This paper reports on the findings of a research project which investigated how a sample of New South Wales government primary schools understand and implement the Australian Curriculum’s general capabilities. The project sought to identify specific factors which facilitated or hindered the degree to which primary school teachers implemented the GCs in their classrooms. Data were collected and analysed in the period leading up to the current COVID-19 pandemic and as such, do not address current contextual factors at play in schools such as remote teaching and learning. The project’s mixed method approach employed an online survey which attracted responses from 185 primary teachers and included an invitation to provide brief written responses. Further data were assembled through 36 interviews undertaken with teachers in 12 primary schools in both metropolitan and rural NSW. Analysis of the interview data was undertaken by using Biesta’s (2010) three functions of education — qualification, socialisation and subjectification — as an interpretive lens. This enabled the researchers to identify, categorise and accord meaning to participant responses and consequently draw conclusions. The analysis of both the online survey and the teacher interviews revealed four main findings and shed light on individual teacher commitment to the general capabilities and associated classroom implementation issues. The transformative role of education through its focus on issues such as justice/injustice, democracy, citizenship and sustainability has long been recognised as important Apple, . The incCurriculum studies is an area of ongoing contestation and dispute Deng, . CentralIn Australia, a “constitutional division of powers in education” , developed content in English, Mathematics, Science, History, Geography, Personal and Physical Education, Technologies and the Arts.a range of generic and employability skills that have particular application to the world of work and further education and training, such as planning and organising, the ability to think flexibly, to communicate well and to work in teams. Young people also need to develop the capacity to think creatively, innovate, solve problems and engage with new disciplines  clearly indicated its commitment to “working with all other states and territories to achieve a high quality core Australian curriculum”  advised that the capabilities of literacy, numeracy and ICT can be embedded into relevant parts of the curriculum VCAA, , p. 13 aThis project sought to investigate how NSW primary schoolteachers understand the GCs and to ascertain the extent to which the GCs are implemented in their classrooms. To enlist NSW primary schools for data collection, the chief investigator emailed 85 NSW school principals. Additionally, school principals in the Riverina, in rural south-west NSW and the mid-north coast were invited to participate in an online survey and face-to-face interviews, as were their teaching staff. Consequently, 185 teachers completed the online survey and 12 schools volunteered to participate, with 36 face-to-face teacher interviews taking place.How participants perceive their own understanding of the GCs;Whether participants implement the GCs in the classroom, and if so, how this is done;If individual schools promote the integration of the GCs in their teaching and learning programs.The online survey employed non‐random sampling as the data compilation method and Likert scales to “build in a degree of sensitivity and differentiation of response while still generating numbers” , Greek 2), Italian (1) and Vietnamese (2). In the 36 face-to-face teacher interviews across 12 schools, grades and geographic locations are outlined in Table , ItalianIn addition, one interviewee identified as a principal; two identified as support teachers; and another, a school librarian. A breakdown of experience and grades is presented in Table The survey comprised four sections, the first comprising a rationale for the survey and its overall purposes. The “Participants were asked to rate statements on their understanding of the GCs according to a five‐point Likert Scale from “strongly agree” to “strongly disagree”. The results are outlined in Table I use specific teaching strategies/activities to implement the general capabilities. Responses are tabulated below  consider that they understand the GCs, with 15.6% stating they lack understanding of the GCs. Written responses to this statement reveal numerous factors impacting the extent of their understanding of the GCs. Written responses from the 26.7% who are “unsure” and those indicating they do not understand contend that a lack of professional development impedes their GC understanding. This was evident in the responses of 28 (15.6%) participants who identified a lack of understanding of the “ethical understanding” and “intercultural understanding”. Furthermore, 15 (8.1%) participants commented that the inclusion of the GCs in classroom programming on top of syllabus outcomes, content and literacy/numeracy strategies would be onerous and deflect attention from these priorities.As indicated above, the responses to 2.2 — I consider the general capabilities to be an important element of the curriculum indicated that 11 participants (6%) disagreed or strongly disagreed. Rather than disagreeing with the principles underpinning the GCs, participants cited other factors impinging on their time and energy to prioritise the GCs. These included preparation and responses to NAPLAN  test results, the behaviour management of students, programming requirements of syllabuses which a number of participants labelled as “content heavy”, accountability and administration duties and extra-curricular obligations.The responses to 2.3 — My school prioritises the teaching of the general capabilities indicate that 33.9% of schools prioritise the teaching of the GCs, whilst 26.7% signalled that their schools do not, and 39.3% were unsure. Of those whose schools prioritise this, 26 stated that this was done informally, rather than through the formal programming in teaching/learning programs.Responses to It is worth noting here that the NSW Curriculum requires teachers to base their teaching/learning programs on syllabus outcomes and assess student achievement of those outcomes across a 2-year learning stage. Teachers are not required to specifically program the GCs or report on student achievement therein. The project sought to understand if teachers did in fact deliberately integrate the GCs into their teaching/learning programs. Participants were invited to respond Yes, No or Occasionally to the statement “I use specific strategies/activities to implement the general capabilities”  and discussion to strengthen GCs such as “intercultural understanding”, whilst six participants used project-based learning and inquiry-based learning with one asserting that such an approach provides “flexible pedagogy” allowing for student differentiation more readily than through conventional direct instruction. In addition, three participants emphasised the use of ICT in the classroom and reported that various software programs allow them to integrate the GCs into their classroom teaching. These participants indicated that they regularly use the NSW Department of Education’s t ideas” .Two participants reported that they use drama and roleplay to target aspects of the GCs, particularly “intercultural understanding”. Both indicated high proportions of culturally and linguistically diverse students and argued that drama activities were effective in opening spaces for discussion of issues related to cultural practices, traditions and languages. Of note is a significant absence of comments on other curriculum key learning areas, for example visual arts, history, geography and physical education. This might provide an area for future research.The 36 semi-structured interviews sought to “allow the examiner to dig deep into the experiences and/or knowledge of the participants in order to gain maximum data” Turner, , p. 757.Of the 36 interviewees, three conceded unfamiliarity with the GCs, and all called for further professional learning on the GCs. The other 33 interviewees, who demonstrated specific and detailed knowledge of the GCs, cited instances of GC inclusion in classroom interactions and teaching. What was apparent in these responses was the commitment to the principles and ideas underpinning the GCs. All participants agreed that the GCs were an important curriculum component, the following comment being typical: “(the GCs) are front and centre of planning” M/LC. The GC Once series by Morris Gleitzman. This participant discussed how she initiated “ethical and cultural conversations” (F/MCa) through the storyline and characters in this novel set in Nazi-occupied Poland in 1942. She further explained that each day offered numerous opportunities to address the GCs, albeit informally.Ten participants indicated that they cover the GCs informally. Whilst they were aware of the GCs, they expressed the view that they as a matter of course in their teaching cover the principles of the GCs in classroom units of work, such as textual study, rather than through formal programming. One specific example was the study of the Eleven participants recounted a more formal approach to the GCs. This entailed the programming of the GCs into teaching/learning programs. For all participants, this required the inclusion of specific GCs in the school’s teaching/learning programming formats which had been revised to accommodate this feature. Usually a simple tick/check was required to indicate which GCs were to be covered in specific units of work, and a review undertaken at the conclusion of each school term and year ensured what each school considered to be a relevant and comprehensive coverage of the GCs.The responses of two participants were distinctive. One (M/MC) explained that the GCs were incorporated into school reports for parents. Student progress in relation to each GC was depicted in the reports as “working at” or “working beyond” (M/MC). Additionally, students were invited to self-assess their engagement with the GCs by undertaking the same process as the class teacher. He added, “You get a lot of kids that are quite accurate. I’d agree with how they rate themselves. They’re pretty honest with themselves” (M/MC). This self-assessment is also forwarded to parents/caregivers.The other distinctive (F/MCb) response argued that explicit teaching of the GCs was crucial to student development academically, socially and emotionally. She utilised the GCs to develop student language skills, with one strategy being the decoration of her classroom with posters depicting specific social interactions between individuals and in groups. She used these as “discussion starters”, where students learn about how to relate and respond to others in social situations. In these classroom interactions, the teacher promoted student discussion and interaction, through “productive classroom dialogue” ; “One of the important things is to get them to understand how to behave and contribute in class discussions” (M/LC); and “While I want them to be relaxed in class and interact, they need to know that there are boundaries” (F/MCa). Participant comments were focused on student behaviours that gave scope for students to participate positively and productively in activities, particularly group work and discussions.This function was identifiable through interviewees targeting the development and shaping of student attributes and personal qualities that enhance individuals’ sense of uniqueness. Subjectification centres on opening spaces for students to shape their own opinions and “test” these with other students; it is a component in the ability to thinking and rationality as a basis for “responsible responsiveness to alterity and difference” Biesta, , p. 41. “(We) encourage our children to explore…just like global citizens…(so) they can really value intercultural understandings…I designed this unit of work to strengthen children’s understanding of the multicultural nature of this society” (F/MC);“We believe our programming is actually getting them ready for the future…it’s about getting my kids ready to be critical and creative learners; be able to solve a problem with reasoning…whether they are in the classroom, at school or outside” (F/MC);“I use them [GCs] a lot…to get a holistic view and make sure I’m coming at the content from all angles so it can suit all the students” (F/EC);“I use picture books to get kids talking—discussing and sometimes debating the issues. It helps them to take a position on issues” (M/MC);“We’ve prioritised asking our children to respond to ideas and issues, not only to help with their literacy skills but also to make sure they are developing thinking and reasoning skills” (F/MC).“There’s pressure with NAPLAN and improving the kids’ results but the General capabilities allow us to work towards important goals to make our kids happy and valued individuals” (M/LC).Fifteen participant comments invoked the subjectification function. This is perhaps unsurprising, in that research into teacher attitudes identifies teacher commitment to holistic child development ;Who thinks they understood what was said and can put into their own words? (active listening);Why do you think that? (deepening their ideas);Can you add to this idea? Do you agree/disagree? Why? (thinking and building ideas together) . Teacher agency, including how teachers interpret and implement the curriculum, has been the focus of considerable research; however, less attention has been paid to the “potential” of curriculum materials (Deng, This research project also illuminated participants’ ability to use the GCs as a “springboard” to enable beneficial student learnings, despite approximately 47% stating that they considered their understanding of the GCs to be incomplete (see question ls Deng, , understls Deng, , p. 45. ls Deng,  who invels Deng, , 1990 anIn using the GCs as “embodiments of potential” (Ben-Peretz, Most of the participants value the GCs. However, only a small minority of them are required to integrate the GCs into their teaching/learning programs. Numerous participants in both the online survey and the interviews argued for greater professional learning provided by the relevant school sector to deepen the knowledge and possibilities for classroom integration of the GCs.Should teachers be required to formally address the GCs in teaching/learning programs?If the GCs are deemed important, how can they be integrated effectively into teaching/learning programs without overloading the classroom teacher?What resources will support teachers in addressing the GCs?Curriculum authorities and the school sectors need to consider the status and role of the GCs in their respective educational jurisdictions and key questions need addressing:We add a provocation here, although we are loath to add to teachers’ burdens by insisting on GC programming. What if we were to adopt a GC-led curriculum, in which the capabilities supersede or replace subject-related outcomes? We propose the GCs of C and CT, P and SC, EU and IU as “higher-order” capabilities. Literacy, numeracy and ICT can be seen as tools for attaining these.The answers to these questions can be shaped by broadly based discussions with teachers, school leaders and curriculum designers, as well as this project’s participants. Their passion and commitment to their teaching is undeniable, and will flourish from further support and consultation.


Monograph Knowing and Checking: An Epistemological Investigation (Melchior Acta Analytica contains contributions by Peter Baumann, Kelly Becker, Marian David, Nenad Miščević, Robert Weston Siscoe, and Danilo Šuster along with my replies.In this Précis, I provide an overview of my Melchior , which i Knowing and Checking: An Epistemological Investigation .M has certain modal features with respect to p.M accurately indicated that S Melchior , hereinap is true. In particular, I contend that sensitivity is the crucial modal condition on checking, i.e., one cannot successfully check whether p is true by using a method that would indicate that p is true if p were false. Sensitivity is a controversial condition of knowledge. Thus, sensitivity is necessary for checking but plausibly not for knowing, thereby marking a crucial distinction between knowing and checking.In KC, I argue that the modal features of the method used determine its appropriateness as a method of checking whether KC aims to achieve three main goals. First, it contains a theory about checking, which includes internalist components such as the intentions of the checking subject as well as externalist components, in particular, the modal features of the method used. Second, it provides a fresh view on enduring knowledge problems, namely closure problems and the skeptical problem, by explaining intuitions about knowing in terms of intuitions about checking. Third, KC aims at settling a dispute about epistemic modal conditions by finding a new home for the intuitively appealing but nevertheless controversial sensitivity condition as the crucial necessary condition on checking.p is true and intentionally reflect about a method for settling this question, we think that for knowing a method is required that it is also appropriate for checking. That means that, in contexts of checking, we have the intuition that knowing requires a sensitive method. Let me now provide an overview of KC.KC also follows an alternative methodological path. Most epistemological theories focus on knowledge as the most significant epistemic concept. However, our epistemological vocabulary is much richer than simply talking of knowing, including the concepts of checking, arguing, proving, understanding, or demonstrating. However, many of these other epistemic concepts are rather neglected in epistemology. This is a shortcoming for two reasons. First, a theory of these alternative epistemic concepts is interesting and desirable in its own right. Second, such a theory can be used to provide a deeper understanding of knowledge. Following this strategy, I develop in KC a theory about checking that I then use to explain existing intuitions about knowing. For example, I argue that, in contexts of checking, when we raise the question whether p iffp is true.p.S believes that p is false, S does not believe that p.In the nearest possible worlds where p is true, S believes that p.In the nearest possible worlds where S knows that Chapter 2 contains an overview of modal knowledge accounts, focusing on sensitivity. Nozick  providedp iffp is true.p.S believes, via method or way of coming to believe M, that p is false and where S uses M to arrive at a belief whether (or not) p, S does not believe, via M, that p.In the nearest possible worlds where p is true and where S uses M to arrive at a belief whether (or not) p, S believes, via M, that p.In the nearest possible worlds where S knows, via method (or way of believing) M, that Condition (3) has become known as the sensitivity condition and condition (4) as the adherence condition. Nozick argues that this definition can solve the Gettier problem and the skeptical problem, since gettierized subjects do not sensitively believe and our beliefs in anti-skeptical hypotheses also fail to be sensitive. Nozick realized that his knowledge account encounters problems if it does not take the belief-forming method into account and provided the following definition of knowing via a method:In cases where S believes via various methods, S knows simpliciter according to Nozick if the dominant method that “outweighs” the other methods fulfills sensitivity and adherence. When analyzing checking, we always consider a specific method. Thus, an analysis similar to Nozick’s concept of knowing via a method will be crucial for a theory of checking.p, knows that p entails q, but still fails to know that q. Nozick regarded this feature as advantageous since it allows knowing ordinary propositions without knowing anti-skeptical hypotheses, but as Kripke , that S uses M with the intention of determining whether p is true, and, (2), that M is an appropriate method with respect to p. The first condition is specified internalistically by the intentions of the checking subject, and the second condition externalistically by the modal profile of the method. Since checking is a process, we can distinguish ex ante reports about checking from ex post reports. In KC (35), I am interested in the conditions of successfully checking. Thus, I focus on ex post reports of checking of the following form:checked that p was true via M iffp is true.S intentionally used M for determining whether p.M is a checking method with respect to p.M accurately indicates that S Chapter 3 is the central chapter of KC. I develop there a sensitivity account of checking, SAC. Two conditions on checking whether I assume in KC that a subject can check successfully simply by using a checking method but without knowing the modal features of the method used. However, I also define reflective checking as checking that involves this kind of knowledge.p is true depends on its modal profile, i.e., it depends on what the method would indicate under certain circumstances or in particular possible worlds. Thus, when it comes to checking, we talk about the modal features of methods instead of the modal features of beliefs based on methods. Methods can have different modal profiles concerning a particular proposition p. In KC, I distinguish various modal features of methods, including sensitivity, adherence, safety, and negative safety, all coming in a weak and a strong version.p were true and M were used to determine whether p, then M would indicate that p is true; and (2) If p were false and M were used to determine whether p, then M would indicate that p is false. However, we also want to allow non-ideal methods as checking methods, for example methods that are asymmetric concerning their indication of p and ~ p. Nevertheless, we do not allow any method to be adequate for checking. In particular, we want to exclude the following three types methods from being checking methods:Random methodsp when used to determine whether p is true.M makes random indications about the truth of Opposing methodsp.M always makes false indications concerning p were true and M were used to determine whether p is true, then M would indicate that p is false and if p were false and M were used to determine whether p is true, then M would indicate that p is true.4If Monotonous methodsp, regardless of whether p is true or false.M always makes the same indication concerning p were true and M were used to determine whether p is true, then M would indicate that p is true and if p were false and M were used to determine whether p is true, then M would indicate that p is true.If Whether a method is proper for determining whether Strong insensitivityp iff: If p were false and M were used to determine whether p is true, then M would indicate that p is true.M is strongly insensitive with respect to Each of these methods fails to be sensitive, since it is strongly insensitive in the following sense:As I argue in KC, fulfilling sensitivity and avoiding strong insensitivity are the crucial modal features of checking methods. Safety, in contrast, is also necessary, but it is not an explanatorily powerful condition. As I show, methods that are safe but insensitive are not appropriate methods for checking, although they might be regarded as appropriate for acquiring knowledge. Moreover, I discuss in Chapter 3 various modal features of asymmetric methods and whether they are suitable for checking.Externalist knowledge accounts face the generality problem, i.e., the problem of determining the method used. Since the checking account in KC is externalist in nature, it seems to be also subject to this problem. However, I argue in KC that this is not the case for checking, since the method is specified by the intentions of the checking subject to use a particular method for checking. Notably, this solution is not available for theories of knowing, since we can acquire knowledge unintentionally without intentionally using a particular method. Finally, I reflect in Chapter 3 on Kripke’s barn case against sensitivity, arguing that with checking the violation of closure is less problematic than in the case of knowing.p (or ~ p) is true. I call this form of checking checking simpliciter. However, we cannot only check whether p is true, but we can also check whether p or a particular alternative q is true. In Chapter 4, I extend the developed checking account, taking specific alternatives into account. If we consider the case of Peter cleaning the kitchen today, then we can distinguish between checking that Peter (and not somebody else) cleaned the kitchen today, checking that Peter cleaned the kitchen today (and not something else), and checking that Peter cleaned the kitchen today (and not on some other day). I argue that these forms of checking differ along two dimensions. First, checking whether p or q is true involves different intentions of the checking subject than checking whether p is true or checking whether p or r is true. Second, the sensitivity conditions for the different forms of checking differ. In cases of checking simpliciter, a proper method would not indicate that p is true if p were false. A proper method for checking whether p or q is true would not indicate that p is true if q instead of p were true. As I argue, these different sensitivity conditions are not reducible to each other. Thus, different forms of checking are independent not only in terms of the specific intentions, but also in terms of the sensitivity condition. Moreover, I provide in Chapter 4 an account of checking de dicto and checking de re. I also distinguish between checking that x is F (and that not something else is F) and checking that x is F (and that x is not something else), and I investigate checking and wh-clauses, for example, checking who was F, where E happened, or why E happened.In Chapter 3, “In the nearest possible worlds where the object in question is x and S uses M, M indicates to S that it is x (and not y).In the nearest possible worlds where the object in question is y and S uses M, M indicates to S that it is y (and not x). S can perfectly discriminate between x and y via M iffThe second part of Chapter 4 is devoted to checking and discrimination. There are obvious differences between checking and the capacity of discriminating. Checking is intentional and involves raising a question and intentionally using a method for settling it. Discrimination, in contrast, is not intentional in this sense. Despite these internalistic differences, there are strong externalist analogies. As I argue, the capacity of discrimination via a particular method is best characterized by the method’s modal profile. Perfect discrimination can be characterized as follows:S cannot discriminate x from y via method M if M would indicate that the target item is x if it were y.5Thus, perfect discrimination has the same modal profile as perfect checking methods. Moreover, random methods, opposing methods, and monotonous methods are not adequate for discrimination. As I argue, sensitivity is the crucial modal condition on discrimination, i.e., p) that q iffp.S knows that q is true, and S infers q from p .q were false, S wouldn’t believe that p (or S wouldn’t infer q from p).if q were true, S would believe that p (and would infer q from p if she were to infer either q or ~ q from it).  for inferential knowledge while others do not. Moreover, I argue, against orthodoxy, that some instances of induction are insensitive but others are sensitive according to Nozick’s account of inferential knowledge.The second part of Chapter 5 applies the considerations on inferential knowledge to checking. When checking, we intentionally use a method for settling a question. This can also involve inferences. The methods of inferential checking can be specified in a narrow sense as consulting the very premises, or in a wide sense as consulting the sources that delivered the premises. If specified in a narrow sense, then the method is trivially insensitive. Thus, only the wide specification is acceptable. This wide specification of inferential checking delivers the same result as Nozick’s account of inferential knowledge. Some instances of deduction can be methods of checking while others are not, perhaps a controversial result. Furthermore, some instances of induction are sensitive and therefore can constitute checking, while others are not, perhaps a surprising view about the sensitivity of induction, and inference to the best explanation can be checking methods.Part 3 of Chapter 5 is devoted to problems concerning knowing and checking necessities. Logical necessities are a tricky terrain for modal accounts of knowing and checking because beliefs in necessities trivially or vacuously fulfill the modal conditions of sensitivity and safety. This has the implausible consequence that any belief in a logical necessity constitutes knowledge, or that any method is an instance of checking according to sensitivity accounts or safety accounts. This problem is well known. Nozick  suggests7p  is true and deliberate about methods for settling this question, we tend to think that we do not know that p via strongly insensitive methods, especially not via monotonous methods. In other contexts, this tendency does not apply. In contexts of checking, when we raise the question whether KSACThe first part of KC develops a theory about checking. The second part explains persistent knowledge puzzles in terms of intuitions about checking. In Chapter 6, I explain closure puzzles, centering on lottery cases and deception cases. The explanation that KC provides relies on an assumption about the connection between intuitions about checking and intuitions about knowing. The main connection is expressed by the following principle KSAC:KSAC is a principle about knowledge intuitions. It remains neutral about whether these intuitions are true or false. KSAC, fully applied, is not only a principle about self-ascriptions. It also includes intuitions about others who we think are in checking contexts. KSAC can provide two types of explanations for knowledge intuitions. First, it explains when we enter a checking context, and, second, it holds that, in checking contexts, we regard methods as defective for acquiring knowledge that are not checking methods. In particular, we regard strongly insensitive methods as defective.o, but not knowing a proposition p, despite knowing that o entails p. We can distinguish two types of closure puzzles. First, there are closure puzzles involving deception propositions, d. Second, there are closure puzzles involving lottery propositions, l. In both cases, we intuitively know the first, ordinary proposition, but not the second proposition even though we know that the first entails the second.KSAC can explain some but not all low-stakes/high-stakes puzzles. However, its main application is closure puzzles. Closure puzzles arise when we have conflicting intuitions of knowing an ordinary proposition d/l is true, we tend to think that we do not know d/l since the evidence for d or l is insensitive.o is sensitive. Therefore, we tend to think in contexts of checking that we know that o. Thus, we have, in terms of sensitivity, an explanation of our conflicting intuitions of knowing ordinary propositions but not knowing deception propositions or lottery propositions.Importantly, deception propositions and lottery propositions are both paradigmatically insensitively believed. Based on this insight, KSAC can be used to explain closure puzzles. In the contexts of checking whether o nor d/l. Moderate invariantism holds that we know both. Ascriber contextualism argues that the standards for knowledge depend on the interests of the knowledge ascriber. When the standards are low, it is true to assert that we know both, but when the standards are high, it is true to assert that we know neither. Subject-sensitive invariantism provides a similar analysis, but it is instead the practical interests of the believing subject, not of the knowledge ascriber, that alter what is known. Finally, one can reject knowledge closure and assume that we know o but do not know d/l. In Chapter 6, I analyze how the KSAC-based explanation of closure puzzles can support these solutions, while remaining neutral about what the correct solution to closure puzzles is. Finally, I compare the KSAC-based explanation to alternative explanations of closure puzzles and argue for the superiority of the explanation provided in KC.Various solutions to closure puzzles are proposed in the literature. Strict invariantism is the view that we neither know p is true by using an alternative source O’ with the same modal profile as O.Chapter 7 investigates whether bootstrapping is a method of checking. Bootstrapping, as introduced by Vogel , is the know that a source is reliable or accurate via bootstrapping. When deliberating about bootstrapping, we tend to enter a context of checking for two reasons: First, because we reason about the reliability (or accuracy) of a source; second, because bootstrapping resembles paradigmatic processes of checking or testing a source’s reliability or accuracy, but in a caricaturing way. In contexts of checking, we regard methods of which we think that they are strongly insensitive as inadequate for acquiring knowledge. The monotonicity and, therefore, strong insensitivity of bootstrapping is obvious for us. Therefore, we regard bootstrapping as an epistemically flawed method. Consequently, we think that we cannot The second part of Chapter 7 is devoted to intuitions about knowing via bootstrapping. The fact that bootstrapping is, due to its insensitivity, an inadequate method for checking also provides an explanation of our intuitions that it is a flawed method for acquiring knowledge. The full explanation of our intuitions that we do not know via bootstrapping developed in KC is as follows:Again, I focus on explaining knowledge intuitions, leaving open at this point whether our negative intuitions about knowing via bootstrapping are true.sh, is false, and, (3) if we have knowledge of the external world, then we know that ~ sh. The skeptic accepts (2) and (3) and rejects (1), while Mooreanism endorses (1) and (3) and rejects (2). Concerning Mooreanism, I identify in KC a further puzzle constituted by two conflicting intuitions:1: Moorean reasoning is flawless. It is in line with the commonsensical and philosophically popular view that perceptual knowledge can be immediate, and it is in line with ordinary reasoning about the external world, about our own mental states and about their accuracy.MI2: Moorean reasoning is flawed because it can only deliver the result that skeptical hypotheses are false. MIThe Moorean puzzleThe final chapter of KC is devoted to explaining and solving the skeptical puzzle. In the first part, I review the skeptical problem and various solutions that have been proposed. The skeptical puzzle can best be understood as a puzzle about three conflicting intuitions, each intuitively appealing but jointly inconsistent: (1) that we have knowledge of the external world, (2) that we do not know that the skeptical hypothesis, ~ p is true, which is distinct  from doubting and checking whether p is true. I explain why various forms of bootstrapping and Moorean reasoning, due to their insensitivity, fail to be instances of checking whether one’s own beliefs are true. Based on these insights about problems and limits of checking whether one’s own beliefs are true, I provide the following explanation of the Moorean puzzle:Doubting one’s own beliefs is typically the first step of a process of checking of one’s own beliefs whether they are true. In such checking contexts, we tend to think that we cannot know that our beliefs are true via strongly insensitive methods, especially not via monotonous methods. Moorean reasoning is obviously a monotonous method, always indicating that the checked beliefs are true regardless of whether they are actually true. Therefore, in skeptical contexts of doubting, we think that we do not know via Moorean reasoning that our beliefs are true and that Moorean reasoning is a flawed response to the skeptical challenge. In contexts of ordinary self-reflection, this tendency does not apply. In these contexts, we think that we have immediate external world knowledge and knowledge that our sense apparati are reliable and that the skeptical hypothesis is false in a way that is a complex form of Moorean reasoning. (KC 233f) The second part of Chapter 8 is devoted to explaining the skeptical puzzle and the Moorean puzzle. First, I reflect on doubting and checking whether one’s own belief that sh, but it is not a form of checking. This view is compatible with Mooreanism but also with checking-based versions of contextualism and subject-sensitive invariantism.This explanation leaves open which of our conflicting intuitions about Moorean reasoning are true. Accordingly, it is compatible with positive and negative views about knowledge via Moorean reasoning. As I contend, we have to distinguish two cognitive processes of higher-level reflection, checking whether one’s beliefs are true and ordinary self-reflection, even if both processes involve the same propositions. Ordinary self-reflection about the truth of our own beliefs involves a complex form of Moorean reasoning. I suggest that Moorean reasoning is a form of acquiring knowledge that ~ of one’s beliefs whether they are true delivers a homogenous picture, since all instances of Moorean reasoning are insensitive and, therefore, fail to be methods of checking of one’s own beliefs whether they are true or not false. Moreover, the account provided in KC avoids a version of the generality problem for Moorean reasoning, as presented in Melchior (In the final part of Chapter 8, I address the heterogeneity problem of sensitivity that I introduced in Melchior . AccordiMelchior .The provided sensitivity account of checking is an open project with further applications. These applications include, for example, a sensitivity-based account of medical testing and a sensitivity-based account of why consulting statistical evidence fails as a method of checking with applications to proof in law.


Grief is a normal psychological response in relatives after the loss of their loved ones, which has shown to be associated with psychological reactions like depression, anxiety, and significant stress that many relatives have to cope with. In Thailand, there are limited research studies on grief, especially in palliative settings. This study aims to examine grief reaction, depression, anxiety, and coping of relatives after palliative patients’ death.A multi-method design was applied. The authors completed the demographic data questionnaire, and the participants finished other measures which included the Hospital Anxiety and Depression Scale (HADS), the Inventory of Complicated Grief (ICG), and the Brief-Coping Orientation to Problems Experienced (Brief-COPE). The qualitative data from the focus group interview was analyzed with thematic analysis.From the quantitative study, the mean scores of HADS for anxiety and depression subscales were 5.05 and 6.34, respectively, which indicated no anxiety and depressive disorders. The mean score of ICG was 19.51 with highest score on acceptance coping subscale. In contrast, the lowest score was on dealing with the substance subscale. There were significant correlations between anxiety subscale from HADS and ICG (r = 0.73), depression subscale from HADS and ICG(r = 0.85), and anxiety and depression subscale from the HADS (r = 0.79). From the qualitative study, the factors associated with grief reaction could be thoroughly explained according to the perceived character of deceased, perceived character of relatives, relationship characteristics, disease, medical care, and support systems.The correlations among grief reaction, depression, and anxiety of relatives after palliative patients’ death were high. The grief reaction was associated with many factors, including communication from medical personnel. This finding emphasized the importance of assessing the reactions after loss and associated factors in the relatives after palliative patients’ death. Also, evaluating the ways that the relatives use to cope with their loss, expressing empathy, and supporting the relatives to cope with loss in an adaptive way were recommended. Grief is a psychological response to the loss of loved ones . It is aHowever, there is variation among people who are grieving. Some individuals experience complicated grief , which dFrom past studies, severe grief reaction was associated with many factors; for example, closeness of relationships to the deceased, higher anxiety-related attachment styles, greater dependency behaviors, focus on negative thoughts about the dead, higher emotionality, greater degrees of loneliness, and negative perceptions about the support they will receive if they reach out to others for help .The death of a loved one is considered the most significant stressor for which most bereaved successfully adapt to the circumstances without any clinical intervention. For many, grief may be too much for anyone to go through alone; as seen in the past, many of the most incredible artwork built throughout time is considered an invitation to share grief . Common In a palliative setting, grief amongst relatives might be mentioned early to help prepare for the loss. However, there is still little study about suffering in this group. This study aims to examine grief reaction, depression, anxiety, and coping of relatives after palliative patients’ death.This study was accomplished using a multi-method design , 13. TheMoreover, to gain a better and deeper understanding of reactions and coping of relatives after palliative patients’ death, the qualitative data was augmented to a quantitative outcome. In addition, the relatives might have a chance to share their experiences and feedback on palliative care from Ramathibodi Hospital, which is essential for improving care for the palliative patients and their families. This study received approval from the Institutional Review Boards COA. MURA2019/1110 on 15 November 2019.Inclusion criteria were1) Be the direct relatives of patients in palliative service of Department of Family Medicine, Ramathibodi Hospital 2) Being lost from the death of a patient from 1 month to 1 year 3) Were classified as "having abnormal grief" by Ramathibodi Palliative care service 4) Be able to communicate in Thai 5) Be willing to participate in this study.Exclusion criteria was the authors cannot contact to ask for consent.Among 229 relatives of patients in palliative service of the Department of Family Medicine, Ramathibodi Hospital, 56 relatives were classified as "having abnormal grief" by Ramathibodi Palliative care service. Of the 56 relatives, 38 met inclusion criteria and were requested to complete the complicated bereavement risk assessment tool, which the Gippsland Regional Palliative Care Consortium developed with permission to use for this study .After the complicated bereavement risk assessment tool was completed for all participants, relatives who received a score of 2 or above were approached to attend an in-depth interview study. A total of 11 participants were willing to participate in the in-depth interview by two authors (TT and VS) at Ramathibodi Hospital or by phone.The demographic questionnaire included age, gender, religion, marital status, educational level, occupation, income, underlying diseases, support system, and loss details.The Hospital Anxiety and Depression Scale (HADS) is a self-rating questionnaire developed to assess depression and anxiety in patients for both hospital and community settings. It consists of 14 items equally divided into two subscales: anxiety (HADS-A) and Depression (HADS-D). Responses are rated on a 4-point Likert scale and range from 0 to 3 . RecommeThe Thai HADS had good reliability and validity for both anxiety and depression subscales. At the cut-off point of > 11, the best cut-off point, the sensitivity of anxiety and Depression subscales of Thai HADS were 100% and 85.71%, respectively. In comparison, the specificity was 86.0% for anxiety and 91.3% for depression. Both sub-scales also showed good internal consistencies with Cronbach’s alpha coefficient of 0.8551 for the anxiety subscale and 0.8259 for the depression subscale .The Inventory of Complicated Grief was developed by Prigerson et al . ExploraThe ICG was permitted to translate and adjust to Thai culture by Orasa Yaiyong and Peeraphon Lueboonthavatchai. It has good validity and reliability with Cronbach’s alpha coefficient of 0.97 .The Brief-COPE is a self-report questionnaire developed to assess a broad range of coping responses. It has 14 subscales: acceptance, emotional support, humor, positive reframing, religion, active coping, instrumental support, planning, behavioral disengagement, denial, self-distraction, self-blaming, substance use, and venting .The Brief COPE inventory-Thai version has acceptable concurrent validity (Pearson correlation coefficient with Proactive Coping Inventory = 0.25–0.45) with high internal consistency  .Descriptive statistics were performed using IBM SPSS version 26. Demographic data, scores of the HADS, ICG, Brief-COPE were analyzed and presented in Mean±SD and correlation among variables. The qualitative data consisted of an interview guide administered to focus groups. The qualitative data was analyzed which consisted of thematic analysis proceeding through several steps to generate the themes. The van Manen approach was used in the thematic analysis to perform a phenomenological qualitative study. The broad aim of such research is to interpret the meaning of phenomena and to understand the lived structures of meanings. There are four steps in the process. 1) Preparing the interview transcript and checking the accuracy of the transcripts by repeat listening to the recording and reading the transcripts until an interview transcription is accurate. 2) Isolating thematic statements using holistic, selective, and detailed approaches. 3) Composing linguistic transformations via writing, rewriting, and generating illustrative examples connected with the phenomenon of interest. 4) Development of descriptions explaining themes while maintaining the essence of the phenomenon of interest .Details for demographic data of participants were presented in From HADS, the mean scores of HADS for both anxiety and depressive subscales  indicated no anxiety disorders and depressive disorders in participants. By ICG scoring, the mean score of ICG in participants was 19.51.The highest mean score of Brief COPE was on item 24 (mean 3.46), followed by item 20 (mean 3.46), in which both things are within acceptance coping subscales. In addition, the two lowest scores were on item 11(mean 1.15) and item 4(mean 1.17) in dealing with the substance subscale. Data are shown in In terms of the correlation between HADS and ICG, the results showed a significant correlation between anxiety subscale from HADS and ICG , depression subscale from HADS and ICG, also, between anxiety and Depression subscale from the HADS .Correlation between ICG, HADS, and Brief-COPE were shown in Factors associated with grief reaction could be thoroughly explained according to perceived character of the deceased, perceived character of relatives, relationship characteristics, disease, medical care, and support systems.Most relatives said that the deceased was friendly and had a positive impact on their life. Many were known as people-pleasers, while some would always do things for others, making them well-loved by everyone.For example, participant V2 said, "… ..My husband is a very good man, and he always helps other people, and everyone loves him. He loved me and constantly took care of me throughout our 40 years period until his death…"Another participant, V3, said, "…I feel like I cannot accept the loss…because she is so nice… really nice. She always smiles and has mellifluous words…she never argues with others. Also, she always pays respect to her parents and mine… .and she does it every day. She told me to give money to my parents every month, whether more or less. She practices dharma, prays every day, and goes to a meditation retreat every month.”Being dependent on close ones, whether physical, mental, or financial, was related to a worse grief reaction when experiencing the loss. One participant, T6, said, "… .We lived together for 30 years…he never left me alone, he takes care of me for everything…illness, food, clothes…he takes me outside every day to make me feel fresh. I’m handicapped with knee ligament fixation, so if I do not wear knee support, I cannot walk straight…And he always takes care of me on this matter.”Another participant, T1, said her mom helped her with a loan payment for a car. “During my financial difficulties, she supported me financially.”History of loss without a chance to say goodbye may worsen the grief reaction. For example, participant T1 said she lost her father from cancer "… ..When I went to the hospital, my dad was already on a ventilator…he could not speak, and he did not have a chance to admonish at last…and he died on that day… .he tried to talk, but everyone forbade him……. It’s still an unresolved issue for me.”On the other hand, participant T2 said the experience of losing his parents helped him cope with the current loss of his wife…. “I abruptly lost my dad, but my mum was in a hospital for many days, with oxygen support before she left me. I knew that one day I would lose my parents, and I have had that experience. When it was my wife’s turn, I felt that I used to cope with losses and I would get through this…”Many survivors said about not having a chance to talk to their loved ones about forthcoming death because they were concerned about the patients. Participant T3, said "….I did not prepare to lose my daughter…even the doctor told me to do so. What would my girl think about this? I cared about her feelings. I would not talk about this approaching death to her and prepare nothing for the coming loss. I hoped she would get better."By contrast, some participants said they did not get comprehensive information about their loved ones’ illnesses. It is the reason why they did not have conversations about preparing with the patients. For example, participant T5 who lost her daughter, said, "…I did not know about her illness. If I knew in the first place…She felt sick for two days before being admitted to the hospital. Her brother was with her, but no one told me. Her boyfriend called me to ask whether I knew this. I thought she knew her condition… quite well…she told others but not me…she did not want me to worry with her illness."Some participants said they were still disturbed by the thought that they could not fulfill the deceased’s expectations. One participant who lost her mother, T1, said, "…My mom repeatedly told me about getting married since I broke up with my ex and was in a relationship with a new guy. She asked me often whether my boyfriend would have a serious relationship or not, would he get married to me? She was so serious about the wedding. I felt that I did not do this when my mom was still alive…just one thing that she expected from me…Why could I not do this for her?”Many participants said they had a very close relationship with the deceased. Participant T3, said "…I looked after her (his daughter) and did everything for her. I took her to school and picked her up every day until she was in grade 7….I slept near her school while she was studying in Bangkok. I have to keep an eye on her.”On the other hand, one participant, T8, talked about the history of separation from a significant person, her mother, for a very long time. She said…. "I did not live with my mom. I wondered why I had to live with my aunt, who had to manage everything for me…Then, in 2001, I had a chance to stay with my mom, and hug her. It made me so happy, and it made me want to be with her to make up for the period of separation."Although most deceased had a chronic illness, mainly cancer, the relatives might feel that the death happened suddenly. Participant T7said, "…I think it was not slow, it’s fast… I’m still confused why it was so fast…"Some participants thought that their beloved ones might have lived longer if they got better medical treatment. For example, participant T5 said, "…From the bottom of my heart, I wonder if the doctor made a mistake…cause my girl was still well…It was late in receiving treatment, and many medical students came in for interviewing…If she admitted to the previous hospital, she might be still alive”In the same way, participant T7 said, "…Nowadays I still in doubt about the received treatment, and I wonder if the more experienced doctor might have additional treatment for my daughter…It has been bothering me. Also, doc did not visit my daughter after he allowed her to go home, but I asked for a more extended stay…and the nurse did not frequently visit my daughter.”One participant, T3, said, "… ..the treatment plans from medical staff were inconsistent…. one said about chemotherapy, another said about pleural tapping, and another said about just taking oral medicine the patient would get better."Some participants felt they were repelled from the hospital. Participant T3 said, "…this doctor wanted to kick out my daughter from the hospital…he said that to me three times…he said "go to your universal health coverage’s hospital "…and I thought my daughter could claim for medical treatment expense… and my girl was in critical condition and could not look after herself…I don’t understand…when he sped up the admission time…he might give drugs that made her death come faster…no encouragement at all…he treated me like villagers…dunces…He asked my son whether we had a plan of the place of her death.”In addition, participant V2 commented, "… .I know, Sleeping or lying down might be impolite. However, relatives surely want to be with the patients in critical moments. Secondly, some of them do not have money to rent a place to stay. Sometimes I saw the relatives were asked to leave the hospital… and I felt terrible about this situation.”In addition, participant V2 criticized feeling utterly repressed from being forced in decision making in a patient’s emergency condition. She said, "… ..and then my husband was moved to the resuscitation room. The doctor asked me whether I had decided to sign the "Do not resuscitate" request while I was hoping that he was just tired…I was forced to answer immediately…he said, "you had to sign for approval or refusal for resuscitation…It was cruel…really cruel…even I walked out the room, he chased me and relentlessly asked for the answer….he said "You have to know that he is dying and so on….I understand thoroughly….but I need to get a grip for making the decision…the doctor might get used to this…but the ordinary people who experienced this situation…it was not normal at all…and the doctor squeezed me to answer and told me to ask the patient…he was unconscious, right? But you had to discuss the pros and cons of intubation. It was the pressure to me in making a decision. I’m not ready…deeply not. I felt terrible…then I talked to another doc, and he said no, not this time. First, we will use the mask first, if he were OK, we would decide on intubation later, and then I felt OK.However, it’s not OK for me at that time. That doc ordered me to sign the form immediately. Don’t you think it is too cruel?..It was a soul-sucking decision….If there is anything I would like the hospital to empathy…it would be the difficulty for patients and relatives to make the decisions…."Participant T4 commented that "… . It’s like the repeated word was briefed to me whenever the team came in….. ’It was the symptoms of disease….the disease was this and that…I was concerned with my dad’s eating difficulty, but I was briefed that it was a symptom…it was blocked by the word "end of life"…We can do nothing, and more procedures might get him hurt and suffer. I could not accept it at that moment, and I neither studied nor tried to understand palliative care…After my father’s death and I searched for information about that, I began to understand and did not regret the hospital. Every personnel did their job…The information made me feel better.”In the same way, participant T7 said, "…I found the information about palliative care and this made me feel better…it told me that my decision was not wrong.”Effects from COVID-19 pandemic. Participant V3 said, "… .I felt the distance…I could not have a chance to stay close to her or give her encouragement. I accused COVID-19 of making us apart, and my girl became upset.”Participant T5 said, "…I still have another child, my son. If not, I don’t want to live, really don’t want to live, doctor. Also, participant T1 commented, "… .I received much support from my relatives. They helped me to find many activities to do and spend time together, like seeing movies, playing with my grandchildren, distracting me from the lost, talking only good things…."On the other hand, participant T6 commented, "…my late husband’s siblings wanted to take many things from me. They didn’t understand that his brother had his own family…..They want my house, my money, my properties, and so on. Moreover, participant V2 said, "…I didn’t want to hear "cheer up!" or "It’s a normal part of life"…something like this from other people…..I felt angry…cause I surely knew what would happen at the end…Even if I gave up, I must face it, right? They should say nothing. But touching, hugging, or touching hands and just saying, "Are you OK?" Those physical communications helped me.”In addition, the feeling of having inadequate support made the grief worse. For example, participant T6 said, "… ..I have no one, and I don’t know where to get help….they just said It’s boring…they didn’t want to hear…I didn’t tell many people and didn’t want them to be disturbed.”Participant T3 said, "…I offered sacred marker round stone ("Luuk Nimit") and boundary stone ("Sima") and wrote my daughter’s name. Moreover, after the funeral, I copied 1000 prayer books for giving to others. In the morning, I offer food to monks and pour ceremonial water for dedicating merit to her.”Also, participant V2 said, "Buddhism helped me a lot. I don’t mean that going to the temple only in suffering time. We should practice our mind since we are OK….to cope with the problem….you have to be mindful and let it go… I’m sensitive…so others might take one month or one year to forget…I believe I need triple…and I also offer food to monks every morning and dedicate merit to him.”The objectives of this study were to examine psychological reactions and coping of relatives after palliative patients’ death using multi-method study design. From the result of the quantitative section, the total score of ICG indicated that the grief reaction was not severe .It was similar to the scores of depression and anxiety subscales of HADS, which were regarded as being in the normal range . Also, tAccording to the coping styles used by the relatives, the top three-highest rated coping styles were Acceptance, Positive reframing, and Instrumental support subscales, respectively, which indicated the adaptive coping styles. These might explain the low scores of the total ICG and HADS scores.Moreover, the total of ICG was negatively and significantly associated with some adaptive coping, such as positive reframing, acceptance, humor, and using emotional support. In contrast, it significantly correlated with some maladaptive coping, such as denial, substance use, behavioral disengagement, and self -blame.Deeper understanding gained from qualitative examination about factors related to worsened grief reaction, which included factors related with character of the deceased, character of the relatives, the characteristics of a relationship, the disease and medical care, and support systems.From this study, the characters or personalities of the deceased and the relatives affected the grief reactions. These were consistent with a previous study in the past , which sCharacteristics of a relationship is another important factor related to grief reaction. From this study, the two most prominent kinds of relationship that affected the grief reaction were that the relatives were being dependent on the deceased and had a very close relationship with the patient, which was seen in the previous study .Communication between medical personnel and the relatives is very important and has a tremendous impact on the relatives . UnclearIt was shown in this study that not expressing empathic responses from the medical team and not giving adequate time for decisions making to the relatives made a significant negative impact on the relative’s grief reaction.Receiving support from others, both from their relatives and surrounding people has shown to lessen the grief reaction. Also, having spiritual anchors helped alleviate the relatives’ grief reaction as well . In thisLastly, during the COVID-19 pandemic was a tragic moment for the relatives. Many did not have a chance to look after their loved ones during the last days of life, whilst some did not get an opportunity to say their last goodbye. Applying the preventive measure to lessen the risk of infection while honoring loved ones’ wishes and cultural traditions before separation should be considered , 29.To sum up, the grief reaction from the relatives could be lessened by giving adequate information about palliative care from the medical team and by giving enough time for relatives to accept palliative care along with making life-threatening decisions. In addition, properly and gradually introducing palliative care treatment, including advance care plan while the palliative patients still alive and concurrently receiving curative treatment, might help in improving care delivered to the patients and their relatives. Lastly, this result suggested that the palliative care team should explore the relatives’ reactions after loss and associated factors, the ways that they use to cope with their loss, express empathy, and support the relatives to cope with loss in an adaptive manner.There are a few limitations to this study. First, the coming of the Covid-19 pandemic during the middle of this study made it more challenging for the participants to come to the hospital for the interview. The authors had to adapt the interview process where many participants were interviewed by phone, which was an obstacle to good communication. Secondly, the relatives’ factors such as financial problems and transportation from distant areas, discomfort to talk about the loss from physical and psychological aspects, and dislike about facing the triggers in the hospital. Also, inaccurate data in the medical record interrupted the communication to the relatives. In addition, low education might be a problem for the relatives to explain their experience about loss accurately.There should be a widely acceptable policy in providing palliative care services for all hospitals, and health providers should encourage patients to discuss their own living wills including advance care planning, particularly for palliative cases. Moreover, relatives should be given an opportunity to take compassionate care leave while caring for their loved ones during the final weeks of life.Communication is very crucial for relatives. The health care team should express empathic responses, not only giving information about the disease. Moreover, the team should be careful in selecting words in the conversation and aware of adverse reactions from the relatives.In regards to Informed consent, health providers should be trained in providing necessary information, where relatives should be given enough time to make decisions about life sustaining measures, along with an opportunity to ask questions without feeling pressured into signing consent forms and providing a channel for providing feedback from the relatives might help lessen their negative emotions.Grief screening should be provided for all deceased’s relatives, not only for assessed high-risk groups. Also, a high alert system for referring suspected complicated grief to psychiatric service would be beneficial.Lastly, providing a resource channel for further care, through a hotline, whatsapp, line contact ID or other valuable sources of information, might help relatives cope with grief by knowing where they may seek support if needed.It might be helpful to ask for more details about relationships in the family which will be accommodated as an early warning system for upcoming severe grief reactions. Moreover, it might be worth considering providing palliative care in the intensive care unit (ICU), which has a high mortality rate. It encompasses communication with relatives which might help alleviate the grief reaction , 31.


Anorexia nervosa (AN) is a serious psychiatric illness with a high mortality rate and a poor outcome. AN in adolescents can be difficult to treat. The prognosis of patients with AN depends highly on how early specialized AN treatment starts. Therefore, the purpose of this study was to explore the experiences of healthcare professionals in treating adolescents with AN. A qualitative study approach was conducted. Through semi-structured interviews, 16 healthcare professionals, including 10 nurses, 3 dieticians and 3 physicians from the paediatric ward at a university-affiliated medical centre in central Taiwan, shared their experiences. Recorded interviews were transcribed and analyzed by content analysis. Five themes and ten subthemes were identified: 1. Building a trusting relationship first: (a) spending time to build trust with the client and (b) establishing a relationship with the client’s parents; 2. The key to treatment success: (a) Clients’ awareness of the illness and (b) parents’ support for clients; 3. Consistency of team treatment goals: (a) maintaining stable vital signs and (b) achieving caloric intake; 4. Empowerment with knowledge about anorexia: (a) continuing education for healthcare professionals and (b) interdisciplinary collaborative care; and 5. Using different interaction strategies: (a) the hard approach and (b) the soft approach. In conclusion, the findings will provide important information for healthcare professionals to apply in monitoring the psychological and emotional states of adolescents with AN. The findings indicate that healthcare professionals should invite parents to participate in the treatment, support and guide them in their adolescent care, develop scales of family stress and support for AN in adolescents, develop interventions, and establish an early therapeutic alliance.  Anorexia nervosa (AN) is a serious illness characterized by self-induced underweight, body image distortion and fear of weight gain ,2,3,4. AA qualitative study approach was used to describe and understand the in-depth complex phenomena associated with healthcare professionals, including nurses, dieticians, and physicians. Purposive sampling was used to recruit healthcare professionals who met the following criteria: (1) experience in caring for adolescents with anorexia nervosa; and (2) agreement to participate in this research.This study was conducted in a general paediatric ward at a children’s hospital. Adolescents with AN who have life-threatening conditions are admitted to our hospital for medical stabilization. The length of hospital stay is about three to four weeks.Healthcare professionals were invited to participate in this study through invitation letters. They were asked to complete a paper-based survey to indicate their willingness to participate in an interview. The inclusion criteria for healthcare professionals to participate in this study were at least one year of work experience in the hospital, and experience in taking care of at least one hospitalized adolescent with AN. The study included 16 healthcare professionals, including 10 nurses, 3 dieticians, and 3 paediatric gastroenterologists. The nurses were all female with a mean age of 30.2 years, ranging from 26 to 40 years; 3–11 years of clinical experience; and experience with caring for 1–8 adolescent patients with AN. The three dietitians were two females and one male with a mean age of 39 years, ranging from 38 to 41 years; 10–13 years of clinical experience; and experience with caring for 2–10 adolescent patients with AN. The three paediatric gastroenterologists were males with a mean age of 50 years, ranging from 33 to 59 years; 8–34 years of clinical experience; and experience with caring for 10–27 patients with AN.Data collection consisted of semi-structured interviews, based on the following questions: (1) Can you tell me about your experience in the treatment and care of adolescents with AN? (2) Can you tell me how to develop a therapeutic relationship with an adolescent with AN? What was your approach? (3) Can you tell me how to guide parents in caring for their children? How can one support and incorporate parents’ ideas? (4) Can you tell me how the medical team can be trained or educated to improve the care of AN? Data collection was conducted from January to June 2019. Each interview was recorded, coded, and analyzed verbatim, and the experience was shared and discussed with experts trained in qualitative research. Data collection was completed using the data saturation criterion through the repetition of information in the statements from a total of 16 in-depth interviews. The interviews ranged in length from 45 to 60 min.Data were analyzed with the qualitative content analysis approach from Graneheim and Lundman  by deterTo ensure the trustworthiness of the study, our procedure followed the guidelines proposed by Lincoln and Guba . The creThis study was performed in accordance with the principles of the Declaration of Helsinki. All the study procedures were approved by the Hospital Human Investigation Committee at each of the medical centres (IRB No. CMUH106-REC1-132(AR-1)). The participants’ rights of anonymity, confidentiality and withdrawal from the study were explained at the time of the interview.The study included 16 healthcare professionals, including 10 nurses , 3 dieticians , and 3 physicians , for a total of 16 participants. The findings were categorized into five major themes and ten sub-themes: 1. Building a trusting relationship first, including the sub-themes: (a) spending time to build trust and (b) establishing a relationship with the client’s parents; 2. The key to treatment success, including the sub-themes: (a) awareness of the illness and (b) parents’ support; 3. Consistency of team treatment goals, including the sub-themes: (a) maintaining stable vital signs and (b) achieving caloric intake; 4. Empowerment with knowledge about anorexia, including the sub-themes: (a) continuing education and (b) interdisciplinary collaborative care; and 5. Using different interaction strategies: (a) the hard approach and (b) the soft approach. The main themes and sub-themes are presented in The need to build a trusting relationship is based on the fact that healthcare professionals  cannot easily establish a therapeutic relationship with a client at the first encounter. In the beginning, the client is highly defensive and reluctant to express her thoughts and feelings. She engages in little social interaction and exhibits apathy and rigid behaviors. Thus, the establishment of the initial trusting relationship is very important. Once such a relationship is built, follow-up treatment can ensue. This theme included two subthemes: (a) spending time to build trust with the client and (b) establishing a relationship with the client’s parents. The first subtheme, “spending time to build trust,” shows that the establishment of trust requires spending time to gain her trust, understand her, make her dependent on us, and slowly persuade her to share her innermost thoughts. Three physicians identified the importance of a trusting relationship.You must take the time to establish a relationship with her. She is willing to rely on you, and she is willing to tell you where the problem is. Slowly change her mind and see if she can recognize that food refusal is not good for her.” (C2).As one physician said, “The characteristics of nurses are very important. They may not be able to take care of them if they don’t have the right characteristics. You need to screen nurses. Like some discharged cases, nurses are also willing to contact them. Because my (the physician’s) time with her is limited, the nurse has more time with her, especially some night nurses.” (C1). However, for most nurses, the routine care to be performed every day is multifarious and complicated, and the work schedule is tight, with an average of 6–7 patients per day. It takes a lot of time to perform general care. When facing patients with anorexia, they need sufficient time to understand the mental illness. As one nurse said, "It often takes more time to establish a relationship with patients with anorexia, but the usual nursing work is already quite busy. So there is no way to deeply understand the case, and it is more difficult to build therapeutic relationships.” (C13).Physicians also believe that the characteristics of nurses are very important, and that they are willing to spend time talking to and understanding the client. As one physician said, “Initially, anorexia patients are alienated from us; they don’t even want to talk to us. So I choose to establish a relationship with the parents of the case first. And then I learn about the reasons for the client’s anorexia, her thoughts, and her preferences from the parents. Knowing that the client likes the punch-in food on Instagram (IG), the Lala Bear, etc., I will go up to see what food is available near the hospital, and then recommend it to her during treatment” (C13).The second subtheme, ‘establishing a relationship with the client’s parents’, refers to the fact that, since it is difficult to establish a relationship with the client at the beginning, healthcare professionals can first establish a relationship with the client’s parents to understand the client’s preferences. As one nurse said, “We still emphasize that parents should give children enough love and tolerance, and they will be easier to deal with and less likely to come to this point.” (C2). Some doctors also hope that parents will realize that it is not appropriate to blame the child. They must understand that the child is ill, and her thoughts will be affected by the disease. For example, one participant said, “In fact, the client is in a state of illness, her thoughts will be affected physiologically. If the parents are willing to accept it, it will be better, instead of blaming the child all the time.” The participant also stated, “We can imagine that their parents and families must be in conflict with anorexia, because the parents must have hurriedly forced her to eat and dragged her to see the doctor.” (C1).It is also important to let parents know that family relationships are very important. As one participant said, “Why did your parents take you to see a doctor? Why did you come to see a doctor?”, the patients will often answer, “I’m fine, it’s my parents who asked me to see a doctor.” (C1). One physician also said, “In fact, these children don’t have enough awareness of the illness. I told (one girl) to go to the intensive care unit, but she would not agree … At this time, her heartbeat had dropped to 28, and she didn’t think anything was wrong with her.” (C3).This theme includes two sub-themes: (a) Clients’ awareness of the illness and (b) parents’ support for clients. The first theme, “Clients’ awareness of the illness,” means that the most difficult aspect of the treatment and care of adolescents with anorexia is whether the patient understands that they have an illness. A patient who is aware of the illness understands that the disease causes physical problems and can generally gain weight through treatment. In contrast, adolescents who do not perceive an illness do not think they have a problem, but their parents take them to a doctor for treatment. In general cases of this lack of awareness of the illness, when the physician asks, “We compared children who lacked awareness of the disease, and they would say that they should not eat this and should not take this IV, because there are too many calories.” (C14).Another dietician said, “the most difficult part of treating anorexic teenagers is not only that the patient has no awareness of the illness, but also, if the parents’ support is not enough, sometimes it is very difficult to treat anorexia.” (C3). It is also very important to let parents know that family relationships have great significance. One physician said, “We still emphasize that if parents give children enough love and tolerance, they will be easier to deal with and less likely to come to the end of the disease. Family relationships and support are still very important.” (C2). Three physicians also hope that parents will not blame the child in an attempt to change the child’s behavior. One physician said, “The child is sick now, not because she is unwilling to cooperate or skip meals, but because her mind is affected physically. If the parents are willing to accept it, they will not be blamed all the time.” (C1).The second subtheme, “parents’ support for clients”, is very important. Three physicians believe that parents should give their children enough love and tolerance, and they should not blame the child, because the child is currently in a state of illness. Therefore, her thoughts will be affected by the disease. One physician mentioned that “This theme included two sub-themes: (a) maintaining stable vital signs and (b) achieving caloric intake. The first subtheme, “maintaining stable vital signs,” refers to the fact that healthcare professionals’ treatment goals must start with physiology, as it is believed that nutritional deficiencies can affect cognitive function. First, the client’s vital signs should be stable. As one physician said, “Anorexia nervosa is most commonly [associated with] a very low heartbeat (30 bpm), or low body temperature (35 °C), low blood pressure, electrolyte imbalances. These are life-threatening conditions, and sometimes they have to be admitted to the ICU, which may be mandatory.” (C1). The second subtheme, ‘achieving caloric intake’, is about focusing on the patient’s dietary intake and weight growth. One dietician said, “We will start by increasing the amount of food she eats at each meal, and try to add to it slowly, and maybe reach her caloric intake. We may use other intravenous methods, or even use nutritional supplements to intervene, and to pull her whole weight up!” (C14). The nurse and the client set a weight goal together, and upon achieving the goal, the client will be allowed outside or discharged from the hospital. One nurse said, “Give her a goal, how much I want you to eat every day, and if you gain this much weight, I can give you time off, and your mother can take you out for fun. And if you gain that much weight, we will let you out of the hospital.” (C4). Our care for anorexia is taught by the attending physician one by one, from the intensive care unit to the ward care, and then to the outpatient care. In fact, education is carried out during the follow-up process and the ward rounds. This kind of education only means that the few people who are cared for know how to take care of them. Nurses still don’t know how to care of them.” (C3). One dietician reflected on the need to improve her knowledge of psychology. As she said, “We should study psychology. Anorexia is not only physical; the psychological part also plays a big role in the treatment.” (C16). The second subtheme, ‘interdisciplinary collaborative care’, reflects the fact that most nurses feel that they lack experience in caring for patients with anorexia, and they look forward to continuing education in this area or sharing their caring experiences in the ward. For example, one nurse said, “We can invite psychiatrists to do ward teaching activities to teach us how to face and how to care for people with anorexia, what conversations and behaviors are helpful to them, and what to avoid.” (C13) Another nurse said, “Interdisciplinary discussions can be held, and paediatricians, psychiatrists, social workers, dieticians, and nurses can be invited to discussions, and individual discussions can be conducted on individual cases to provide patient-centred care.” (C10). Physicians expect a dietician to function not only in nutritional assessments but also in psychological assessments. As he said, “If a dietician falls into a machine and it looks like she’s taking care of a machine, she doesn’t take into account the whole body and mind of the patient. What the patient needs, such as providing what to eat, should not only focus on nutrition, but also on whether it tastes good or not!” (C3). This theme refers to the ways medical team members can improve collaborative care and their related knowledge of anorexia, and then continuously improve their care. This theme includes two sub-themes: (a) continuing education for healthcare professionals and (b) interdisciplinary collaborative care. The first theme, “continuing education for healthcare professionals,” describes the lack of knowledge of healthcare professionals, especially nurses and dieticians, in the care of anorexia and the expectation of continuing education related to anorexia. One physician said, “This theme includes two sub-themes: (a) the hard approach and (b) the soft approach. The first theme, “the hard approach,” refers to the fact that some participants would use coercive methods to require patients to increase their caloric intake and achieve body weight goals. Most children fear the insertion of the nasogastric tube the most, so one physician said, “If you stop eating again, I will put you on a nasogastric (NG) tube. I will force-feed you, I will transfer you to the intensive care unit, and then put the TPN, and I will force you to be given nutritional injections.” (C3). Even placing the NG tube where the child can see it can be effective; as the nurse stated, “put the nasogastric tube at the end of the bed.” (C5).I use chatting, and every time I go in, she will chat for more than 30 min. And when I go in, I will hug the child and touch her hand. Then I’ll tell her that she can tell me anything, and also allow her parents to be by her side.” (C2). From the physician’s point of view, a massage strategy can be useful for building a trusting relationship. One physician stated, “I also do a lot of things that general doctors can’t do. I sit down and talk to the children…I will give the children massage, and they have no flesh but bones, then the parents will be by their side, and gradually I will teach the parents. I’ll say, when you are in contact with the child, give her a massage and physical touch when you have time, because if you don’t develop a little relationship with her, she will never make progress.” (C2) Regarding the use of euphemisms with a strict manner, as one physician said, “I am more euphemistic. I don’t scold people, but at this time, it is necessary to make comparisons. If she does not cooperate, I may need to be stricter and tell her clearly that she can’t do this, and if she doesn’t cooperate, the less I will bargain with her.” (C3). Regarding creating an agreement with patient, as one nurse said, “The doctor made us draw up three rules with the child: not to self-harm, not to hurt the parents, and not to engage in violent behavior; otherwise, she would be transferred to the psychiatric ward.” (C5). Regarding empathy, as one nurse said, “At the beginning of taking care of such a case, when I spoke, she would just stare at me and her hostility was very strong. I would empathise in the here and now; if I were her, what would I want?” (C4).The second subtheme, ‘the soft approach’, describes the approach of some participants of using gentleness or physical comfort, combining euphemisms with a strict manner, creating an agreement with the patient, and expressing empathy. For gentleness or physical comfort, one physician said, “The main objective of the present study was to explore the experiences of healthcare professionals in treating adolescents with AN by interviewing physicians, nurses, and dieticians. Our results showed that, beginning at the patient’s admission, it was crucial to build a trusting relationship in the treatment process by spending time to understand the patient and establish a relationship with their parents. This finding is similar to those of previous reports ,29, whicAnorexia nervosa is a psychiatric disorder with a considerable risk of serious physical morbidity, and even death. Healthcare professionals must look at extremely thin, malnourished bodies , so the The healthcare professionals in this study perceived that the key to treatment success was the patient’s awareness of the illness and the parents’ support. Although it is difficult for a patient with AN to recognize her own disease, parental support is so important that treatment of anorexia nervosa in adolescence should always involve the parents . They toRegarding the component of knowledge about anorexia, the nurses and dieticians in this study perceived that they lacked knowledge about caring for patients with anorexia. Therefore, they had an expectation of continuing education related to anorexia. This finding is similar to previous reports ,40 that Regarding the use of different interaction strategies, our study found that healthcare professionals will interact with patients with AN in different ways to build a trusting relationship and increase their caloric intake. The hard approach was mentioned in a previous study , indicatMoreover, our study also found that participants described interaction strategies with a soft approach . These findings are similar to those of Geller & Srikameswaran , who indFirst, this study recruited 16 experienced health professionals  who had cared for patients with AN in central Taiwan. Therefore, the experiences presented here cannot be generalized to health professionals from other parts of Taiwan, or to health professionals in western countries. However, the experiences of the participants are powerful and add richness to the existing knowledge on health professionals’ experiences with patients with AN, and they provide motivation to rethink the design of in-service education for AN patient care. Second, the paediatric gastroenterologists were all male, while the nurses and dieticians were all female, and the dieticians were 2 females and one male. The sample of participants was very unequal, not only in gender but also in number . It is recommended that the question of whether different genders have different care experiences be explored in the future. Finally, because patients under the age of 18 in Taiwan are admitted to paediatric wards, adolescents with AN will first be hospitalized in a paediatric ward for observation, and not in a psychiatric ward. In addition, paediatric nurses do not have experience in supporting each other across departments, so their care experiences may be limited.Patients with anorexia have extremely fragile and malnourished bodies, and healthcare professionals can be shocked by the sight them—reduced to only skin and bones, these patients even face the risk of death. Healthcare professionals are therefore more focused on the visible signs of anorexia, namely, the physical condition and weight maintenance, and they find it more difficult to focus on the individual’s thoughts and feelings. All physicians will first spend time to build a trusting relationship with the patient, and they will address the patient’s emotional problems. If both are not simultaneously addressed, the risk of relapse and readmission after discharge is high. Thus, it is well established that both mental and physical recovery are very important in patients with AN. The results of this study should provide further understanding of the perspectives of medical professionals, ways to face the disease of anorexia, and ways to function as a team and to strengthen the team’s knowledge about anorexia.