternative careers and redress systemic barriers. While these factors and the hypothesized decision-support tool will help facilitate alternative career choices for IEPs, research and engagement initiatives to inform employers and other stakeholders about the IEPs’ situation and potential strategies to enhance their professional integration through alternative careers should be recognized as a pressing need.


Synthetic biology is a new research field which attempts to understand, modify, and create new biological entities by adopting a modular and systemic conception of the living organisms. The development of synthetic biology has generated a pluralism of different approaches, bringing together a set of heterogeneous practices and conceptualizations from various disciplines, which can lead to confusion within the synthetic biology community as well as with other biological disciplines. I present in this manuscript an epistemological analysis of synthetic biology in order to better define this new discipline in terms of objects of study and specific objectives. First, I present and analyze the principal research projects developed at the foundation of synthetic biology, in order to establish an overview of the practices in this new emerging discipline. Then, I analyze an important scientometric study on synthetic biology to complete this overview. Afterwards, considering this analysis, I suggest a three-level classification of the object of study for synthetic biology (which are different kinds of living entities that can be built in the laboratory), based on three successive criteria: structural hierarchy, structural origin, functional origin. Finally, I propose three successively linked objectives in which synthetic biology can contribute (where the achievement of one objective led to the development of the other): interdisciplinarity collaboration , knowledge of natural living entities , pragmatic definition of the concept of “living” (that can be used by biologists in different contexts). Considering this new theoretical framework, based on its potential objects and objectives, I take the position that synthetic biology has not only the potential to develop its own new approach , distinct from other subdisciplines in biology, but also the ability to develop new knowledge on living entities. Since the discovery of DNA , severalbiobrick » , distinct from other subdisciplines in biology, but also the ability to develop new knowledge on living entities (as objective).It is crucial to study the way groups of scientists emerge and develop shared visions of their research topic, and eventually create what Kuhn coined as a paradigm ». I present and analyze in this section five main research projects (or “research programs”) composed of different pathways at the foundation of synthetic biology, which will allow to better define the objects and objectives to this new discipline in the next sections of this manuscript  pathway attempts to build new living entities by taking as a starting point a simple natural unicellular living organism  that will be reduced to the minimum of its structures and functions following mainly genetic manipulations on their genome, in order to obtain the minimal living cell. For example, the studies on reducing the genome of the bacteria mycoides , Mesoplaa florum  and Eschhia coli .The “Bottom-up” (or ascendent) pathway, for its part, attempts to build minimal living cells through the assembly of molecular modules (biobricks) made of protein, DNA, RNA or membrane vesicles. For example, the study on building protocells with a lipid vesicle that could self-replicate  or the bLet us emphasize that the “top-down” pathway is more particularly favored over the “bottom-up” pathway by synthetic biologists at the moment, considering the large gaps in our knowledge to understanding how cells work. Indeed, it is easier to build the minimum living cell by stripping a given living cell step by step and piece by piece, rather than trying to build an all-functioning living cell all at once with various molecular pieces . That saThe “Natural” pathway allows the reproduction of biological functions found in natural terrestrial entities using non-natural structures created in the laboratory  pathway allows the artificial integration of new functions within a natural living entity, by modifying or interchanging natural structures from one entity to another in the laboratory. For example, the studies on genetically modified organisms , and non-natural functions are also supported by non-natural structures . That said, the non-natural function expose by Benner seems to be a natural function  transfer artificially from one natural living entity to another one. We could say that the transferring technic is non-natural, but it could happen in nature in some way following natural evolution process. Could we imagine a non-natural function, not found in nature, that a natural living entity  could express following laboratory building? In order to apply these natural and non-natural principles more broadly to all kinds of structures and functions, I suggest a redefinition of the research program of Benner into four pathways, where the “natural” pathways could refer to structures and functions found in Nature, while the “non-natural” pathways could include structures and functions imagined and artificially designed in the laboratory by humans. I will develop and use this classification in This revised research program of Benner could be complementary to Rasmussen’s program , considein vitro and in vivo . I will develop this point of building and knowing in Then, we note that Endy’s program develops different pathways in connection with other disciplines , thus questioning the distinction of synthetic biology from other disciplines, and reinforcing the “multidisciplinary umbrella” label attached to synthetic biology.Finally, we find similarities between Endy’s and Benner’s program , where aForster-Church’s team  develop in vitro” pathway builds autonomous biochemical systems without a cellular membrane. For example, the studying on creating in vitro molecular systems composed of DNA  by reducing, modifying or redesigning their genome  and “in vivo” (pathway biologist) aspects.Let highlight a few points of discussion on the Forster-Church’s program. First, the “in vitro” and “in vivo” pathways seems very similar to each other considering that they operate concretely on the same hierarchical level of complexity: DNA molecule. Indeed, the “in vivo” approach focuses on modifying genomes and testing them in a cell, while the “in vitro” approach concentrate on DNA segments linked to RNA and protein expression.Also, the “in vitro” and “in vivo” can generate entities from both natural and non-natural structures and functions.Finally, Forster-Church’s program pathways could be complementary with the revised program of Benner, considering that the “First, the “DNA-device construction” pathway aims at building modular biological components  using a “bottom-up” method .Second, the “genomic cell engineering” pathway aims to synthesize minimal genomes and insert them into genome-less cells. To do this, genomes would first be generated theoretically by bioinformatics and then constructed in the laboratory following “bottom-up”  and “topThird, the “creation of a protocell” pathway has the objective of creating a complete functional cell from scratch. To do this, the cell would be constructed by assembling cellular subsystems (modules) and membrane vesicles using the “bottom-up” method .Let’s raise a few points of similarities between the program of O'Malley and the other programs. First, at the level of experimental techniques and methods, “Device-DNA construction” and “creation of a Protocell” pathway correspond to the “bottom-up” pathway of Rasmussen’s program, while “genomic cell engineering” pathway corresponds to the “top-down” pathway of Rasmussen’s program.in vitro” of Forster-Church and “bottom-up” of Rasmussen. On the hierarchical cellular level of complexity, the “genome and cell” pathway corresponds to the pathways “in vivo” of Forster-Church and “top-down” of Rasmussen. That said O'Malley develops a more detailed, flexible and complementary gradation of these hierarchical pathways than those presented by Forster-Church and Rasmussen.Second, at the level of molecular hierarchical level of complexity, the “gene” pathway corresponds to the pathways “Finally, we also note that O'Mailey’s program is complementary to Benner’s program (as are those of Forster-Church and Rasmussen), considering that its different paths of construction generate entities that can be “natural” or “non-natural” for their structures and functions.Considering this analysis of the different research programs in synthetic biology, we could develop a more general and common research program based, on the one hand, on the structural hierarchical level of the constructed entity (or object of study), similar to the programs of O'Malley, but with a broader scope to include entities beyond the cellular level. On the other hand, we could develop a research program based on the structural and functional origin of the constructed entity (or object of study), like the revised program of Benner exposed previously.in vivo” and “in vitro” pathways, Rasmussen’s “bottom-up” and “top-down” pathways, or Endy’s disciplinary pathways) considering that they could be modified over time and eventually become obsolete due to technological advances. That said, all research projects (and pathways) should use and share different methods and techniques in a complementary and collaborative process to achieve its objectives, as proposed by the research program thesis of In doing so, we should not define a research program based on laboratory techniques  for a given discipline.An important scientometric study, published in 2016 by The study analyzes synthetic biology according to a classification divided into 4 methodological categories. The first three categories are directly linked to O'Malley’s research program : “biobriThat said, of these four categories, the authors assert that the pathway of “biobrick engineering” would be the most important at the foundation of synthetic biology, considering its specific potential to create new modules (biobricks) or whole systems (living entities) not found in nature. In doing so, this pathway casts a new and innovative light on the study of natural living entities and on scientific practices in the laboratory not found in other disciplines. This new avenue could contribute to the development of new knowledge on living entities, as I will expose in the last section of this manuscript.per se, but rather an umbrella that encompasses an amalgam of techniques and concepts. In doing so, the authors assert that synthetic biology has for the moment only potential for technological innovation, through its capacity to build biological entities. That said, this heterogeneity might heralds the emergence and stability of this new discipline in the making.The scientometric study also points out a general heterogeneity within synthetic biology, suggesting that this discipline is not a new science I would add to their affirmation that the plurality and diversity of propositions should be encouraged when brainstorming ideas. But over time, they can become confused if they are not analyzed, organized and articulated with one another, as part of a main comprehensive plan of actions. Thus, I’m for an organized heterogenous discipline, where the diversity of the propositions  is analyzed on their similarities, differences, and complementarities, in order to articulated them as a whole . The present manuscript is a respond to establish a more articulated and heterogenous research program for synthetic biology, based on its object and objectives.Following this assertion, let us analyze the heterogeneity of synthetic biology which, as I will demonstrate, seems for the moment to be more homogeneous than the authors of the article suggest.Synthetic biology is a nascent field, and there is currently no systematic, global effort to coordinate the developments in this field. Much of the research so far has been pioneered by individual groups in the US, and the European research community has been relatively slow to embrace the field. What is needed [.] is a framework for coordinating the current research, fostering a community of researchers [.] and creating a forum for the establishment of clear goals, shared tools and agreed standards ».First, the study reveals that the core of synthetic biology was developed mainly in the United States The indicator “business development” was built from three kinds of information: participation in a Scientific Advisory Board (SAB), creation of a start-up, and ownership of patents as inventors […] The “business development” indicator is particularly strong compared to the other two indicators. The proximity of members of the core-set with commercial activities is almost systematic, suggesting that the relationships between academia and industry are particularly structuring ». In doing so, this criterion orient and homogenizes their scientometric study towards an economic aspect, reinforcing again the idea that synthetic biology is merely an extension of biotechnology. For my part, as I will expose in the last section of this manuscript, I prioritize an objective that is more fundamental than economics, in order to establish a broader, objective, heterogeneous and collaborative discipline that has the potential to develop new knowledge on living entities (rather than economic aspects).Secondly, the authors use three “Indicators” to select the articles in the scientific literature in order to describe and define synthetic biology: core institutions, business development, governance. The “business”  indicator, which selects, for example, research on the production of drugs, biofuels and cosmetics through synthetic biology, is particularly strong in this selection process, as the authors themselves underline , p.14-15Finally, the scientometric study concludes that the specific object of study in synthetic biology is mainly located at the DNA level, associated with the used of the terms: genomes, biobricks, genetic networks and circuitsThat said, focusing only on the DNA molecules (or proteins) might seem reductive and homogeneous for the object of study of synthetic biology, considering the different structural levels of the hierarchy in Nature , as well as the diversity of the biological entities on each of this level. In order to widen and heterogenized the field of study of synthetic biology, we should consider extending its object of study to other hierarchical levels of complexity of living organisms. In doing so, it could help to better define this new discipline. Indeed, a discipline can be defined in different ways depending on the point of view chosen: academic institutions , social « i) what they are about ; ii) their stance toward that object, in terms of a concern with knowing, doing or being ; and iii) the extent to which they are operating in a normal, reflexive or philosophical mode  ». In the case of synthetic biology, the “object dimension” could be the living entities  and technologies (methods), as well as its specific objects and objectives, could reveal a more heterogeneous discipline, which could then be analyzed  in order to articulate a comprehensive core research program for synthetic biology.I present in the next two sections of this manuscript some thoughts on the objects and objectives of synthetic biology that might help this potential new discipline to pass from “child” to “coming of age” state of development, as an articulated heterogenous discipline.I present in this section a proposition of classification of the objects of study built by synthetic biology based on three successive criteria, inspired mainly by the “research program” of O’Malley . This clFirst, inspired by the research program of O'Malley , we findAs criticized previously following the analysis of the research programs and scientometric analysis, synthetic biology limits for the moment its object of study mainly to the level of molecule  within a computer, and therefore evolve ». For example, computer programs that would enable the design of virtual cells  systems, which display functions that do not exist in nature ". This type of function allows for the exploration and extension of the functional limits of living entities, as O'Malley underline : « Instead of being an end, the production of unnatural functions by engineering can be framed as a profound question about biological plasticity and how our understanding of natural phenomena can be extended ». For example, the production of a new drug by cells created in the laboratory , a structural origin  and a functional origin . For example, synthetic biology could build a cellular entity , with a non-natural structure , which express a supernatural function .Moreover, a combination of these classify structures and functions are also possible. Indeed, we could build a structural hybrid entity with different hierarchical levels (molecules and/or cells and-or population-communauté and/or ecosystem and/or biosphere), using different structural origin . For example, we could build a natural multicellular entity  to which an artificial molecular module or cell or organ has been grafted . We couThe constructed entity may also have a hybrid function, such as integrating a multicellular entity with a non-natural function into a natural ecosystem performing natural functions. For example, a bacterium with a new module which produces a new molecule that could neutralize a toxic molecule in the natural geochemical cycle of an ecosystem.Thus, this classification of the objects of construction and study of synthetic biology demonstrates the potential of this discipline to go beyond the construction of DNA or cellular entities as an object of study, with a variety of structural and functional origins. These objects of study could help define the objectives of this new discipline in development, as I will expose in the next section.Following the analysis of the research programs and the scientometric study in synthetic biology, we note that the fundamental objectives of this potential discipline are not clearly established for the moment. That said, based on the classification of the objects of synthetic biology I suggested in the previous section, I propose in this section three successive fundamental objectives for synthetic biology, where one objective brings the other following this sequence: Interdisciplinary collaboration, Knowledge on living entities, Definition of the concept of “living".Each discipline has its specific object of study, objectives, and methods, but in order to develop knowledge on complex objects or questions, we sometimes need to go beyond the classic border of disciplines, toward an interdisciplinarity collaboration . That beMoreover, as presented previously, synthetic biology contains aspects of several disciplines at its foundation: biochemistry, molecular biology, chemistry, biotechnology, genetics, engineering, computer science, microbiology, biophysics, mathematical and computer biology . Thus, ssubscribed to by all members of the field”  of the object studied in synthetic biology  in establishing a definition of the concept “living” and identifying living entities, we could add at the intersections of the three spheres of the model whether the constructed entity is characterized as “living” or “non-living”. In doing so, the light gray areas in my model correspond to the intersections of the spheres where we could identify and construct knowledge about living entities according to philosophy . The dark gray area in my model corresponds to the intersection of the spheres where we could not construct knowledge about living entities  since philosophy  is not involved in this intersection.Self-sustaining chemical system capable of Darwinian evolution ». More fundamentally, Biglan classify the discipline philosophy in the “non-living system” group, despite the fact that philosophy is at the center of the epistemology of the concept “living”, and that it might play a main role to identify which entities are living and non-living, as expose by my model with the gray intersections  of the “living” concept he used to classify his disciplines. For example, a chemical system classifies as a “non-living system” by Biglan could be characterized as living using different or flexible definitions of the concept “living”, like the definition use by NASA : « Self-sections .Thus, “Theoretical Sciences”, which have been dissociated from biology for several decades, would regain their place alongside the experimental sciences through the development of synthetic biology  is not sufficient in this epistemological quest, considering that it represents only one example of life (n = 1), as ncestors . We mustncestors . These tThis objective requires, as exposed previously, the collaboration of all the disciplines , from NaIn an environment that is free from stress and provides all necessary nutrients, what would constitute the simplest free-living organism?Second, from this plurality and diversity of living entities, we could then extract or distill a minimal entity common to all these living entities , IV, V. Third, once the minimal living entity is “extracted”, we could verify if we can make this natural minimal living even more minimalism by replacing a natural module supporting a given function by another laboratory-designed module , structural origin  and functional origin .Finally, considering its objects of study, I propose three successively linked objectives in which synthetic biology can contribute: to maintain internal and external interdisciplinary collaboration ; to develop knowledge on living entities (by building a great variety of them); to establish a pragmatic definition of the concept of “living” .These fundamental objects and objectives could correspond to a new theoretical framework or “research program” for synthetic biology, which defines this new discipline. Thus, considering this epistemology, we might conclude that synthetic biology is a discipline at his “coming of age” step (rather than at his “child” step, as affirm by


Collecting post-mortem brain tissue is essential, especially from healthy “control” individuals, to advance knowledge on increasingly common neurological and mental disorders. Yet, healthy individuals, on which this study is focused, are still understudied. The aim of the study was to explore, among healthy potential brain donors and/or donors’ relatives, attitude, concerns and opinion about post-mortem brain donation (PMBD).A convenience sampling of the general population (twins and their non-twin contacts) was adopted. From June 2018 to February 2019, 12 focus groups were conducted in four Italian cities: Milan, Turin, Rome and Naples, stratified according to twin and non-twin status. A qualitative content analysis was performed with both deductive and inductive approaches. Emotional interactions analysis corroborated results.One hundred and three individuals (49–91 yrs of age) participated. Female were 60%. Participants had scarse knowledge regarding PMBD. Factors affecting attitude towards donation were: concerns, emotions, and misconceptions about donation and research. Religion, spirituality and secular attitude were implied, as well as trust towards research and medical institutions and a high degree of uncertainty about brain death ascertainment. Family had a very multifaceted central role in decision making. A previous experience with neurodegenerative diseases seems among factors able to favour brain donation.The study sheds light on healthy individuals’ attitudes about PMBD. Brain had a special significance for participants, and the ascertainment of brain death was a source of debate and doubt. Our findings emphasise the importance of targeted communication and thorough information to promote this kind of donation, within an ethical framework of conduct. Trust in research and health professionals emerged as an essential factor for a collaborative attitude towards donation and informed decision making in PMBD.The online version contains supplementary material available at 10.1186/s12910-023-00980-3. Brain collections play an important role in advancing knowledge about neurological diseases and mental disorders . Yet, itThere is still a lot to understand about the attitude and concerns of healthy individuals towards post-mortem brain donation (PMBD). Being aware of motivations and cultural beliefs favouring or impeding the donation will be fundamental, as they might be both control donors and potential decision makers in the role of a deceased person’s close relative.Those who consent to PMBD seem to be mostly influenced by the context and by the cause of death –18, but It is noteworthy that a great number of articles on brain bank construction were recently published, possibly reflecting an increased interest in this area of investigation . Both inLastly, PMBD provided by specific subgroups of the general population could be of a greater value. Twins samples, for instance, allow effective models of investigation, able to disentangle the contributions of genetic predisposition (‘nature’) and environmental exposures (‘nurture’) to the expression of many complex traits such as neurodegenerative disorders, considering that twins have been shown not to differ from the general population, particularly with respect to social  and behaRole of LSD1 in Aging-Dependent epigenetic drift leading to FrAilty-associated mood disoRders (RADAR)”. Among the project aims there was a sensitization programme to enhance awareness among citizens towards PMBD for research in the field of Frailty  (FG Naples), that might be explainable by the fact that “the brain is not the heart or the liver…” (FG Rome).Moreover, the brain was often conceptualized as the Ego, the natural seat of the Self; many declared that its importance and value was not comparable with other parts of the human body. Consequently, arising emotions and fear for its loss emerged during discussions. Several participants expressed the idea that donating the brain is like donating one’s own thoughts, one’s own mind. A secondary opinion by some participants focused on a widespread reluctance to undergo mental health therapies: ““one never knows what may happen after death”. Some individuals were worried that the loss of such an essential part of the body cannot be conjugated with life after death.Religious precepts such as the inviolability of the integrity of the human body was addressed by a few participants, and uncertainty about what may happen after death emerged: should I donate to help others or shouldn’t I for my religious faith and the consequent respect of the integrity of the body?”. At the same time, the opinion that religion (i.e. Catholicism) has now developed broad-minded positions against therapeutic obstinacy, and other progressive ideas was addressed, making it easier the adoption of more favourable positions towards PMBD and OD.A deriving conflict between OD and PMBD and burial or cremation procedures was also highlighted. Discussions around a common moral conflict occurred in various FGs that can be synthesized as follows: “nothing really has value anymore”. Moreover, both OD and PMBD were seen as a civil duty: “a part of myself can be useful and I can embrace a civil view of donation”. Other interpretative frameworks were: PMBD “gives significance to life” or represents a “gift” or “an actual contributing engagement”.Conversely, a secular view was detected across all the FGs when informants expressed outright pro-PMBD support. This view mainly addressed the idea that after death “Difficulty to cope with the issue of “death” and “disease” was prevailing across all the FGs. Some participants underlined that events such as “death” or “disease” were psychologically better managed by people in the past.The ascertainment of brain death was a main concern, around which many worries and fear (sometimes anxiousness) emerged.forced” to think about the removal of the brain as this can evoke images of “cruelty” of the surgical procedure. In particular, in Turin the need to “elaborate” and “accept” in advance the idea of the brain explant was clearly explained; it was also deemed that, in itself, the surgery has a certain undisputable degree of violence.Many individuals envisaged that they might experience negative emotions if “A feeling of reluctancy was reported when coping with mental illness while facing PMBD. A few individuals in Milan underlined the usefulness of meetings such as FGs to speak about mental diseases, they felt they might facilitate acceptance.Finally, the donation of a portion instead of the whole brain was considered far less worrying and emotionally more acceptable by the most participants in all the FGs.A higher attention concerning the role of “family” was recorded during the FGs in Naples, compared to the other FGs, even if “family” was found to be a key issue in the process of decision making for PMBD across all the FGs, sometimes controversially. For this reason we deemed that the “role of family” deserved a thoroughful examination.In particular, the decision taken by people during their conscious life was considered, almost unanimously, essential. In general, only if the dying person had not been clear about his/her will for PMBD, their next of keen were allowed to give a consent for it.Other recurrent comments underlined the heavy responsibility of family members for the decision to be taken and the difficulties they can meet when the dying person is a loved one. In Naples, it emerged that family members’ bereavement grief is a major obstacle for a relative to choose PMBD. Moreover, a few participants who declared their willingness to donate their brain, felt that it was necessary to inform their general practitioner, or the hospital staff as they thought that only a clear official procedure would really guarantee their will.The duty to take into account the opinion of each family member and to respect their sensitiveness when making the choice for PMBD was also emphasised. Few individuals expressed their preference to leave the choice to the children at the time of their death.In Turin, one participant showed a real concern for his family members, believing that they would inevitably face moral, psychological and emotional difficulties in making the decision to consent to PMBD for him.In Rome, the opinion that consent for PMBD can be given only by close relatives  was clearly expressed; a few participants directly stated that they would give consent to PMBD if they had a dying relative. A solid reason to opt for PMBD was the presence of a neurodegenerative or neurological disease within the family, which was seen as a strong facilitating factor.From a cultural and social perspective, a potentially positive attitude towards PMBD was highlighted when participants referred to the comparability of OD and PMBD in terms of “life-saving” activities, the former to directly save another life, the latter to improve research on specific diseases that might help to save lives in the future. Another speculative view focused on the chance of “prolonging life” and giving meaning to a dying persons’ life through PMBD. Someone explored the subject and came to a practical consideration regarding the usefulness of using the brain deliberately against its inevitable deterioration.Various opinions can be viewed within an “altruism and solidarity” framework. In this category, there were ideas of a general solidarity that donors can have towards society for biomedical progress and, sometimes, for a sense of social responsibility towards other humans. In the same area, a sort of “utilitarian” attitude also emerged, with some participants talking about a costs-benefits balance between the benefits gained from previous biomedical research advancements deployed in our times, and the act of PMBD today for medical improvements in the future.… Once I have donated, I forget it”.Trust was another key element raised several times during discussion. It involved themes such as reliability of research, of the institutions/investigators in terms of their reputation and, more generally, of research transparency. Many individuals highlighted the threat of unjustified experiments and/or manipulations, and the risk of an undue brain tissue removal before the ascertainment of the brain death. Potential unjustified commercial deployment of the biological specimens was also mentioned. Conversely, a few people reported a high level of acceptance, and a relaxed attitude: “Participants’ attention frequently focused on families of people affected by mental and neurodegenerative diseases as the most suitable “micro environment” to be comfortably informed about PMBD. Many participants thought that only an open dialogue between health professionals and family members could raise awareness on the topic.Education emerged as crucial. According to most of the participants, school and communitarian environments might play an important role in educating young people to responsible solidarity.” were largely addressed, especially those affecting elderly people. Furthermore, “aim and objectives of the research that makes use of the brain tissue” should also be highlighted to promote PMBD and, in particular, both distinction and comparability of PMBD and OD for therapeutic purposes should be well disseminated.Regarding the most helpful topics to be propedeutically developed for ehancing PMBD, “mental health and neurodegenerative diseasesParticipants identified health professionals and general practitioners as possible “actors” to be involved in raising awareness and informing about PMBD.Specific tools to formalize individual informed consent for PMBD were mentioned, such as the living will, or a registration in a personal card, similarly to the OD acceptance on the Identity Card, legally required in Italy. Finally, a large number of individuals thought there was a need for new standards to regulate PMBD.Themes and subthemes derived from the analysis are reported with a few key quotes from participants in Table The results showed that PMBD was a new topic for the great majority of participants. Despite a more frequently reported general enthusiasm for scientific research detected during the FGs of twin subjects, no evident differences between twin and non-twin groups emerged regarding knowledge, attitudes and concerns about PMBD.Participants were often inclined to express themselves in terms of what “others” (e.g. their own relatives) or “society” as a whole might think about the issue of PMBD. The complexity of the potential role of family members, with multiple and often conflicting opinions, was striking and it is a distinctive finding of our study.Indeed, while several previous studies detected single themes regarding the role of family , 11, 18,Family sub-themes were sometimes conflicting, ranging from the appreciation of family members’ involvement in the decision-making process, to a resentment or a concern that family members might not respect the will of their decesead loved one. A potentially highly interfering family role towards PMBD was already known , 11, 37,Compared to healthy individuals, motivations leading to PMBD are more easily detectable among patients with neurological or neurodegenerative diseases and their families, as the disease is a central factor in shaping willingness to donate , 37. Yet“might recover from it”. However, there is contrasting evidence on this issue: even if PMBD rates are higher among those with higher knowledge regarding brain death, an accurate knowledge about brain death does not seem to be a driving force of the willingness to donate [Indeed, the ascertainment of brain death emerges as a potentially hindering factor for PMBD, and following this issue, many individuals landed on an emotional non-acceptance of “death” and “illness” that are likely to play a major role in personal decision-making. They declared a sense of ambiguity about brain death ascertainment and an underlying hope that a dying individual o donate . Other ro donate . Whateveo donate , and empo donate . It is, o donate .Central was also an underlying role of religion and spirituality in framing events and decisions concerning death and PMBD, it emerged in our study as in previous research. A few studies, in fact, identified a positive contribution of religious beliefs , 21, othA part of me, of my body, may be useful, therefore I may help others this way” is an expression that summarizes an emerging general solidarity; many individuals spoke about PMBD as a “good act” to help others through potential research advancements or in terms of “gift”. A few opinions were formulated, from a utilitarian perspective, showing the importance of a trade-off between benefits and costs. In this perspective, one can take advantage from the biomedical findings to which other people contributed in the past, and, correspondingly, one has got a chance, sometimes considered a duty, to give a contribution for the generations to come.“Overall, the role of solidarity, framed by utilitarianism, religion or spirituality had a clear place in the discussion in favor of PMBD.Lastly, the topic of a societal “trust” towards research and its actors emerged as well. Concerns about possible inappropriate procedures or unclear research aims, and subsequent lack of trust towards researchers and physicians, were already found as pivotal drivers in shaping the behaviour of healthy individuals towards PMBD .From a legal perspective, it is also important to point out that in Italy steps forwards were recently made to highlight as central the role of one’s deliberate choice and free will to donate one’s body for research purposes . HoweverFor what concerns limitations, the choice of the method was crucial to an in-depth investigation of opinions and concerns about a quite an unknown topic such as PMBD. However, the study has the limits of a qualitative research, there is a need to implement quantitative studies on wider samples drawn from the general population, to assess the impact of the several emerged factors in relation to PMBD. Moreover, the study investigates opinions and concerns in a theoretical framework, further research is necessary for detecting reactions on the ground of concrete proposals to join a PMBD programme.Finally, there was a high rate of refusal of participation in the South of Italy (i.e. islands), and it will be necessary to investigate this phenomenon promoting additional research.The complexity of the process leading to PMBD emerged clearly. Our study reinforces the need for public interventions to promote PMBD, as already addressed by various scholars during the last decades , 37. In However, we deem of importance that an inner understanding of the role of the brain as conceptualized among individuals and within society should be encouraged while promoting PMBD outside the clinical context. Moreover, cultural efforts are needed to support a larger societal acceptance of “death” and “disease”, as well as to promote an ethical debate for the best poise between the value of scientific and health care advancements and the inner needs of human beings.Below is the link to the electronic supplementary material.Supplementary Material 1


Dear Editor,p = 0.02). After adjusting for age, gender, SOFA score, and the decision to withdraw/withhold treatment, the modified-FRAIL > 0 was no longer associated with 90-day mortality , confirming previous data and in contrast to a robust multivariable association of CFS > 4  with mortality. We cannot directly compare the frequency of TLTs since these data were not collected. Of note, the decision to withdraw/withhold treatment in patients with CFS > 4, FRAIL > 0, and modified-FRAIL > 0 was exactly 36% in all three groups.We would like to express our sincere gratitude for the thoughtful comments made by Cheung et al. in their response to our letter . We evalWe summarise that both the CFS and FRAIL are associated with the frequency of withholding treatment, but only the CFS is independently associated with mortality. However, we recognise that the FRAIL checklist attempts to integrate pre-existing conditions and hospitalisations with functional impairment and believe that it is possible that such an approach could further improve frailty assessment.


Evidence highlights the need for professionals to be aware of their stigmatizing attitudes and discriminatory practices in order to minimize the negative impact on the people they take care of. However, nursing students’ perceptions of these issues have been poorly studied. This study explores the perspective of senior undergraduate nursing students on mental health and the stigma around it, by considering a simulated case vignette of a person with a mental health problem. A descriptive qualitative approach was chosen and involved three online focus group discussions. The findings show various manifestations of stigma, both at an individual and collective level, which indicates that it is an obstacle to the wellbeing of people with mental illness. Individual manifestations of stigma concern its effect on the person with mental illness, while at the collective level they concern the family or society in general. Stigma is a multifactorial, multidimensional, and complex concept, in terms of identifying and fighting it. Thus, the strategies identified involve multiple approaches at the individual level, aimed at the patient and family, namely through education/training, communication, and relationship strategies. At the collective level, to intervene with the general population and specific groups, such as groups of young people, strategies suggested include education/training, use of the media, and contact with people with mental disorders as ways to fight stigma. Globally, mental health is a leading cause of ill health and is explicitly prioritized in the 2030 Agenda-Sustainable developmental goals . The impDiscrimination has been seen as a behavioral response caused by negative attitudes . VariousPrejudice generally refers to attitudes, emotions, or behavior towards group members, which implies, directly or indirectly, some negativity or antipathy towards that group . PrejudiStereotypes reflect preconceived opinions and attitudes about members of certain groups . The general population has negative and stigmatizing attitudes toward mental health patients, and many myths and stereotypes remain ,8,9. EveStigma is distinguished from discrimination, prejudice, and stereotypes; it is described in three conceptual domains  , which cStigma is defined by Goffman as an “attribute that is deeply discrediting, reducing someone “from a whole and unusual person to a tainted discounted one”  p.3. SubThe term “public stigma” refers to the stigmatizing perceptions that the general public holds of those with mental illnesses. The internalization of public stigma constitutes self-stigma , when peThe stigma attached to mental health conditions is universal, permeating all cultures and contexts in countries worldwide . Only seFor many people with mental health problems, stigma and discrimination create severe barriers to receiving quality health care . It is eSome studies reveal positive attitudes in nurses ,27, but Recent literature reviews highlight the need for professionals to be aware of their stigmatizing attitudes and discriminatory practices to minimize the negative impact on the people they take care of ,31. OnlyIt has been noticed that stigma does not diminish significantly with theoretical learning, and there is a need to input contact with patients into clinical practice ,33. AnxiWhile various measurement tools quantify mental health stigma, we believe there is still a lack of a holistic, comprehensive approach to this issue in nursing students, which is crucial to designing the strategies to curtail barriers to mental health practice, promote help-seeking behaviors, and expand mental health nursing education. To address this gap, this study’s primary goal was to understand senior undergraduate nursing students’ perspectives regarding mental health stigma and discrimination. For this purpose, the study was intended to understand the views of a group of nursing students about mental health, starting with a simulated case vignette of a person with a mental health problem.A descriptive qualitative approach was chosen, which involved online Focus Groups (FG); it was designed using Krueger and Casey’s methodological framework . The ConThree FG were run, with 19 nursing students  from 38 potential students in the 4th year of the bachelor’s degree program at one Portuguese nursing school. It is generally accepted that between four and twelve participants are sufficient for each FG . The parParticipants were selected using a purposeful sampling procedure based on previous clinical experience with a person with a mental illness. The inclusion criteria were as follows: (1) adult nursing students (≥18 years old); (2) can communicate in Portuguese; and (3) agree to participate in this study. We excluded participants who had no access to any electronic device for joining the online interview.The option of conducting online FG was chosen because there were no classes during the study period, and we wished to ensure low dropout rates. In addition, the threat imposed by the COVID-19 pandemic further strengthened the rationale for conducting FG research online .The online FG sessions took place over two months (October 2022 and November 2022) using the videoconferencing application Zoom, and each session was approximately 70 min long. Before each FG, participants completed a short questionnaire with some sociodemographic and health-related variables. Although they did so from the beginning of the meeting, participants were asked to keep the cameras on, and they complied. During the data collection, all participants had the video cameras and audio-activated to ensure the visualization of the nonverbal cues in their interactions. This information was negotiated before each focus group started. The FG sessions were recorded with the participants’ permission and then transcribed for a more efficient analysis of the discussion content and the answers.The sessions started with a simulated case vignette of a victim of stigmatizing attitudes toward mental health: John is a 22-year-old university student with anxiety symptoms. He had several anxiety crises and panic attacks, which his colleagues interpreted as a way to get an advantage in school evaluations. They did not understand why he behaved this way, because they judged that he should be able to control the symptoms. After the case presentation, a discussion was held with a group of questions , and parThe study was conducted following the Declaration of Helsinki and approved by the Local Ethics Committee . Written informed consent was obtained from each participant before participating in an FG. The moderator thoroughly explained the study’s aim and the participants’ right to confidentiality and anonymity. Videoconferencing software Zoom allowed for encrypting all FG sessions and for using a passcode to protect the privacy of a focus group meeting.The content of the answers was analyzed using Braun and Clarke’s methodology of reflexive thematic analysis . This apAccording to Braun and Clark , the theIn the third stage, which corresponds to the search for topics, the codes were categorized into topics likely to be related to stigma. The review of themes (fourth step) was confirmed by reviewing all codes and the dataset.Fifth, topics were defined and named, producing a final thematic tree. Finally (sixth step) a thematic review was used to help write the report. Coding involved two (co)investigators: the principal investigator (O.V.) coded all transcripts, which were then coded independently by co-researchers with scientific training and competence in data processing (T.C. and L.M.). When differences or disagreements arose during coding, the coders conferred until a consensus was reached. A fourth researcher (C.T.) was consulted to reach a final decision. Interrater reliability was calculated using the percentage of agreement . Thus, wSelected quotes from the Portuguese transcript have been translated, in italics, and inserted in the following report. Example extracts from the participants were numbered according to the FG number (1–3), by sex (XX/XY), and by interviewee number.The interviews were planned and conducted by the research team consisting of the principal investigator and the co-researchers who had insiders’ points of view and knowledge about stigma in the person with mental illness. To ensure reliability and validity, the interviewers underwent training and reflection sessions, including a discussion on the FC script. During the data collection period, the FC facilitators participated in regular feedback sessions based on the recorded FC.The principal investigator  was effective in conducting engaging conversations with participants; this facilitated getting to know the participants and having empathetic and assertive relationships. The principal investigator showed neutrality, without value judgments, providing some time for the participants to expose their doubts, difficulties and to make some comments about their experiences in an internship in mental health and psychiatric nursing.The findings were reviewed by co-authors (researcher triangulation) and resulted in the revision of theme and sub-theme names to legitimately capture the essence of the findings. We also maintained an audit trail, which included field notes, coded transcripts, and comments and reviews from group coding meetings, following best practices in qualitative research.The research team consisted of nine certified mental health nurses and one certified medical-surgical nurse-all with experience in conducting studies using qualitative approaches. The principal investigator (Ph.D.) and two co-investigators  followed the FG interview. All were specialists in Mental Health and Psychiatric Nursing in a School of Nursing. They had previous research experience and were familiar with the student group. One of the co-investigators was the secretary of the FG sessions.The students were informed about the researchers, their personal goals, and the reason for the research.n = 7) and very good (n = 5)  . NonetheFrom the data analysis, done with a reflexive thematic analysis , emergedThe data relating to the attributed meanings of stigma were analyzed according to the meaning of social stigma , which hManifestations of stigma emerged, whether at an individual or collective level, which indicated that it was an obstacle to the wellbeing of people with mental illness. Individual manifestations concerned the person with mental illness, while at the collective level, they referred to the family or society in general.The strategies for stigma reduction were grouped according to their individual or collective nature. Individual strategies referred to strategies directed to the person with mental illness and/or their family, while collective strategies referred to strategies directed toward groups or society in general. In the following subsections, the findings presented in Stereotypesmad” (FG1-XX-4), “crazy” (FG2-XX-3), “they start calling him crazy, crazy boy and say that they have no patience for crazy people” (FG1-XX-2).The participants identified rigid ideas and attitudes involving negative and harmful emotional content for the person with mental illness, with expressions appearing that labeled them as “he’s making a big show... as a way of him to get some advantage” (FG3-XY-1), not understanding the reason why it was happening.Other situations were identified in which the participants believed that the behavior presented by the person with mental illness was aimed to obtain gains “because he’s crazy, he doesn’t deserve it, I do not have patience (...)” (FG2-XX-2), “When I started my internship, I had a patient with schizophrenia and I couldn’t get to her, (...) I realized that the problem was me, not her because I was afraid of her, I was afraid that she would attack me, I don’t know... I was afraid of not speaking the right words to her, of saying something that would trigger her madness, her irritation, and her aggressiveness” (FG3-XY-3); “When I went to the internship, I was afraid that I wouldn’t be able to interact with people and would have some communication difficulty” (FG1–XX-5). One of the participants gave the personal example of “a relative who has a mental illness that went to an emergency room and because he was mentally ill, we get a green bracelet, but he was having a stroke” (FG3-XY-1), “I sat down at the coffee table and one man came up to me and started asking me for help messing with my phone and stuff like that, and I really got to thinking, what does this crazy guy want” (FG2-XX-4).“The behavior of health care professionals regarding the existence of stereotypes towards people with mental illness was highlighted by the participants when they stated thatPrejudice... the fact that the young man had an anxiety attack during the exam and they immediately thought that what he was going through was not exactly physiological, it was unclassifiable” (FG1-XY-1), “... if it was another disease like a stroke, for example, that had these symptoms, maybe they would pay more attention” (FG2-XX-6), and “an example (...) in my family, a teenager asked his mother to see a psychologist because he felt stressed and had panic attacks and his mother said that he had to go to school because that was an adolescent problem and would pass” (FG3-XY-1).“When talking about the meanings of stigma, participants referred to prejudice in expressions such asDiscriminationcolleagues criticized him and kept away from him” (FG2-XX-6), “when they criticize him and do not try to understand his colleague’s situation” (FG3-XY-1), discrediting the behavior of the person experiencing stigma, non-verbal communication “non-verbal communication, the way they look at him, I think that’s where stigma starts” (FG2-XY-1), devaluation “it’s related to what colleagues said ... with the devaluation of him” (FG1-XX-8), “I have a relative who has a mental illness and went to an emergency room and as he had a mental illness and was a nutter the green bracelet was put on and he was having a stroke, so the symptoms were devalued” (FG3-XX-2) and the discredit towards those with mental health problems “if someone knows that he is undergoing treatment for something ... the person might not be seen with that much seriousness and confidence” (FG2-XY-5) “Knowing that a colleague has a mental illness will generate negative thoughts and negative feelings”(FG1-XX-5); the fact of using therapy to deal with situations related to shame and difficulty in talking about the problem was also mentioned “we once had a patient who was homosexual and because he was homosexual and did not want to assume it and had difficulty to say it to his family, they gave him an antidepressant, they always gave him only medication, but the problem was something else, it was losing his shyness and say that he was homosexual and not hiding through medication” (FG1-XX-3).“The behaviors described by the participants as discriminating were criticismstigma that could threaten the identity of the stigmatized person, and the way they feel: “…a stigmatized person may feel fear or shame, which can lead to anxiety and depression” (FG1-XX-2). The stigma according to the participants can make them feel that they are not normal, that they have no value, with a decrease in self-esteem and self-confidence: “…the person feeling that he is… different, that he is crazy, something that is not it’s normal” (FG1-XX-6). The person may still believe “that he or she is good for nothing, therefore, self-esteem is greatly affected” (FG2-XX-3); “many situations and attitudes that people have, make us believe that we are disabled” (FG3-XY-1). These beliefs can affect the person’s life: “the feeling of inferiority concerning other people… it leaves scars for the rest of their lives” (FG3-XX-2).Students identified manifestations of the self-stigma/internalized stigma, that is, they referred to a perception of devaluation, marginalization, shame, and isolation:in addition to the person who is dealing with the stigma of others, he may eventually come to deal with his stigma, self-esteem, that is, from dealing with these situations so much he ends up realizing that there is something wrong with him and that he has to change, that he is not well” (FG1-XX-3); “…the stigma, … has to do with labeling, with an exclusion, which is often done concerning a situation, a specific person, which can even lead to discrimination itself” (FG3-XY-1).“At the individual level, they also mentioned …people who suffer from mental illness are ashamed, they are ashamed…” (FG2-XX-6); “a look in a strange way, you can see it as being judgmental or recriminating him, taking away his self-confidence, causing him to have derogatory feelings about himself”. Related to the internalized stigma, people withdraw from social activities: “…the person does not feel understood, feels isolated or isolates himself.” (FG3-XX-2).Feelings of shame and derogatory feelings are mentioned: “Inability/resistance to seeking help was also unanimously mentioned: “instead of asking for help and getting better, it turns out to be the opposite” (FG1-XX-5). Stigma can affect medication adherence:…the responses he received from society, instead of helping him progress in dealing with the disease, made it even more difficult to the point where he wanted to hide it and not want to take the medication…, that is, he did not adhere to the therapy because he felt this stigma, because he felt he was not like the others” (FG2-XX-6).“the denial on the part of the person going through the situation and resistance to not seeking treatment” (FG3-XY-E1).Indeed, the stigma may lead the person not to accept their  illness and resist seeking treatment: “...social rejection: “social exclusion often happens in face of mental illness, …” (FG1-XX-4); “…what happens is exactly the distancing from society, rejection…” (FG2-XY-5). The stigma of mental illness can be so harmful that it leads family members not to accept the illness of that family member—changed familiar dynamics—“...the family itself sometimes does not accept that the family member has to take psychiatric medication” (FG1-XX-6); “sometimes families try to hide it…” (FG2-XX-3). Other family members isolate themselves: “many families isolate themselves or try to hide it” (FG-3XY-1).The participants identified manifestations of stigma in terms of myths associated with mental illness were also identified in the students, such as, that people are dangerous: “... I was afraid of not saying the right words to her , of saying something that triggered her madness, her irritation, and her aggressiveness … I was afraid of her; I was afraid that she would attack me” (FG3-XX-2). Some of the participants mentioned their stigma: “ourselves, as we said in class, suffer from stigma” (FG2-XX-6).Some education and training strategies for the person with mental illness and his/her family:... I agree with health education. I think that primary health care units could play a more interventive role because they end up receiving a large part of these family members in the appointments. They also can bring together, for example, the children and the parents, i.e., they could take advantage of it and work on this topic with the family members. I think that it would also be important to create moments in which people who have already suffered stigma or who suffer stigma could meet and talk” (FG2-XX-3).“The participants identified communication and relationship strategies with people with mental illness:... it is important to understand, to know how to maintain calm, to know how to talk to people, sometimes even lowering ourselves to their level and trying to understand what the problem is, what is going on, why they are feeling this way and what can I do to help them” (FG1-XX-2).“At the individual level, they also mentioned many of the users of the institution say that they would like all professionals to have a little time to listen to them... and not to treat them differently...” (FG1-XX-3)), but also by society in general... if we were more human, I think that’s the right word to use, more understanding with others, we would pay more attention to these things, without that hatred, to worsen the situation of the person who already has a certain difficulty in dealing with some things. This difficulty can be overcome with the support of someone close, a colleague from college, a neighbor, or all, ....” (FG3-XX-5)..“Within the collective strategies, it was also possible to identify I would like to say here something that I think would be important, which is the organization of more lectures in schools, such as lectures on sexually transmitted diseases. I never attended one about mental illness and I think that education also starts, mainly, with the younger people and I think that it would be important to invest more in this...” (FG1-XX-4).“This intervention may occur at a societal level or in groups:Strategies involving the media to make mental health visible: “... to work on the sensitization of journalism and the media, i.e., to provide more balanced information...” (FG3-XY-1) and “... avoid perhaps sensationalist types and language in the media...” (FG2-XY-5). In particular, the use of television news, soap operas, or reports were evident in the group’s discourse: “I think, for example, that soap operas are great disseminators of knowledge on this issue” (FG2-XX-6).sharing of experiences by the person with mental illness and, to the same extent, the contact with people with mental illness were also mentioned: “the stigma is in all of us, not in all of us, but in most of us and I think that our stigma, I think I can speak for all of us here, has greatly reduced after the internship and after we have contact with people with mental illness”(FG3-XX-2).The Even when the morbidity and mortality of mental illness are low, but the condition is highly stigmatized, the burden of stigma can exceed the burden of the illness, namely impacting social, emotional, and professional functioning, thus negatively affecting the person’s quality of life . Stigma crazy” or “nutty”, that is, labeling, which came from the recognition of differences or marks in the character’s behavior [Stereotypes represent cognitive schemes that contain beliefs and opinions about the characteristics, attributes, and behaviors of the members of various groups , such asbehavior ; it was behavior .Stereotypes of the person with mental illness bring disadvantages to themselves and their participation in life in society . In the When I got there in the internship, I had a patient with schizophrenia, and I couldn’t get to her” shows the existence of stereotypes on the part of health professionals. The same author points out that the higher level of training of professionals reduces attitudes and behaviors related to stigma.The existence of stereotypes about mental illness is identified in the general population but also among health professionals. They are not safeguarded from internalizing the stereotypes assumed by society  which maEvidence shows that stereotypes are evident in general society and among health professionals . In addithose actions the boy has in the face of anxiety something unqualified” and devaluation about mental illness problems demonstrated in expressions such as: “.... if it was another disease like a stroke, for example, that had those symptoms, maybe they would pay more attention” which is confirmed by some authors [Attitudes that imply some negativity may be the evaluation of behaviors such as “ authors ,54 when because he felt stressed and had panic attacks and his mother said that he had to go to school, because that was a problem of adolescence, and it would pass”. Not accepting the existence of the problem may be related to the belief that those suffering from mental illness are not able to recover from their condition and will never be able to work or live independently [Prejudice is also expressed in the difficulty in accepting that a family member may have a mental health problem, as can be seen in the expression “endently .The stereotypes identified by the participants seem to materialize in prejudices such as devaluation both in the care provided by health professionals and in family and social interaction.colleagues (...) would push him away” are corroborated by literature [The discrimination behaviors identified, including pushing away “terature . The litterature ; howeverterature .serious or trustworthy”, which may have consequences in terms of finding a job, sharing accommodations, or even starting an affective relationship [In addition to disengagement, other discriminatory behaviors were identified by participants as the fact that the person is not viewed as “tionship ,56. The tionship .hiding the therapy” [Aware that they may be stigmatized, people with mental illness sometimes adopt behaviors such as “therapy” , which mtherapy” .Discrimination, according to the participants, can manifest itself in the form of verbal and non-verbal behaviors, i.e., in various forms of communication and interaction. Communication is implicitly necessary to achieve mental health, build social relationships, and be an active participant in the world . HoweverOur findings show the existence of discriminatory attitudes in the distancing, discredit, and lack of trust toward people with mental illness. Non-stigmatized people try to avoid interactions with stigmatized people, which contributes to a decrease in the size and quality of the social networks of stigmatized people.In this sense, the participants were unanimous regarding the experience of stigmatization affecting the identity of those with mental illness, leaving scars, and resulting in loss of self-esteem, attributing to themselves characteristics of incompetency .Loss of identity seems to be a major factor in the experience of internalizing stigma/self-stigma. The literature shows the negative effect of stigma and discrimination and its role in shaping the internalization of stigma ,63. SociThe fear of being stigmatized or labeled is one of the main reasons why many people living with mental illness do not seek help. The stigma associated with mental illness prevents people from making use of community resources . Many peSocial rejection was also identified by students as a collective manifestation of stigma. These results are in line with other studies that suggest that rejection experiences were more prevalent among people with mental illness ,69.Stigma not only directly affects individuals with mental illness, but also the loved ones who support them, often including their family members . It shouWith a lower frequency, some myths/beliefs associated with mental illness were addressed by students, such as the person with mental illness being aggressive and showing stigmatizing and fearful attitudes. These results are in line with a study carried out with medical and psychology students .Therefore, there is an urgent need for specific intervention strategies to combat stigma. In this sense, participants were unanimous about the need to develop strategies to reduce stigma. In the thematic analysis of the data, it was possible to identify strategies that were grouped according to their collective or individual nature. These findings agree with the available evidence that identifies stigma as a global phenomenon, which requires intervention approaches that target multiple levels, including the individual, interpersonal, community, and structural levels .In the realm of individual strategies, it was mentioned that education/training of the person with mental illness and/or family is an important strategy in fighting stigma. This strategy is often identified in the literature as a psychoeducational intervention with the potential to help patients gain more knowledge about mental illness and improve their understanding and ability to cope with the stigma of mental illness ,75. SuchFamily education/training is also identified as a possible strategy in other studies that point to positive results such as changes in affective attitudes, cognition, and behavior, namely, family members learn to act, express their feelings, and think in a flexible way about the disease, but there is no significant evidence on the results of these interventions on stigma .The other strategy at the individual level is related to communication and relational strategies with the person with mental illness, both by health professionals and society in general. Communication is essential in any context, particularly in health, but it is even more important in mental health, due to both the nature of the problems and their potential impact . This inAt the collective level, the education/training of society or groups was also mentioned as a strategy to be adopted in the fight against stigma. About the education of students on this topic, referred to by several participants, a systematic review of randomized controlled trials for the identification of anti-stigma interventions on mental health targeting students identified that education through lectures and case scenarios, contact-based interventions, and role-playing as strategies to combat mental illness stigma demonstrated significant improvement in attitude towards mental illness and help-seeking. Mental health knowledge also helped to reduce both public stigma and self-stigma and improved literacy and attitude towards mental health illnesses ,34,80. AIn the domain of collective strategies, the media were pointed to as a way to uncover stigma through programs, journals, and reports. The available evidence indicates that persuasive and purposeful education aimed at the public to correct misconceptions associated with mental illness, with attention to language, can help reduce stigma in mental health .Other strategies are identified in the literature but not in this study, like protest and advocacy, policy, and legislation changes . PossiblA strength of this study is that it takes the in-person perspective and explores reflection-beyond-action. The interaction between participants, which is a feature of FG, stimulates thoughts and allows respondents to add their experiences and sentiments that would not be expressed in individual interviews, and this appears to have been accomplished. The option of conducting online FG proved to be an appropriate option with a high level of engagement, perhaps because participants felt comfortable and safe at home during their participation. Furthermore, young people become a “digital native” generation, developing digital competencies by attending online classes and virtual social networking from home .By giving nursing students a voice and anticipating self-analysis and self-reflection in the face of stigma in mental illness, this study contributes to making them aware of their internalized stigma, which becomes central to intervening responsibly and therapeutically.This study also has some limitations, including the sample size and the fact that the sample population only included fourth-year nursing students from only one institution. It should be replicated with participants from other academic backgrounds and different levels of expertise and competence. Moreover, some constraints of performing online FG were mentioned, such as difficulty observing body language, missed non-verbal cues, and the distractor environment in some cases.This study promotes the training of nurses in general, particularly mental health and psychiatric nurses, as well as teachers, for the recognition and effective and efficient action involving individuals/families with mental illness and who suffer from stigma and discrimination, easing the difficulties surrounding these feelings. Another implication related to education is the need to reorient nursing curricula through critical reasoning skills and competency-based education .On the other hand, the implementation of research activities, in the context of stigma, involving students, can be a way of learning through experience, in a collaborative process and joint development of investigative and reflective skills that can contribute to the change of school culture and, ultimately, for social change.Based on our findings, mental health stigma can make the person the target of prejudice, isolate themselves, be reluctant to seek help, and consequently, possibly not adhere to treatment. In this sense, the perception of nursing students about stigma and its manifestations is necessary to reflect on the strategies to be adopted to reduce stigma. Stigma is a multifactorial, multidimensional, and complex concept, in terms of identifying and fighting it. The strategies identified refer to multiple approaches at the individual level, aimed at the patient and family, namely through education/training and communication and relationship strategies—and at the collective level, in order to intervene with the general population and specific groups, as is the case of young groups with strategies such as education/training, use of the media as a way to fight stigma, and contact with people with mental disorders. These interventions had already been identified with evidence in other studies, except for communication and relationship strategies, so we suggest that interventions for the development of communication and relationship skills should be part of anti-stigma intervention programs, as well as further studies in this area.