Non-professional care provided in domestic settings by a family member or someone from the close environment and without a connection to a professional care service, is increasingly assumed by older people, mainly the spouses of those requiring care. The aim of this study was to describe the experience of older people providing care at home to older dependents.A qualitative study was carried out to describe and explore the experience of older people, caregivers of dependent older people in the home.Four themes emerged as a result of the analysis: interpersonal relationships established in the caregivers’ immediate environment; the need and request for public and private resources; consequences of providing care during old age; and adaptation to the circumstance of being a caregiver during old age. Older people who provide home-based care, experience their situation as stressful, feel that it limits their daily life, deprives them of their freedom, and affects their interpersonal relationships and social activities.Older caregivers learn quickly and can manage the skills issues. The volume of work is their challenge. Interpersonal relationships are altered depending on the length of time spent together and the demand for care. Public services and benefits are not adapted to the demands of caregivers or dependent persons. The unprecedented worldwide phenomenon of population aging has been increasing over the past few decades. This is the inevitable result of the decrease in birth rates and a progressive increase in life expectancy . Global Care for dependent older people is organised through hospital care and primary care, globally and specifically in Spain. In spite of this, 60% of care in the European Union is provided by informal caregivers . TraditiCaring in old age increases the risk of illness and worsens health self-perception, taking into account factors such as sex, old age, low income or duration of care, negatively influencing the health of older caregivers –16. PrevThere is no consensus in the available literature about the benefits or disadvantages of being a senior citizen and providing nonprofessional care to an older dependent relative. While some studies show that elderly care can reduce levels of distress in the older family caregiver, by finding positive meaning in care ,21, otheOften, older people assume the role of caregiver with a feeling of loneliness, in which the older caregiver can suffer their own limitations related to mobility or a variety of diseases associated with their aging process ,26. In SWith a view to furthering the limited research performed to date on the experience of being an older people caring of an older dependent person in the home, and to address the wide range of concerns regarding how best to care for such people, the present qualitative study was undertaken in order to explore the experiences of the informal caregivers. Therefore, the aim of this paper was to describe the experience of older people caring for dependent older people in their homes.This was a qualitative study, performed from the descriptive phenomenological perspective of Giorgi et al. ,31 by caOlder people were purposefully sampled. The inclusion criteria were: age of 70 years or more; living in the same home as the person receiving care; not receiving additional help besides the one provided by the state for the care of the dependent person; and the communicative capacity to be interviewed. In addition, the person receiving care had to meet the following criteria: age of 70 years or more; presenting some degree of dependency; and unable to go to their primary care centre autonomously.The researchers contacted primary care nurses in the city of Valencia (Spain), who are the ones who usually monitor dependent persons at home. They were informed of the objective of the study and inclusion criteria for potential participants of the sample. Once the potential candidates were selected, the principal investigator contacted them by telephone, explaining the objective of the study and the conditions of their participation in it. The principal investigator did not know or have prior contact with the participants. Once the principal investigator, who has extensive experience in the use of qualitative methodologies and a high level of knowledge of the study topic, obtained their acceptance to participate in the study, a date and time for the interviews with the participants were set. Neither the nursing professionals nor the participants in the study received any type of economic compensation for their collaboration. To carry out the interview, an appointment at the home of the individuals who agreed to participate was scheduled according to their preferences and availability. Interviews were conducted alone between the principal investigator and the participant. All potential contacted candidates agreed to participate in the study. Data saturation was reached with interview number 13, thus a total of 13 interviews were conducted. Before beginning the interview the interviewees signed their informed consent to participation. Their subsequent narratives were audio-recorded and the principal investigator was also taking notes. Each interview lasted approximately 60 minutes. Thus, these in-depth interviews used an open, global starting point without anticipating specific topics: for example, “Tell me about your day-to-day experience of caregiving”.In addition to the phenomenological interviews, we collected descriptive data to better understand the characteristics of the older caregivers we interviewed. These were: the degree of independence in the basic activities of daily living (BADL) measured using the Barthel Index , the objThe interviews were transcribed verbatim and the texts were analysed following the process described by Giorgi et al. ,35 whichThe interview transcripts were forwarded to the participants so they could read them and verify their accuracy. In the case of those who could not read them, the principal investigator read them aloud to them at home. There were no corrections from the participants, as they felt that their experiences related to the study topic had been completely captured. Then, units of meaning within the transcripts were discriminated, leading to the emergence of ‘the objective’ and ‘the given’. Eidetic reduction was subsequently used to identify the invariable aspects of the experience elements whose elimination or alteration would have substantially changed the experience. When such facets were identified, we used phenomenological reduction to obtain the ‘statements of meaning’. These specific phenomenon-related topics were significant to the participants narrating them because they constituted their personal experience; thus, these particular phases transform significant units (everyday language) into scientific language. When there was a relationship between these specific issues, common themes emerge, and these were the invariable essence of the phenomenon of caring for an older dependent at home during old age. The researchers did not use any software to perform the data analysis.The collaboration of the participants was voluntary and altruistic. Written informed consent was obtained from all the participants, according to the principles set out in the Declaration of Helsinki and the Belmont Report . The proSample comprised 13 older caregivers over 70 years of age, 8 women and 5 men, with a mean age of 81.7 years; 9 (69.2%) were completely independent in terms of the BADL and 4 (30.8%) were partially dependent. Regarding the objective load generated by care provision, 8 (61.5%) presented a high level of overexertion and 5 (38.4%) did not present any extra exertion. Likewise, 8 (61.5%) presented an intense subjective overload; 2 (15.3%) were subjectively overloaded, and 3 (23%) did not present any subjective overload .Four common themes emerged from the interview analysis: 1) interpersonal relationships established in the caregivers’ immediate environment; 2) the need and request for public and private resources; 3) consequences of providing care during old age; and 4) adaptation to the circumstance of being a caregiver during old age .During interviews participants talked about the interpersonal relationships they experienced from three different perspectives: their relationships with 1) health professionals, mainly primary care; 2) relatives and close friends; and 3) the person they were caring for.According to their narratives, their relationship with the primary care team in general, and especially with doctors, became increasingly less direct and close. In addition, they described their perception of paternalistic attitudes from these professionals. Home visits, usually by nurses, were perceived as routine, short, and infrequent.The family doctor has only come twice, because I asked them to. Twice in four years. They treat her from there, by phone (…) E5.(…) The nurse came and as always, took our blood pressure. She gave us the vaccine and left so fast that I didn’t remember to tell her about the sores, and I didn’t tell her anything, or that he has another one on this side [points to {his} left side] (…) E10.The relationships that older caregivers have with their family members depend on their relatives’ stage of life. The participants stated that both their children and grandchildren were progressively distancing themselves, so that they had less and less time to participate in and share the tasks of caregiving. In fact, in this sense, some of the participants expressed a certain feeling of not being reciprocated for the care they had given their relatives in the past.(…) {my} children have so many activities with work, they don’t have enough time. {The} grandchildren neither, because they’re doing, I don’t know what, if not English, then gymnastics, or I don’t know what. We don’t see them. After having raised them all. E3The type of relationship between the caregiver and the person they cared for prior to the care situation also emerged in the narratives as an important element in their current relationship. When the past relationship and experience of cohabitation were valued positively by the caregiver, and the relationship remembered as one of respect, trust, and love, the task of providing care was more easily assumed. However, where the previous relationship was perceived and remembered as having been asymmetric, where the older dependent person had dominated and communication was impaired, assuming the care tasks was more difficult.You can’t talk to him [crying], you can’t… so all day I don’t say anything to him, I don’t speak to him, only well, badly [crying], there is no relationship (…). It’s that he’s got a very fast temper… he has a fit of anger and everything you say to him, everything is NO. He rejects everything. So many years and always fighting, {it was} always like that, always like that, and me putting up with it. (…) Oh! what mistakes we make in life. E1Most of the narratives described the people dependent on the participants’ care, especially the main factors limiting their mobility and the cognitive impairment preventing their verbal communication or other interactions with the environment. These pathologies had been evolving for many years and created a high care demand.(…) She’s been {like this for} six or seven years, she can’t walk anymore, nothing, not at all, or stand up, nothing, always in the wheelchair, (…) her head goes, she’s gone deaf, and her sight is failing, she has a tube for eating and to pee. I’m so fed up with all the years we’ve been like this. E4(…) since the first operation, it’s been about 14 or 15 years (…) now she doesn’t hear, you have to shout at her, and even then, she doesn’t understand much. They say she has Alzheimer’s (…) we’re doing tests, {it’s} a disaster (…). E7The descriptions of relationships with neighbours are often very positive. These are sometimes described as very close relationships of friendship and trust in which the neighbour even becomes a source of support and a resource for helping with the daily care tasks.(…) the neighbour in front comes over, and since she’s going to buy something, I tell her, “Well, bring this for me from the pharmacy, or something else”, or “come with me to go shopping and keep me company”, because for me, going alone, I’m very bad {fragile}, I can’t (…) I can’t lift as I could before, I can’t move anything by myself and she helps me. E10Participants usually described economic problems related to an imbalance between their income and their needs. Some of the interviewees stated that they did not receive their own pension (and so they depended on the pension of the person they cared for) because of situations experienced during their working life, which affected their retirement entitlements.My husband didn’t want me to make {social security} contributions while we worked together in the shop. All his life he said: “you, why should you have to pay anything” (…), {but} now I would {have} receive{d} a pension and so look, my work was for nothing… E6Some also mentioned a perception of incoherence between the assessment of public administrations about the status of the person they care for and the benefits they receive. The interviewees considered the latter scarce and poorly adjusted to the real need for support.First, they send me to one, and then {they} send {me} to another [dependence-law evaluator] and, of course, when they saw him [her husband], they gave him the highest grade. Of course, a person who does nothing, totally dependent, and now it’s going to be three years (…) The social worker offered me a professional carer for an hour. Right, tell me, a woman for one hour, sincerely, will not solve anything, and on top of that I {would have} had to pay {her} €10. And I said, “I don’t need these favours”. And so… does this seem fair to you? I don’t expect anything anymore, I don’t expect any help because, they haven’t even bothered with us since then”. E8One of the interviewees commented that when the social security benefit they received became consistent with their needs, their own health and that of the person they cared for both improved.They decided that our health was quite poor, and they granted us {the help where} they bring food at home. At least at lunchtime, we eat, and we both now have better health. E2Older caregivers stated that they performed all the domestic tasks, as well as those related to the care, and contracted domestic help services based on their economic means. Some of them said that they had hired young people to help with the task of transferring the person receiving care and other tasks related to their workload, because they themselves could no longer cope with these tasks.A girl comes once a week or every 15 days, depending on the money {situation} (…) as he cannot move, I {have to} handle everything. E3(…) I pay a boy who comes two hours every day and puts my husband to bed, because I can’t, with this [pointing to her husband] I can’t. E13For their part, older male caregivers mentioned that they usually delegate basic care to female relatives or to domestic help services, which they usually hire from Monday to Friday, meaning that at the weekend they do not have this resource.I pay a helper. She is here all morning for everything that has to be done at home and to take care of my wife. She gets her up, feeds her, controls her tube, her treatments, everything (…). E4Participants said that long-term care at home caused them stress, greater physical and emotional exhaustion, abandonment of their personal projects, and resulted in family conflicts and wealth loss, sometimes leading the older caregiver to abandon some of their care tasks.Sometimes I have tantrums when I feel low, which happens to me a lot. I’ve been bad for two or three days now, I don’t get excited about anything, I’m joyless (…) Look at my hair [pointing out its lack of colour]. I can’t go to the hairdresser. My head hurts all the time… I don’t feel like doing anything, I’ve lost my appetite. Terrible, a disaster, I’m a disaster. E8(…) the family relationship is very tense, the older one [daughter] is single, she would also like to live her life differently, many days she’s aggressive. I, because she pressures me, well, I get angry, and when I get angry, we argue… and that’s it (…) this is the atmosphere of a house where there’s a sick person like this (…) it changes everything, from top to bottom. E5(…) I bought one of those hospital beds (…) E10Participants said they had had to make alterations to the organisation of spaces in their homes, depending on the needs of the dependent person and the care tasks the caregiver had to carry out.Before, the house was more organized, but now, if I put my bag away, then I can’t find the money or the keys. If I put these away [pointing to some packs of {adult} diapers], my daughters can’t see them and they start {asking} “Mum, where’s this or that?” In the end, I put everything here [in the dining room dresser], and there aren’t any problems, everything is at hand. E3Narratives show that the decision to provide home care is based on a commitment to the older dependent, in the sense that the person receiving care had expressed their desire not to start living in a long-term residency center. The female older caregivers assume the role of care giving naturally. To them, they are the ones who have to take care of their spouses because “that’s the way it’s always been”. In addition, they also consider the distance to the residential center, negative experiences, and their distrust of the professionals working in these centers, stating that at home they can better control their own time and pace of life.(…) that’ll be when I can’t attend to him anymore, while I {still} can, that won’t happen [crying]. She makes me talk and everything, but I take care of him. E12They told us to bring her home or take him to the long-stay hospital. It was like abandoning him, so far away. I thought: “no, there they’ll let him deteriorate, no, no, I’ll take her, I prefer having him at home. If something has to happen, let it happen in front of me” (…) those [professionals] get used to it, if the relatives aren’t there it seems like nothing gets done… E5The narratives of participants also showed that they learn about how to carry out the care tasks through trial and error, observation, experience, and by following nurses’ verbal or written instructions. In any case, the caregivers included in this study stated that the care tasks became increasingly complex as they themselves got older or as their own health had declined; they felt that they were not prepared for this work and showed signs of insecurity and doubts about what they had done in certain situations.(…) I give her insulin and something else that you put {inject} in{to} the belly. I don’t know if you know, I don’t know if I gave her too much, but that’s when she started to get really unwell. In short, a disaster. (…) E9I treat him every day. I learned by watching. At first the nurses told me how to do it, “look, first wash him with this water”, I have a little bottle {of it} there, by the way, I don’t have any left. “I wash him and then put this ointment on him”. Whatever it is, I put it on. E13According to the narrations, experience, patience, knowing each other and being able to anticipate certain situations, love for the other, humour, religious beliefs, and/or emotional suppression are some of the strategies used to face these adversities. Going out to go shopping every day, to the doctor, or to the pharmacy are the moments these caregivers identified as distractions, which allowed them to maintain social relationships.(…) the experience comes from afar; I watched a lot of things. The family doctor tells me that I could be a nurse. E9I have a lot of patience, a lot of patience. I think I’ve adapted, after living through so much and so many years (…). E8The narratives showed that older caregivers were mostly satisfied with the care they provided. However, some older female caregivers said that they had always performed this role, without it being recognized or valued.At first, {there was} a problem, what do I buy? What do I do? Now, I’m fending for myself. I’m learning. This {thing} is useful to me, this {one} isn’t useful to me. This {experience} is like that. I’m learning. For me it’s an achievement. (…). E5I took care of my mother, (…) when my mother died, I spent three years looking after my father, who was blind. Then {looking after} my own family, and now this (…) always the same, {it’s} a pity. E1This study reveals the stories of older caregiver who care for dependent older people. This care is complex and requires excellent skills and abilities to meet the needs of sick family members and manage their own lives. The results of this study reveal the conditions and challenges faced by these caregivers, both personally, the mobilisation of resources and the impact on their quality of life.Participants felt that their relationship with health professionals was insufficient and too routine. In this line, some studies have also indicated the inadequacy of the professional care received by caregivers in terms of the number of visits, the time spent during each visit, and the criteria used to decide if a primary care worker home visit is necessary . Even thOur findings suggest that older care providers consider caregiving as an act of reciprocity; they internalise the role of primary caregiver and avoid seeking help, which generates feelings of ambivalence in them: they feel that they are stuck between their caregiving obligations, exhaustion, and conflicts of interests with their descendants ,40. TheyAging in place has implications for older people in terms of their sense of connection, identity, security, and familiarity , and so Some of the older male caregivers in our study do not provide all the attention on their own, but instead "delegate" certain basic care and household chores to private domestic assistance services and / or female relatives. Traditionally, it is women who have taken care of dependent family members –47, showLike other studies, our results show that providing care during old age generates stress, loss of wealth, increases physical and emotional wear and tear, and can lead to social isolation. In addition, older caregivers harbour feelings of dissatisfaction and/or unhappiness, more often suffer situations of family conflict, and perceive a loss of opportunities because they have had to dedicate themselves to care in a stage of their life they had believed would have been devoted to rest and calmness ,29.Factors such as excessive demands by the person receiving care, as well as factors related to the older caregiver such as being a woman, a spouse, objective and/or subjective overload, not understanding the demands or evolution of the care receiver’s disease, and emotional and social isolation, increase the risk that older caregivers could behave abusively, and may even lead to the abandonment of care tasks . TherefoThe analysed data in this study reflect on the lived experiences of a specific group of older people who care for dependent older people in their home. Understanding this from an experiential learning perspective, far from global generalizations, provides researchers and professional workforce with useful information to make concrete decisions about the issues identified as weaknesses of the Health Systems and older caregivers perceived needs.The findings of the present study contribute to an increase in knowledge and comprehension of older people who care for dependent older people in their home. Care has a temporal dimension, in which the caregiver must adjust and acquire skills, as their family member’s condition progresses. The decontextualization, on the part of the healthcare system, of the family caregiver makes them feel invisible to that very same system. The lack of information and support for caregivers would appear to go unnoticed by healthcare providers. Consequently, it would be recommendable that healthcare professionals could incorporate caregivers’ experience, along with the dependent people caring process by implementing inclusive politics.S1 File(DOCX)Click here for additional data file.


Toxoplasma parasites. In fact, microbial cell cycles are so diverse as to raise the question: ‘Does a ‘conventional’ cell cycle actually exist?’ Non-binary-fission cycles are common among protozoan parasites, including most of the Apicomplexa, a phylum including medically important parasites such as Plasmodium, Babesia, Toxoplasma and Cryptosporidium (The cell cycle is a fundamental process in biology: all living organisms must be able to generate new cells. The ways in which they do this are surprisingly variable. Cell cycle machinery has been studied in exquisite detail over several decades in model organisms such as bacteria, unicellular yeasts and mammalian cells, giving rise to the concept of ‘The cell cycle’ – a binary division process that is stereotypic and highly conserved. However, as horizons have expanded beyond these model organisms, it has become clear that binary division is not the only mode of replication. In particular, early-diverging eukaryotic microbes often divide by ‘unconventional’ means, such as schizogony in malaria parasites and endodyogeny in poridium , and theporidium .This Research Topic explores the breadth of eukaryotic cell cycles at the cellular and molecular levels through Reviews, Perspectives and Primary Research articles. These articles report upon the diverse cell cycles of eukaryotic protozoan parasites: their molecular mechanisms and the concepts that unify or divide these organisms.Gubbels et al. discuss the concept of plasticity – how the same organism can vary its mode of cell division and the number of progeny it produces at different points in its parasitic life cycle. This is a common theme in Apicomplexa, which may, for example, switch between endodyogeny and schizogony by altering the circuitry that couples or uncouples genome replication, karyokinesis and cytokinesis. In binary fission, these processes are hardwired to occur in succession, whereas a fundamental concept of more flexible, ‘unconventional’ cell cycles is that they can be uncoupled. Morano and Dvorin, meanwhile, focus on one part of the molecular machinery that is crucial for generating daughter cells, the basal complex. How does this contractile ring, which separates new cells, differ in Apicomplexa compared to model organisms such as S. cerevisiae, and what can this tell us about how these divergent organisms achieve cell division?Two review articles explore the modes of cell division in Apicomplexan parasites. Plasmodium. Simon et al. ask ‘How many is enough?’ – how do parasites measure and control the number of progeny generated by syncytial division, and how might this have evolved to maximise parasite fitness in variable host environments? A complementary article from Machado et al. discusses the issue of how a parasite undergoing schizogony copes with cellular genome contents from 1n to >20n, asking if there are unique implications for managing transcription in these unusual syncytial cells.Continuing the focus on Apicomplexa, two perspective articles discuss some of the most conceptually challenging aspects of schizogony in Trypanosoma cruzi and Trypanosoma brucei. In these, division is ‘conventionally’ binary, but the executive machinery is very divergent. In particular, it seems that the whole eukaryotic kingdom has evolved only one way to divide a replicated genome: a cell must assemble a mitotic spindle and pull the sister chromatids apart using microtubules. But how is that mitotic spindle built? There is certainly more than one way to generate a centriole or a kinetochore, just as Morano and Dvorin suggest that there may be more than one way to build a contractile ring. Brusini et al. report a proteomic study of the T. brucei kinetochore, which contains almost none of the proteins used in yeast or human kinetochores. Alonso et al. examine the tubulin component of microtubules in T. cruzi, elucidating the role of acetylation in regulating these microtubules.Finally, two primary research articles examine some very different parasites, the kinetoplastids in vitro culture systems. Parasites such as Cryptosporidium, Theileria and Sarcocystis are less accessible to research and therefore remain relatively understudied, as does an enormous variety of uncultured fungal species (Overall, this collection of articles ranges from the conceptual to the highly molecular – accurately reflecting the state of the art in research on diverse eukaryotic cell cycles. Beyond the basic biological interest of this topic, it is also highly important to global One Health because many eukaryotic microbes are major parasites of humans and animals, causing diseases such as malaria, toxoplasmosis, avian coccidiosis and African sleeping sickness. Targeting the unusual cell cycles of such parasites is a potential avenue for chemotherapy that would be parasite-specific, leaving the cell biology of mammalian or avian hosts unaffected. Accordingly, research interest is rising rapidly, particularly in the cell cycles of Apicomplexa, and this has coincided with major advances in the availability of research tools and molecular-genetic technologies . Neverth species . A lot oCM wrote the manuscript. All authors contributed to the article and approved the submitted version.CM: ERC research grant ‘Plasmocycle’. ZL: NIH R01 grant AI101437. MB: Swiss National Science Foundation 31003A_179321.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Unstructured text, including medical records, patient feedback, and social media comments, can be a rich source of data for clinical research. Natural language processing (NLP) describes a set of techniques used to convert passages of written text into interpretable datasets that can be analysed by statistical and machine learning (ML) models. The purpose of this paper is to provide a practical introduction to contemporary techniques for the analysis of text-data, using freely-available software.We performed three NLP experiments using publicly-available data obtained from medicine review websites. First, we conducted lexicon-based sentiment analysis on open-text patient reviews of four drugs: Levothyroxine, Viagra, Oseltamivir and Apixaban. Next, we used unsupervised ML  to identify similar drugs in the dataset, based solely on their reviews. Finally, we developed three supervised ML algorithms to predict whether a drug review was associated with a positive or negative rating. These algorithms were: a regularised logistic regression, a support vector machine (SVM), and an artificial neural network (ANN). We compared the performance of these algorithms in terms of classification accuracy, area under the receiver operating characteristic curve (AUC), sensitivity and specificity.Levothyroxine and Viagra were reviewed with a higher proportion of positive sentiments than Oseltamivir and Apixaban. One of the three LDA clusters clearly represented drugs used to treat mental health problems. A common theme suggested by this cluster was drugs taking weeks or months to work. Another cluster clearly represented drugs used as contraceptives. Supervised machine learning algorithms predicted positive or negative drug ratings with classification accuracies ranging from 0.664, 95% CI  for the regularised regression to 0.720, 95% CI  for the SVM.In this paper, we present a conceptual overview of common techniques used to analyse large volumes of text, and provide reproducible code that can be readily applied to other research studies using open-source software.The online version contains supplementary material available at 10.1186/s12874-021-01347-1. The last decade has seen an exponential increase in the volume of routinely collected data in healthcare . As a reClinicians are uniquely positioned to identify opportunities for ML to benefit patients, and healthcare systems will benefit from clinical academics who understand the potential, and the limitations, of contemporary data science . DespiteWritten text, for example medical records, patient feedback, assessments of doctors’ performance and social media comments, can be a rich source of data to aid clinical decision making and quality improvement. Where text-based data exist on the internet , it is technically possible to capture these using a process called web-scraping, which is straightforward to perform using open-source software . Web-scrOften, these open-text datasets are so vast that it would be impractical to manually synthesise all of the useful information with qualitative research techniques. Natural language processing (NLP) describes a set of techniques used to convert passages of written text into interpretable datasets that can be analysed by statistical and machine learning models , 14.Sentiment analysis is the process of assigning subjective meaning to words, phrases or other units of text . Sentimetemporality and experiencer of common medical conditions . The sentiment of sarcastic remarks is often more dependent on context than the words themselves, and while attempts have been made to create sophisticated “sarcasm detectors”, this still poses a challenge to sentiment analysis [Sentiment analysis can be complicated by negation and sarcasm. For example, the word “not” reverses the sentiment of the word “recommend” in the sentence “I would not recommend this hospital to a friend or family member”. One potential way to handle this is by first splitting (tokenising) the sentence into bi-grams (pairs of adjacent words), rather than individual words . This caanalysis .Supervised and unsupervised ML algorithms can also be trained to assign sentiment to passages of text either independently, or with a lexicon as a hybrid approach. These approaches can account for complex interactions between words in a sentence more intricately than purely lexicon-based approaches. This paper demonstrates the simplest and least computationally intensive form sentiment analysis (the use of a publicly available lexicon only), but more advanced techniques have been described in detail elsewhere , 27.Unsupervised ML algorithms aim to find previously undefined patterns within datasets, for example by grouping similar observations into clusters. They use data that have not been “labelled” by a human supervisor  .When applied to text analysis, unsupervised machine learning can be used to identify common themes within text by clustering words or sentiments that frequently appear together. This process is called “topic modelling” and is similar to an inductive thematic analysis , 28. ThiSupervised machine learning algorithms aim to make predictions about an outcome (dependent variable) based on a set of features (independent variables). They use labelled datasets to learn how features and outcomes are related in order to predict outcomes from new, unlabelled, datasets . They doBroadly, supervised machine learning algorithms fall into two categories: regression algorithms and classification algorithms. Regression algorithms aim to predict a continuous outcome  while classification algorithms (or classifiers) aim to predict categorical outcomes . It is worth noting that in ML, the term “regression” is used slightly differently to traditional statistics, where regression can also be used to predict categorical outcomes. For example, a logistic regression model that aims to predict a binary outcome would be described as a classification algorithm rather than a regression algorithm, within ML literature .Supervised ML algorithms have been combined with NLP to extract patient-centred outcomes from unstructured medical records , to deteThis paper contains practical examples of common text analysis techniques, which we perform on a freely available dataset that contains over 200,000 patient drug reviews . The dataset is similar to what might be obtained by scraping online patient forums or healthcare provider review websites.We provide code that can be modified and applied to similar analyses in other datasets. We aim to demonstrate to clinicians and qualitative researchers the type of text analyses that are easily performed with open source software, and provide practical understanding to academics that wish to apply these techniques in their own research.Basic NLP techniques for data cleaning in open-text datasetsPositive and negative sentiment analysis of drug reviews, with a freely-available lexiconUnsupervised machine learning to identify similarities and differences between drugs, based on the words used to describe themSupervised machine learning (classification) to predict whether a free text drug review will be associated with a dichotomised “Good” or “Bad” numerical scoreThe methods section of this paper is structured into four parts, which in turn cover:We present samples of code written using the R Statistical Programming Language within the paper to illustrate the methods described, and provide the full script as a While this paper is intended for readers who are relatively new to the field, some basic familiarity with the R programming language and machine learning concepts will make this manuscript easier to follow. Before attempting to recreate these experiments, readers may wish to read our introductory paper to machine learning in general, which covers R programming, supervised machine learning and model interpretation in more detail than is described in this paper .In recent years, the R and Python programming languages have become extremely popular for machine learning tasks . They arWe have performed these analyses using R version 4.0.3 in the RStudio computing environment. The experiments have been designed to run relatively quickly on a personal device. We used a 2017 MacBook Air, running macOS Mojave Version 10.14.6 on a 1.8 GHz processor with 8 GB of random-access memory.In these experiments, we used the Drug Review Dataset from the University of California, Irvine Machine Learning Repository . The datIn English text, many different combinations of characters can be used to mean the same thing. For example, “won’t”, “will not”, “Will not”, and “will not!” all use a different set of characters to convey very similar meanings. The main goal of data cleaning in NLP is to standardise text so that these variations are interpreted as the same feature by the machine learning models downstream.There are a number of NLP techniques for standardising the free text comments . We expaWe also performed stemming with an English language stemmer. Stemming is the use of algorithms to reduce similar words to a common stem, for example by removing suffixes . In our Next, we removed English “stop words”  , and worNext, we assigned a sentiment to each word in the dataset using a freely available lexicon known as “Bing”, first described for use in consumer marketing research by Minqing Hu and Bing Liu in 2004. The Bing lexicon ascribes either a “positive” or “negative” sentiment to 6786 different English words .We chose to evaluate the overall sentiment of reviews for four different drugs, which we chose based on their diverse indications and pharmacological properties: Levothyroxine, Viagra, Oseltamivir and Apixaban. Levothyroxine and Viagra are used to treat hypothyroidism and erectile dysfunction respectively. Oseltamivir is used to treat and prevent influenza infections, and Apixaban is used to treat and prevent blood clots. Many people who take Levothyroxine and Viagra experience relief of troublesome symptoms, while people taking Oseltamivir or Apixaban prophylactically may not experience any appreciable benefit other than a lower risk of developing influenza or blood clots. We tested the hypothesis that Levothyroxine and Viagra are reviewed more positively than Oseltamivir and Apixaban.To do this we tabulated the positive and negative sentiments assigned to all reviews of each drug, and calculated the percentage of sentiments that were positive.Text data can be structured into a semantic hierarchy. A “token” is a series of characters that form the smallest semantic unit. In the experiments described in this paper, each word stem is its own token. If we had tokenised the drug reviews into bi-grams , then each token would be two adjacent words. A “term” is a class of token with the same characters . A “docuBefore we can apply statistical or machine learning models to our text, we must first convert it into numeric data in a meaningful format. This can be achieved by creating a data table known as a document term matrix (DTM), sometime also referred to as a term document matrix (TDM) . In the For our illustration of unsupervised machine learning, we chose to explore patterns between drugs based on the words used to describe them. To do this, we constructed a DTM where all the reviews of a given drug were combined into one document, representing the description of that drug by multiple reviewers. We then removed terms that were absent from ≥ 99.5% of documents Fig. . The resThe values in our DTM represent term frequency, but it is also possible to weight these values by scaling them to account for the importance of a term within a document. A common way to do this, that readers should be familiar with, is the term frequency – inverse document frequency (TF-IDF) index. The term frequency is the number of times a term appears in a document. The inverse document frequency is the natural logarithm of the total number of documents, divided by the number of documents with a given term in it. The inverse document frequency gives an impression of the “importance” of a term within a corpus, by penalising common terms that are used in lots of documents. The TF-IDF is the product of the term frequency and the inverse document frequency, and provides insight into document-level semantics by measuring the frequency of a term within a document, and weighing this against the “importance” of the term within the corpus .To cluster similar documents (drugs) together, we used an unsupervised machine learning technique called latent Dirichlet allocation (LDA). The LDA algorithm clusters terms into a predefined number of “topics” based on the probability of those terms being used together within a document. It then predicts which topic a document will belong to, based on the terms in that document.Unlike other forms of clustering, such as k-means, it is possible for a term to belong to more than one topic in an LDA analysis . This geWe programmed the LDA to cluster terms into 3 topics  most likely to belong to each topic. We hypothesised that similar drugs would be described in similar ways, and therefore cluster together.Next, we rearranged the dataset into a DTM where each review was an individual document. Sparse terms were removed, resulting in 808 remaining features (terms), which were weighted by TF-IDF. We randomly selected a sampled 1000 reviews to further reduce computational burden. Clearly, researchers aiming to generate robust models should use as much data as possible, although this can add to the computing time and hardware requirements.For each review, we took the associated star rating and dichotomised it into a binary outcome. A star rating of 1–5 was categorised as a “Bad” review and a star rating of 6–10 was categorised as a “Good” review. We then aimed to train 3 different supervised machine learning algorithms to predict whether a review was “Good” or “Bad”, depending on the words that were used in the review.We split the data into training and test sets to create and evaluate our models respectively. We randomly assigned 75% of the reviews to the training set and 25% to the test set Fig. .Fig. 4SpThis split resulted in a training dataset with 524 “Good” reviews and 226 “Bad” reviews. Training data with unbalanced classes can cause classifiers to predict the more frequently occurring class by default, particularly when sample sizes are small and features are numerous . This caTo address the issue of class imbalance, we used the synthetic minority oversampling technique (SMOTE) . The SMOThe SMOTE algorithm transformed our training data into a dataset with 678 “Good” reviews and 678 “Bad” reviews. We then used this dataset to train 3 different types of supervised machine learning algorithm: a regularised logistic regression, a support vector machine (SVM), and an artificial neural network (ANN). These three types of classifier represent a spectrum of ML algorithms, ranging from relatively simple, easily interpretable and with a low number of parameters (regularised regression), to complex and difficult-to-interpret algorithms with a large number of parameters (ANN).Regularised regression is similar to traditional regression, but applies an additional penalty term to each regression coefficient to minimise the impact of any individual feature on the overall model. Depending on the type of regularisation, and size of the penalty term, some coefficients can be shrunk to 0, effectively removing them from the model altogether. The purpose of regularisation is to prevent overfitting in datasets with many features .Support vector machines aim to model a linear decision boundary (or “hyperplane”) that separates outcome classes in high-dimensional feature space. Model parameters can vary the way in which data are transformed into high-dimensional space, and how the decision boundary is drawn .Artificial neural networks are so-called because they share a conceptual topography with the human central nervous system. They consist of interconnected neurons arranged in layers. Each neuron sums its inputs, multiplies this by a weight, and transforms the signal through an activation function. The weight of each neuron and their collective arrangement will affect model performance .We would recommend that readers consult our previous instructional paper for a more thorough description of regularised regression, SVMs and ANNs . For theIn this study, model parameters were iteratively adjusted and tested across 10 bootstrap samples of the training dataset. When recreating this experiment, the number of bootstrap samples can be increased to improve model performance (reduce overfitting), but this will add to the computational demand. The parameters that maximised classification accuracy were chosen for the final models, which were then evaluated in the test dataset. Model performance was assessed with classification accuracy, area under the receiver operating characteristic curve (AUC) and confusion matrices.The results of our sentiment analysis are displayed in Table The ten terms most likely to appear in each topic are presented in Table The ten documents (drugs) most likely to belong to each topic are presented in Table The regularised regression and ANN took approximately 10 min each to train. The SVM took approximately 40 min to train. Model performance statistics are presented in Table In this paper, we have demonstrated techniques used to perform a range of common NLP tasks, and have provided annotated code which can be built upon and applied to other datasets . We wereThe primary purpose of this study was to provide a practical illustration of basic NLP techniques, and as such, there are notable limitations in the methods described. Firstly, in order to reduce the computational requirements of these tasks we sampled relatively small amounts of data from the Drug Review Dataset. In both statistics and ML, models with large numbers of independent variables (or features) require large sample sizes. Using small datasets, as we have done, increases the chance of model overfitting . It woulWe used relatively unsophisticated techniques for data cleaning. For example, we used stemming to remove inflexional suffixes. A limitation of this is illustrated in Table Our supervised algorithms were relatively simple, and authors should consider incorporating other features into their training datasets. For example, we could have added columns to describe the sentiment of a review (based on the Bing lexicon), its lexical diversity, or its length in words or characters. When doing this, it is important to normalise the values of these features before algorithm training.In this study, we used a decision threshold of 0.5 for our classifiers. In other words, the algorithms would classify a review as “Good” if they predicted the probability of it being “Good” as greater than 0.5. This threshold can be adapted for situations where either model sensitivity or specificity is particularly important.There are many applications of web scraping, NLP and ML within healthcare and qualitative research. These techniques can be used to understand the health concerns of a population from social media, to process large volumes of medical records, or to qualify and quantify patient outcomes and experience from their own words. A basic understanding of these techniques will enable clinicians and qualitative researchers to work with data scientists, to identify areas of healthcare that could benefit from this technology.We have presented a practical introduction to common NLP techniques including data cleaning, sentiment analysis, thematic analysis with unsupervised ML, and predictive modelling with supervised ML. The code we have provided in the Additional file 1.


Moral distress is a poorly defined and frequently misunderstood phenomenon, and little is known about its triggering factors during ICU end-of-life decisions for nurses in Iran. This study aimed to explore the experiences of nurses’ moral distress in the long-term care of older adults via a phenomenological study.A qualitative, phenomenological study was conducted with 9 participants using in-depth semi-structured interviews. The purpose was to gain insight into the lived experiences and perceptions of moral distress among ICU nurses in hospitals affiliated with Tehran University of Medical Sciences during their long-term care of older adults.Five major themes are identified from the interviews: advocating, defense mechanisms, burden of care, relationships, and organizational issues. In addition, several subthemes emerged including respectful end of life care, symptom management, coping, spirituality, futile care, emotional work, powerlessness, relationships between patients and families, relationships with healthcare teams, relationships with institutions, inadequate staffing, inadequate training, preparedness, education/mentoring, workload, and support.This qualitative study contributes to the limited knowledge and understanding of the challenges nurses face in the ICU. It also offers possible implications for implementing supportive interventions. Nursing, as a profession, requires regular ethical decision making, which is a vital component of the nurse-patient relationship . In otheMoral distress is one of the most challenging ethical issues in nursing . JametonCorley  drew froMoral distress has undesirable consequences on nurses’ wellbeing , potentiMany studies have investigated the moral distress of nurses in intensive care units (ICUs). Major contributors to moral distress include providing end-of-life care, decision making in organ and blood donation , patientCompassion fatigue is commonly found in staff caring for patients and their families faced with critical illness and death . Peer suHowever, little is known about moral distress in the care of older adults. Due to the physical health problems older adults may experience and their dependence on others in the different aspects of their life, a special emphasis on ethical issues in the care of all older patients is essential , 25. In becoming, professionalizing, institutionalizing, and working). In the becoming condition, nurses’ core beliefs are evident from their experiences in caring for others, their commitment to upholding professional and institutional norms, and their experiences when core values are challenged. Professionalizing condition involves adhering to professional and ethical standards while institutionalizing condition involves the work environment and culture which can be congruent or not with nurses’ core beliefs and professional norms. Lastly, the working condition notes that the type of work varies for each nurse with challenges and great rewards. These conditions are incorporated in the act of patient care. Nevertheless, a morally troubling event may challenge the integration of core beliefs with professional and institutional norms, resulting in “situational binds” that create a juncture in nurses’ lives. Binds involve serious conflicts within individuals resulting in moral ethical dilemmas. Nurses are caught in these situational binds and often experience a sense of helplessness. Unresolved situational binds result in negative personal and patient care consequences of moral distress. The subsequent stage of resolution results in a choice of either making a stand  or giving up. The final stage of reflection allows nurses to reflect on their behaviors and actions which may last a lifetime and include remembering, telling the story, examining conflicts, and living with consequences  about [end-of-life decisions].”"We aren’t prepared for that.”As one nurse expressed, “When you have some residents who are really problematic, and you’re not getting the type of response you want… Not everyone in administration… I have to be honest with you. You can have a supervisor who is very concerned and into the problem and will jump into it. But you can get some who will keep on… pushing everything back on you to do it, despite the fact that you are up to your neck.”Participants in one-on-one interviews commented that a lack of support from the administration was evident when addressing staffing issues and dealing with the residents’ care plans. Participants felt unsupported and ignored by the administration, and they often felt trapped in their situations. They claimed the administration did not value the nurses’ input, made unilateral decisions, and ignored their suggestions about improving their work conditions. This was concerning for participants who felt that the administration would not provide the resources they needed. For example, participant No. 2 believed that:“My work performance is impacted when I feel like I am being pulled in many directions.”“I feel like I have become less empathetic and careless, due to workload.”“No helper available when I was busy. I felt so much stress and so behind in care.”“I was not supported in situations that were comfortable. I feel that my coping and work performance became stressed, and I didn’t work as efficiently or effectively.”Moreover, participants No, 1, 4, 5, and 8 respectively stated:The intensive care unit is a unique working environment where nurses often deal with life threatening situations, and face frequent ethical dilemmas while providing care. In circumstances where patients are treated in the ICU for an extended period , moral distress can be a common experience among healthcare professionals. Many factors have been identified to be positively correlated with high moral distress among ICU staff such as job dissatisfaction, high patient-healthcare ratio, and perceived stress from patient demands .Moral distress among ICU staff has recently received more attention in the literature. Moral distress has been linked with quality of care, clinical decision making accuracy, work satisfaction, job retention, and patient satisfaction , 39. AccThis study has revealed some of the central concerns related to moral distress experienced by ICU nurses treating older adults over a long-term period in Iran.Advocating is relatation to moral distress as there are often discrepancies among what patients need, what the family wants, and what is allowed or disallowed by regulations. Nurses are often caught in the middle of these conflicting situations and take responsibility for decisions and face potential consequences. The consequences include the patient’s clinical outcome (made better or worse), while personal consequences include negative judgments from others, possible administrative sanctions, or conflict with other staff. On the other hand, choosing not to advocate avoids problems that may occur, but can also lead to feelings of guilt, as the patient’s needs are not met. The grey areas of right and wrong ultimately contribute to moral distress among nurses in their daily duties. As recommended by Dunger et al. [r et al. , nurses Defense mechanisms encompass the way nurses personally deal with overcoming their experience of moral distress. They reflect internal processes of self-generated mechanisms to form a protective barrier for a potential psychological threat that may arise from moral distress. As a part of their duty to maintain the quality of care, ICU nurses need to be able to handle (and often set aside) moral distress to perform their work. This is made more difficult when the working environment is not supportive. As mentioned by most participants, talking to peers and practicing spirituality are the most common ways of dealing with moral distress. Peer support and socially-supportive organizations are an important part of ICU settings, and therefore need to be nurtured by healthcare leaders. As previously discussed by Borhani et al. [i et al. , sufficicare burden” as found in the present study.It is undeniable that, in some cases, nurses’ moral distress is influenced by the patients themselves. Patients’ conditions may be irreversible or terminal which brings a sense of helplessness to nurses and may lead to the belief that the only option for them is to improve the patient's quality of life while they are alive. It is also common for patients and their families to build a relationship, and become more emotionally connected with their treating nurses. This may either increase nurses’ work satisfaction because of their success in gaining trust from the patient and family, or make their work emotionally demanding as they become more committed or emotionally invested. These conditions may co-exist and can lead to “Individuals in the Human Resource Management workforce are in position to support nurses in ensuring appropriate ICU staffing and continuous professional development. As quoted by the participants, inadequate staffing, insufficient training, and poor preparedness, education, or mentoring increased nurses’ burden and distress. Borhani et al.  discusseThis qualitative study contributes to the limited knowledge and understanding of the challenges nurses face in the ICU from an Islamic lens. Given that nursing is a global profession, this study provides a new insight for non-Muslim nurses who practice in Islamic countries. It also offers possible implications for implementing supportive interventions to improve the wellbeing or nurses and reduce moral distress.


In 2020, the emergency due to the COVID-19 pandemic brought a drastic and sudden change in teaching practices, from the physical space of the classrooms to the virtual space of an e-environment. In this paper, through a qualitative analysis of 44 collected essays composed by Italian mathematics teachers from primary school to undergraduate level during the spring of 2020, we investigate how the Italian teachers perceived the changes due to the unexpected transition from a face-to-face setting to distance education. The analysis is carried out through a double theoretical lens, one concerning the whole didactic system where the knowledge at stake is mathematics and the other regarding affective aspects. The integration of the two theoretical perspectives allows us to identify key elements and their relations in the teachers’ narratives and to analyze how teachers have experienced and perceived the dramatic, drastic, and sudden change. The analysis shows the process going from the disruption of the educational setting to the teachers’ discovery of key aspects of the didactic system including the teacher’s roles, a reflection on mathematics and its teaching, and the attempt to reconstruct the didactic system in a new way. Not just everything But at least something will be fine!(A mathematics secondary school teacher)This study aims to explore how Italian mathematics teachers managed their teaching activities in the context of a total lockdown imposed as part of the government response to the COVID-19 pandemic. The lockdown was decreed in different parts of Italy at different times between the end of February and the beginning of March 2020, a timeframe in which activities in almost all sectors were interrupted and citizens were forced to stay at home. Italy’s education systems did not constitute an exception to this norm: schools and universities were suddenly closed, and teachers and learners shifted from the usual face-to-face to distance education. As a consequence, the learning process moved from the physical space of the classrooms to the virtual space of an e-environment. The reorganization of didactics in the schools has not been structured. The responsibility of such reorganization has been in the charge of the didactic managers and the teachers. Each teacher or each institution created their own e-environment, choosing an online teaching platform with communication and collaboration facilities and eventually with software for specific domains. New teaching settings required the teachers to engage with new designs of their teaching processes, impacting also on the affective aspects of such processes.Our study took place about a month after the forced closure of schools, at a time that education was at full distance with no prospects for a return to the classroom.The situation in which our study moves is not like a typical distance setting before the pandemic in which participants do not know each other or they are located across large geographic areas. In our context, the pandemic forced teachers and students to move to the new online distance settings. As this move happened as a consequence of government decisions, teachers and learners had very limited prior technological and/or methodological preparation that foresaw the new settings.In this frame, we are interested in exploring how teachers of mathematics perceived and responded to the abrupt transition from face-to-face to distance education. In particular, we look at the teachers’ attitude towards mathematics teaching within the new educational system. We base our study on the integration of two lenses: the e-learning tetrahedron model Albano,  and the It is by integrating these two lenses that this article intends to read the teachers’ attitudes during the movements within the didactical system. To this end, we conducted a survey among Italian mathematics teachers from primary school to the undergraduate level. We selected a narrative approach, asking teachers to tell about their experience, focusing on affective aspects, and reflecting on their role as teachers during this time of sudden change.To date, literature concerning e-learning mathematics education is focused mainly on research in blended settings (online and face-to-face)  in mathematics teaching and learning is widely consolidated , collaborating and looking at the educational project from different perspectives for a nontrivial and effective exploitation of technologyThe Tutor, who takes care of scaffolding and fostering the student’s learning processThe Mathematics, that is, the knowledge to be taught/learnt.The actors of the didactics system have been modeled as tetrahedron vertices Fig.  and are Technology is considered inside and outside the didactic system: on one hand, we are immersed in a technology-connected world (outside the tetrahedron); on the other hand, the intentional use of technology for teaching and learning poses the technology within the didactic system (inside the tetrahedron). Looking at the faces of the tetrahedron can give a view on various facets of the educational process. The face Author–Mathematics–Student concerns a context where the Student can autonomously interact with the Mathematics, starting from a didactical transposition by the Author or constructing herself some new resources, so acting as an author. The face Mathematics–Student–Tutor highlights the mediation between students and knowledge to be constructed, realized by interactions and communication with an expert. The face Author–Mathematics–Tutor focuses on the design and validation of the activities in the e-environment, realized by the collaboration among people who plan and people who interact with the students. The face Author–Student–Tutor refers to bridging action of the Tutor between the Author and the Student, as a mediator in one direction and as a feedback collector in the converse direction.A further feature of the tetrahedron model is the dynamicity of its vertices, intended as positions/roles that any actor of the didactic system can play. This makes it possible to design and analyze didactical situations where the student can be in charge of some didactical functions Albano, , such asTeacher knowledge is located in ‘the lived lives of teachers, in the values, beliefs, and deep convictions enacted in practice, in the social context that encloses such practices, and in the social relationship that enliven the teaching and learning encounter’  of Di Martino and Zan  and the As anticipated in the Introduction, we aim to investigate the teachers’ perceptions of the changes due to the transition from a face-to-face setting to distance education within the new educational system. The tetrahedron model and the teachers’ attitude model fit very well with our aim to investigate the changes in teaching/learning processes starting from teachers’ perceptions. Through this theoretical frame, we will consider the changes in the teachers’ relationships with the vertices of the tetrahedron, paying particular attention to the linked affective factors.We ask you to write an essay entitled ‘Teaching/learning in the days of the coronavirus. From face-to-face to distance education. Logbook of a change’. You can deepen the aspects you consider most important, whether they are cognitive and methodological or affective  or metacognitive (reflections). Please, give more details also on how your choices and beliefs about the various aspects considered have changed as your distance learning experience has progressed. The essay can be of varying length, organized as you prefer .At the end of March 2020, a month from the onset of total lockdown in Italy, when every face-to-face activity was suspended across the country, we distributed a call for essays among Italian teachers from various grade levels, since teachers of every level were involved in the shift to distance education. We conducted a qualitative study using a narrative approach. We set an online form with one open question, given in Italian, with the following instructions (in the English translation):We disseminated the form link by means of emails sent to all teachers who are members of the Italian Association for Research in Mathematics Education and to teachers who are part of local communities known to the authors of this paper. The teachers joining the call had about 1 month to submit the essay.In line with established methodologies of narrative data collection Kaasila, , we prefA priori we chose to frame the collected data from a systemic point of view, using the tetrahedron model, by taking into account the affective aspects involved, using the teachers’ attitude model. The qualitative analysis of the essays showed that the changes described by the teachers can be interpreted by us as “movements” in the tetrahedron, where the affective aspects assume an important role.We refer to “movement towards a vertex” when the teacher assumes the role, respectively, of Student, Author, Tutor, and of a mathematics scholar who reflects on Mathematics and on its teaching.The teacher moves towards the StudentThe teacher describes herself as a student, that is, one who must/wants to learn something new. In our context, we look for excerpts showing the teacher’s need/wish to learn .The teacher moves towards the AuthorThe teacher describes herself as someone who feels the need to take part in the process of designing resources, tasks, and activities and setting up teaching/learning situations suitable for given didactical objectives. Here, we look for excerpts wherein the teacher refers to herself as being in charge of the design for learning.The teacher moves towards the TutorThe teacher tells about the need of building a new relationship, less asymmetrical, with her students both at affective and cognitive levels. We look for sentences revealing more and different interactions and attention to the students.The teacher moves towards the MathematicsThe teacher tells about the need for a reflection on Mathematics with respect to the teaching/learning process. Here, we look for the excerpts from which this reflection emerges.In this perspective, we highlight how the various teachers’ movements emerge from their narratives, as follows:For every movement towards a vertex, we observed related changes of teachers’ attitudes that show us why and how these movements happen. More precisely, we observed the attitude towards the “new” processes of mathematics teaching and learning, by looking for emotional disposition, view, and perceived competence coming out from the teachers’ words. Table We collected 44 essays throughout Italy, eight from primary (1st to 5th grade) teachers (indicated by PT#), ten from teachers of the 6th to 8th grade (indicated by MT#), 17 from high school (9th to 13th grade) teachers (indicated by ST#), and nine from university teachers (indicated by UT#). The excerpts presented in the analysis that follows have been chosen as representative of the various aspects that are the focus of our observation and analysis. For every excerpt, we include the original Italian quotations in square brackets.turning point It is a Monday in the beginning of March in a particularly dry winter, in which the sunny days have followed one another with a stable and pleasant trend. There is in the air, now close to the equinoctial transition, a flash of estrangement, which immediately reverberates in the eyes of the students. [...] Nobody could imagine what was going to happen. [...] That’s why, this morning I feel vulnerable to those glances. […] Three days after the dive into surreality: we sink abruptly, like Carroll’s Alice, into a space with an unknown and deforming topology. (ST14) Nessuno immaginava quello che stava per succedere. [...] Ecco perché, questa mattina mi sento vulnerabile davanti a quegli sguardi [...] Tre giorni dopo il tuffo nella surrealtà: sprofondiamo bruscamente, come la Alice di Carroll, in un spazio dalla topologia sconosciuta e deformante.]50 days have passed since the morning when the bell stopped ringing. I still feel the echo of it. (ST16)[Sono ormai trascorsi 50 giorni dalla mattina in cui la campanella ha smesso di suonare. Ne sento ancora l’eco.]From an emotional standpoint, the incipit of essays PT2, PT6, MT3, MT6, ST5, ST13, ST14, and ST16 is very strong, recalling the moment when everything changed. Many teachers begin their narratives by telling about “that” particular day, the weather or the sensations, and perceptions they felt. A very detailed emotional contextualization that shows how that was experienced as a “watershed,” a  Bruner,  after whOnly after such touching prose, do the teachers continue narrating what happened to their teaching process in the new distance education setting.The new situation led the teachers to move towards the Student, in the sense that they narrate the experience of “becoming Students.” This movement takes place at two levels. On the one hand, the teacher becomes a Student because she feels the need of an educational training that will allow her to acquire skills in managing the new situation from a teaching point of view. On the other hand, the teacher becomes a Student to acquire digital skills that she is forced to use in distance education.At the beginning I was quite shocked: I was not prepared and I felt it to be very distant from my usual way of teaching ... Not being able to interact with the children, hear their opinions and listen to their suggestions, PLAYING AS A TEAM WITH THEM...IT MADE ME SAD AND IT BLOCKED ME.The movement seems to be characterized by different attitudes  towards mathematics teaching in the new situation, with the model’s dimensions strongly intertwined. As a first reaction to the new situation, the writers of essays PT2, PT6, MT2, and ST16 claim to be uncomfortable. This emotional disposition is often linked to the fear of not being able to preserve the vision of mathematics and of teaching mathematics in the transition to distance education:I will never succeed ... in distance education it is impossible! I will miss the best! … (PT1)[Non riuscirò mai …con la didattica a distanza è impossibile! Mi perdo il meglio!]The teachers PT1, PT2, PT3, PT5, PT6, ST3, ST13, ST16, and UT1 declare a feeling of sadness for their prediction of losing positive emotions without being face-to-face in the schools:Obviously the Distance Education caught me ‘unprepared’. Due to my character and the characteristics of my students, my teaching is very much based on relationship, empathy, emotion and not least on physicality, very often theatrical, in the classroom. (ST3)For some of those  who claim to feel this way, the view of mathematics teaching emerging from the essays is as something that passes strongly through the relationships that are established in the classroom and therefore as something that they find difficult to rethink in the distance setting.”I was asked about distance learning while I could only ever describe my discomfort and my inadequacy, because that’s what I feel. (MT7)In PT5, MT7, and MT11 essays, the negative emotions of the initial bewilderment are linked to a sense of inadequacy, therefore to a very low perceived competence towards teaching in the new situation:I started ‘studying’ how to carry out distance learning. After all, the peculiarity of the teachers is to be ‘lifelong students’, to maintain  the desire to learn and not to retreat in the face of challenges. (ST2)However, essays PT1, PT2, MT2, MT9, MT11, ST3, ST2, and ST16 reveal that, after the initial emotion of discouragement, there is a positive change in attitude. We believe this change is linked to the rethinking of one’s own vision and beliefs, to the desire to get back into the game as students, accompanied by positive emotions of challenge.ST16 explicitly states:Even my vision of distance education has changed during this period, due to the continuous interactions with the pupils, almost 24 h a day! (ST16)Indeed, as suggested in the last excerpt, some teachers  note that the incentive for this change comes from different factors, such as the need to not lose contact with students and also collaboration with colleagues and passion for their work. These factors positively influence the perceived competence in moving towards the Student, with the possibility to “re-imagine,” “re-build” oneself:But a real sailor can be seen in storms, right? So I had to ‘re-imagine, re-build myself’. (PT1)Thanks to the advice of some colleagues who had attended that famous course and were already using the Gsuite platform, after realizing that there was no time to lose, I started to ‘study’ how to carry out distance education. (ST3)This change of attitude can already be seen in the titles of essays PT2, MT2, MT10, ST3, ST6, and ST13. For instance, ST3 states, “You never stop learning”:In this movement, positive changes of attitude are linked to a positive attitude towards teaching with technologies, in particular due to a good perceived competence. This emerges from the essays written by teachers  who claim to have a good relationship with technology already in their teaching practices preceding the lockdown. The resulting perceived competence seems to help overcome more quickly the initial discouragement and to provoke positive emotions towards having to get back in the game.I am convinced that what we are experiencing can also be considered an opportunity to take contact and refine our knowledge of digital tools  that will be very useful also in everyday teaching. (UT3)[Sono convinto che quella che stiamo vivendo può essere considerata anche un’opportunità di prendere contatto ed affinare le nostre conoscenze degli strumenti digitali  che potranno essere utilissimi anche nello svolgimento della didattica ordinaria.]The teachers MT1, MT5, MT11, ST1, ST3, ST12, ST14, ST15, and UT3 find themselves in a new situation, putting themselves in the position of those who must/want to learn how to use new tools to manage it. However, different behaviors emerge from different teachers moving towards the Student. Some of them  refer acquiring technological skills, such as UT3:Personally, in order to continue the class work started in September and ended in early March, I thought it was appropriate to support the lessons in videoconference (with google-meet) i.e., synchronous, with lessons I’m going to record (with Screencast or matic) i.e., asynchronous.[...]. Students can learn more easily if the calculation, the reasoning, takes place in a face-to-face setting: the Mathematica software allows me to write the procedure in a clear way, without the help of the graphic tablet.In brief, I hope I get by. (ST8)Other teachers  move towards the Student by trying to understand how to use technologies with educational objectives from the beginning, such as ST8: Gli alunni riescono ad apprendere più facilmente se il calcolo, il ragionamento, si svolge alla loro presenza: il software Mathematica mi consente di scrivere la procedura in modo chiaro, senza l’ausilio della tavoletta grafica. Insomma speriamo che me la cavo.]I hope I get by [speriamo che me la cavo]) is a typical “student” expression in the geographical region in which the teacher belongs .The expression concluding ST8’s essay It is worthwhile to note that ST12 goes towards the Student in a very deep sense, almost as a researcher, who spends some days “looking for what was in the literature” about distance education:: I don’t have the control of this work among peers…. How to promote it, even at a distance, so that it can encourage learning? ).Positive attitudes towards technology seemingly favored the prevalence of a sense of challenge over that of bewilderment and confusion. Moreover, some essays suggest that, in addition to the movement towards the Student, there is also the movement towards the Author (such as ST13Distance education triggered me to reflect on my way of teaching [La didattica a distanza ha innescato in me riflessioni sul mio modo di insegnare.])The radical change, the emotional impact, and the reflection on one’s own teaching led the teacher, in some cases, to describe what we interpreted as a movement of the teacher towards the Author and involving a change in the didactical transposition, due to the transition to distance education  that are seen as limits to one’s work.The teacher goes towards the Author because she needs to design new teaching situations.I thought about a new ‘project/activity’ to be carried out online with the main aim of doing mathematics in a playful, joyful and engaging way, even if at distance. I then structured a class activity called ‘a team of detectives’. (PT1)We identified two different ways to change. Some teachers try to make a didactical transposition trying to remain as similar as possible to what they did in a face-to-face setting, whereas some others feel the need for a change (others “suffer” this change). These views and beliefs are associated with different emotional dispositions. As an example, PT1 is one of the teachers expressing a positive change in her attitude, after the initial discouragement:the attempt was to restart teaching as similar as possible to the previous one (MT2)[il tentativo era quello di riprendere una didattica più simile possibile a quella precedente.]For PT3, PT7, MT2, ST15, UT1, and UT3, the new didactical transposition is an adaptation of the previous one. As an example:What I had to redefine in this first period is the idea of the lesson itself (PT5)[Ciò che più ho dovuto ridefinire in questo primo periodo è l’idea stessa di lezione.]Nevertheless, the essays of PT5, MT8, MT10, ST4, ST5, ST6, ST12, and ST13 show the need to rethink and redefine a new didactic transposition. As an example:it is not possible to ‘migrate’ teaching and learning practices in the classroom in Distance Education mode, you have to change more or less radically the contents and teaching practices [...] Making them immediately part of my choice, I exclude that Distance Education coincides with video lessons, precisely because I do not believe that you can transpose the ‘physical’ class into a ‘virtual’ class. The video lesson will be an important but not exclusive moment. (ST12) Escludo, facendoli subito partecipi della mia scelta, che DAD coincida con videolezioni, proprio perché non credo che si possa trasporre la classe ‘fisica’ in una classe ‘virtuale’. La videolezione risulterà un momento importante ma non esclusivo.]While at beginning the term “video lessons” is widely used to indicate an adaptation of face-to-face lessons used before the lockdown; in this case, as ST12 writes, video lessons have a different meaning:My first impact with distance education was a great joy for me, I was happy to be able to apply methodologies and tools that I could not always use in class. [...] I am focused exclusively on learning and not at all on completing programs, an anxiety that, unfortunately, I was experiencing even if I was aware of the mistake [...] there is room for knowledge and skills but above all for development and evaluation of competencies. (ST6) sono concentrata esclusivamente sugli apprendimenti e per nulla sul completamento dei programmi, ansia che purtroppo vivevo anche se consapevole di sbagliare […] c’è spazio per conoscenze e abilità ma soprattutto sviluppo e valutazione di competenze.]In some essays, the positive emotions in the movement towards the Author seem linked by a real “sense of liberation” from traditional teaching and anxiety for the syllabus:Distance education needs a preliminary phase of didactic design through the selection of contents, the identification of objectives and the contextualization of the didactic unit within the disciplinary program. A work of selection and organization of materials to be used, of activities to be proposed for education and curricular disciplines carried out in synchronous and asynchronous way. (PT3)The reflection linked to the movement towards Author leads teachers to consider aspects of their own professional activity that may be new to them, as in the case of PT3:Here, PT3 refers to teaching processes that ought to always be taken into consideration yet are evidently new to him. The process, in this sense, only comes to the surface when PT3 loses some of her certainties.What is changed is that now it is no longer a question of homework or teaching, it is about being an adult reference and less a teacher. Having an appointment every day helps to sustain this situation made of fear, sometimes of sick parents, of flimsy internet connections, of crowded rooms, of embarrassment in showing one’s home intimacy and nostalgia of the classmates. [...] the only thing that I have managed to do till today I think is not having lost them but this has nothing to do with teaching. (MT7) l’unica cosa che ad oggi sono riuscita a fare credo che sia il fatto di non averli persi ma ciò con la didattica non ha nulla a che fare.]By looking into this movement, we commit to study the dynamics whereby unexpected and sudden change in teaching delivery influenced the teacher–student relationship. Many of the essays analyzed here focus on such mechanisms. PT2, MT7, ST1, ST2, ST14, and ST16 narrate how the first and very strong perceived need was not related to teaching/learning mathematics; rather, it was about making children feel close , behaving more than before (and in a different way) as an “adult reference point” for the students, in such a moment of general disorientation. The emotions emerging from the essays are very strong, both positive and negative, described with emphasis and with many lines of text, as the following excerpt shows:The narratives of PT5, MT9, MT11, ST2, ST7, ST13, ST17, and UT1 show new awareness of emotions, that perhaps were previously not so explicitly relevant:I realized I love my pupils very much. (MT11)[Mi sono accorta di volere molto bene ai miei ragazzi.]We see a relationship in which the collaboration and the willingness to meet each other become the real drive to move forward and to build a functional future for us and for them. (ST17)[Vediamo formarsi una relazione in cui la collaborazione e la volontà di venirsi incontro diventano la vera forza per andare avanti e per costruire un futuro funzionale per noi e per loro.]This shift towards the Tutor is very evident in the essays of teachers of all levels, even in the ones from high school:This activity, however, although tiring and expensive, brings me closer to my students, in some way it seems to me to ‘cuddle’ them, caress them one by one, in order to be able to follow and advise them [...] I must recognize that this anomalous situation has greatly increased the confidence and trust among us; I perceive the need they have to be reassured and guided and I realize that the trust they place in me has increased. (ST2) devo riconoscere che questa situazione anomala ha molto aumentato la confidenza e la fiducia tra noi; percepisco il bisogno che hanno di essere rassicurati e guidati e mi accorgo che è aumentata la fiducia che essi ripongono in me.]The shift furthermore entails a change in the relationship, an increase in confidence and trust:The emotional pain will be long, but being able to start again communicating with the students is a cure-all for me. It gives a purpose to my days. (MT1)In the essays of PT2, PT5, MT1, MT6, UT1, and MT2, this great need emerges also in the opposite direction, that is, the need of the teacher themselves to be tutors for their students, in such a particular moment:free from the bureaucratic trammels and cancer that afflicts our school: number grades. [libero dalle pastoie burocratiche e dal cancro che affligge la nostra scuola: i voti in numero.]), focusing instead on feedback and formative assessment .This movement also includes a change in the teachers’ understanding of assessment. Distance as well the greater amount of data provided by technological equipment allows the teacher to have a holistic view of the students’ knowledge. In this sense, the teacher tends to make more extensive use of formative assessment and therefore dropping summative assessments. Indeed, it seems that MT1, MT3, MT5, MT8, MT10, ST3, ST4, ST6, ST8, and ST10 feel “free” to behave as tutors in relation to the assessment, not worrying about “grades” .In many families, the lack of digital skills and tools necessary for ‘distance education’ has widened the gap between social classes, undermining the essential value of universality that the right to study should have. (MT8)[In molte famiglie la mancanza di competenze e strumenti digitali necessari per la ‘didattica a distanza’ ha aumentato il gap tra le classi sociali minando l’imprescindibile valore di universalità che dovrebbe avere il diritto allo studio.]MT8, whose essay narrates a very difficult social context, writes:That’s why I’m angry at the slogan ‘Let’s leave no one behind’ [...] In lower socio-economic demographics, but also in the medium poor and difficult or simply heterogeneous ones, distance education often let the last ones remain last, therefore behind. (MT12)[Ecco perché mi fa rabbia lo slogan: ‘Non lasciamo indietro nessuno’ [...] Nei quartieri di frontiera, ma anche mediamente poveri e difficili, o semplicemente eterogenei, con la Dad succede che gli ultimi rimangono ultimi, perciò indietro.]Needless to say, distance education has unfortunately accentuated the enormous social gap that already exists among students of our schools. (ST16)[Inutile dire poi che la didattica a distanza ha purtroppo accentuato l’enorme divario sociale già esistente tra gli alunni delle nostre scuole. ]Still very strong negative emotions emerge from MT12 and ST16:on the day of a hypothetical return to class, the differences between students will be enormous [...] Distance education is not inclusive by nature, and in my humble opinion, it can never be. (PT5)[il giorno di un ipotetico rientro le diversità dovute al nucleo familiare saranno enormi. [...] La didattica a distanza non è inclusiva di natura, e a mio modesto parere, non potrà mai esserlo.]Just two teachers  think with fear at the moment when they will “return back to class”:The movement towards the Mathematics is determined by the movement towards the other vertices of the tetrahedron. This movement is activated by the need of the teacher to revise her previous didactic transposition to be effective in this new context, which requires a reflection on Mathematics.I am experiencing that these didactic goals4are achievable without complicating life with unnecessary algebraic ‘baroque’ manipulations . The students are reacting well. Better than they did pre-coronavirus. (ST4)[Sto facendo esperienza che questi obiettivi sono raggiungibili senza complicarsi la vita con inutili ‘baroccheggiamenti’ algebrici . I ragazzi stanno rispondendo bene. Meglio di quanto fatto pre-coronavirus.]As an example, ST4 illustrates her view of mathematics (see the terms “unnecessary” and “baroque” in the excerpt below), suggesting that the new context allows her to manage the teaching/learning process in a way coherent with her views. Moreover, ST4 notes that this coherence between the view and the didactic action allows her to achieve the intended educational goals: the essay reveals that she is perceiving such experience as entirely new:For this new transposition, the teacher needs to pass through the Student (she reflects on the technologies to use in order to carry out the new transposition) and the Author . These movements reveal how the view of mathematics and its teaching ultimately influences the emotional dispositions of teachers.And all of this has to do with mathematics? I studied and lived in my own skin and in that of the ‘fragile’ children I meet, that emotions are fundamental in every learning process, and also in numbers, and even in this difficult moment! I will continue, with my wizard hat, to meet the pupils and they, perhaps, will feel as a friend, which encourages them because ‘learning is a fantastic adventure’! (PT1)On the one hand, for UT1 and UT2, the fear of failing to keep their own vision or a low perceived competence influences the emergence of negative emotions, especially at the beginning. On the other hand, PT1 and ST12 reconsider mathematics as a meeting place, as an occasion even more important than before to strengthen relations with students, rather than a knowledge to be taught. For PT1, for instance, the creation of a comfortable environment can support students from an emotional point of view and support their learning process too:When it was necessary to introduce an absolutely new [mathematics] topic and trying to make it understood, I found myself in great difficulty. I found a setting that seems to work. (PT3)The excerpts of PT3, MT3, MT4, MT10, MT11, ST6, and ST7 highlight how the teacher moves towards the Mathematics feeling the need to pass via the Author:Then I had to introduce new arguments, so I introduced multiplication using all the different possible strategies [...] But then the big problem of feedback arose [...] only the relationship guarantees useful feedback to me and the students because it allows me to go further and reach that emotional and motivational level, so important for learning [...] A distance education program can’t take care of all that. The term ‘distance’ itself says so. (PT5) Ma poi si è posto il grande problema del feedback. [...] solo la relazione mi permette di garantire feedback utili a me insegnante e agli alunni, perché mi permette di andare oltre e raggiungere anche quel livello affettivo e motivazionale, così importante per l’apprendimento [...] A tutto questo una didattica a distanza non può per natura sopperire. Lo dice il termine stesso ‘distanza’.]The teachers PT5, MT9, MT2, MT4, MT6, MT7, ST3, ST5, ST6, and ST10, instead, move towards the Mathematics via the Tutor. For example, PT5 reflects on the importance of the feedback to maintain contact with students:This study is based on the assumption that the researchers interpret phenomena by means of the narrators’ words, producing sense and understanding Bell, . SummingThe analysis of the essays was carried out through a double theoretical lens, the e-learning tetrahedron model Albano, , and theCarrol’s Alice, into a space with an unknown and deforming topology ) and a second one of reflection and elaboration  flexibility, on the best way to transmit and involve ). This second period is generally perceived differently, as if the situation was less negative than expected before, and a change in the attitude seems to emerge, in particular with high school teachers, together with the movements towards the vertices of the tetrahedron.First of all, in the collected data, we can identify two temporal periods: a first period of bewilderment .The description of the second period (of reflection) starts very often with the description of distance education in negative terms: “it cannot,” “it is not,” “it is impossible”. Generally, it is just what is missing that triggers a reflection, from which it emerges that the teachers take into consideration new (for them) perspectives on various functions of the teacher, on educational objectives, on mathematics, and on mathematics education. Interestingly, the teachers refer to this situation in terms of opportunities. For example, a primary teacher (PT6) writes that “the tempting opportunity that this situation has offered us is the possibility to rethink and re-evaluate our school microworld” [l’occasione ghiotta che ci ha offerto questa situazione è la possibilità di ripensare e rivalutare il nostro micromondo della scuola.]. Similarly, a secondary school teacher (ST10) writesActually, what teachers report concerns educational issues widely discussed in the literature in mathematics education such as educational goals, design of learning activities, assessment, and so on. Nevertheless, these issues coming out from reflection appear as completely new for these teachers. In other words, they seem to discover some key aspects of the didactic system in which they are embedded, thanks to the disruption of the didactic system itself.possible worlds  become actual worlds.Generally speaking, the traumatic change in the educational setting plunged teachers into an unexpected and unthinkable world where the teachers become aware that the didactic system has to be reconstructed. Therefore, totally different educational worlds are imagined: a school where the summative assessment disappears; a school where mathematics is not a set of formula and procedure; a school where the teachers design activities to promote reasoning and, more generally, competency-oriented activities; and a school where technology is really integrated in teachers’ and students’ usual practice. These imagined educational worlds are new (for the teachers) due to a different role of the teacher, a different teacher’s attitude towards mathematics, and its teaching and a different epistemology of mathematics. We think that it is relevant that teachers take into consideration different The construction of possible worlds can foster different teachers’ attitude towards their professional development, enabling an alignment and a dialogue between the new (for them) issues described above and the related development and results in mathematics education research. This alignment can have a deep impact on teachers’ education that has to be further explored.possible worlds.However, future research is needed to investigate the teachers’ reflection and the teachers’ movement in the tetrahedron along the persistent pandemic. New periods could be identified besides the two temporal periods above described, and it would be interesting to inquire about the role that these new periods can have in the actualization of the Finally, from the point of view of the elaboration of the theoretical framework, two specific issues remain open. The first concerns the role of technology in the tetrahedron. It appears from the essays as a means for approaching teachers and students within the didactic system: this approaching is bi-directional, since it is not only the teacher who is in charge of institutionalizing students’ knowledge, but she is recognized by the student as the one who takes care of the students’ learning and works to this aim. The physical distance prompts teachers’ reflection on the role of the contact between teacher and students, and this suggests somehow a relation between external and internal spheres of the tetrahedron model that need further exploration.The second unresolved theoretical issue concerns the relations between the theoretical constructs used in the analysis. The teachers’ attitude model (Coppola et al.,