In our model, no influences from configuration space are required, as everything can be described in 3-space. Importantly, the setting up of an experimental arrangement limits and shapes the forward and osmotic contributions and is described as vacuum landscaping.In the quest for an understanding of nonlocality with respect to an appropriate ontology, we propose a “cosmological solution”. We assume that from the beginning of the universe each point in space has been the location of a scalar field representing a zero-point vacuum energy that nonlocally vibrates at a vast range of different frequencies across the whole universe. A quantum, then, is a nonequilibrium steady state in the form of a “bouncer” coupled resonantly to one of those (particle type dependent) frequencies, in remote analogy to the bouncing oil drops on an oscillating oil bath as in Couder’s experiments. A major difference to the latter analogy is given by the nonlocal nature of the vacuum oscillations. We show with the examples of double- and  This counters the traditional belief, usually expressed in the context of orthodox Copenhagen-type quantum mechanics, that quantum theory is an “ultimate” theory whose main features will prevail for all time and will be applicable to all questions of physics. Note, for example, that, even in more recent approaches to spacetime, the concept of an “emergent spacetime” is introduced as a description even of space and time emerging from basic quantum mechanical entities. This, of course, need not be so, considering the fact that there is “plenty of room at the bottom,” i.e., as Feynman implied, between present-day resolutions and minimally possible times and distances, which could in principle be way below resolutions reasonably argued about in present times .One of the main attractive features of the de Broglie–Bohm interpretation of the quantum mechanical formalism, and of Bohmian mechanics as well, lies in the possibility to extend its domain into space and/or time resolutions where modified behaviors different from quantum mechanical ones may be expected. In other words, there may be new physics involved that would require an explicitly more encompassing theory than quantum mechanics, i.e., a deeper level theory. Our group’s approach, which we pursued throughout the last 10 years, is characterized by the search for such a theory under the premise that even for nonrelativistic quantum mechanics, the Schrödinger equation cannot be an appropriate starting point, since the wavefunction is still lacking a firm theoretical basis and its meaning is generally not agreed upon.For a similar reason, also the de Broglie–Bohm theory cannot be our starting point, as it is based on the Schrödinger equation and the use of the wavefunction to begin with. Rather, we aim at an explicit ansatz for a deeper level theory without wavefunctions, from which the Schrödinger equation, or the de Broglie–Bohm guiding equation, can be derived. We firmly believe that we have accomplished this and we can now proceed to study consequences of the approach beyond orthodox expectations.Throughout recent years, apart from our own model, several approaches to a quantum mechanics without wavefunctions have been proposed ,2,3,4,5.We propose a “cosmological solution” in that the Big Bang, or any other model explaining the apparent expansion of the universe, is essentially related to the vacuum energy . We assume that from the beginning of the universe each point in space has been the location of a scalar field representing a zero-point vacuum energy that vibrates at a vast range of different frequencies across the whole universe. More specifically, we consider the universe as an energetically open system where the vacuum energy not only drives expansion, but also each individual “particle” oscillation ing bath ,9,10,11:one “superclassical” world instead: a purely classical world plus “cosmological nonlocality,” i.e., a nonlocal bath for every oscillator/particle due to the all-pervading vacuum energy, which—mostly in the context of quantum mechanics—is called the zero-point energy. Thus, it is the one classical world together with the fluctuating environment related to the vacuum energy that enters our definition of a quantum as an emergent system. The latter consists of a bouncer and an undulatory/wave-like nonlocal environment defined by proper boundary conditions  are  are 3) aoltzmann ,(4)ΔQ,,5), withEquation  as(7)δpThis, then, provides the additional kinetic energy term for one particle asm-dimensional space, including this new term for each of them, yields Thus, writing down a classical action integral for With the definition of forward and osmotic velocities, respectively,Equation  as(11)AP is practically negligibly small, the expression of the form This can be considered as the basis for our approach with two momenta, i.e., the forward momentum Equation  looks coEquation , nonlocaIntroducing now the Madelung transformation1ψ=ReiℏSwEquation  as(14)AN-particle Schrödinger equationThus, with the identity P the modified Hamilton–Jacobi equation familiar from the de Broglie–Bohm interpretation, i.e.,U is known as the “quantum potential”Note also that from Equation  one obtaU asMoreover, with the definitions of Equation  one can However, as was already pointed out in , with thitten asuj=12ωjmjEquation  then proemergent. One can illustrate this with the situation in double-slit interference . Due to the purely additive terms in the expressions for the total current and total probability density, respectively, also for N particles, Equations n-slit syEquation  becomeslocities  with difN-particle systems in real 3-dimensional space. The central ingredient for this to be possible is to consider the emergence of the velocity field from the interplay of the totality of all of the system’s velocity channels.In sum, with our introduction of a relational intensity In P, the latter is a distribution around P pertaining to the far-away particle might be minuscule, it still may become effective immediately through the zero-point field.In the foregoing sections, we pointed out how nonlocality appears in our model. Particularly in discussing Equations –11), it, it11), P by a Gaussian with long non-zero tails throughout the whole apparatus. As we have seen, in order to calculate on-screen distributions  of particles that went through an n-slit device one at a time, one only needs a two-momentum description and a calculation that uses the totality of all relational intensities involving the relative phases determined across the whole apparatus.The physical reason for bringing in nonlocality is the assumed resonant coupling of the particle(s) with fluctuations of the zero-point vacuum filling the whole experimental setup. Take, for example, a typical “Gaussian slit.” We effectively describe relevant environment , to which the particle oscillations lock in. Moreover, if an experimenter decides to change the boundary conditions , such a “switching” would establish yet another definite order. The introduction or change of boundary conditions, which immediately affects the probability landscape, and the forward and the osmotic fields, we term “vacuum landscaping.”exclusively the latter that must be prohibited in order to avoid causal loops leading to paradoxes. See Walleczek and Grössing [In other words, the change of boundary conditions of an experimental arrangement constitutes the immediate transition from one cosmological solution in the relevant environment  to another . The “surfing” bouncer/particle simply locally jumps from the old to the new standing wave solutions, respectively. This is a process that happens locally for the particle, practically instantaneously , superluminal or other. As implied by Gisin’s group [A to B, but its non-signaling character is still in accordance with relativity and the nonlocal correlations of quantum mechanics. Practically instantaneous vacuum landscaping by Alice and/or Bob thus ensures the full agreement with the quantum mechanical predictions without the need to invoke  signaling. Our model is, therefore, an example of nonlocal influencing without signaling, which was recently shown to provide a viable option for realistic modeling of nonlocal correlations [Similarly, Aspect-type experiments of two-particle interferometry can be understood as alterations of vacuum landscapes. Consider, for example, the case in two-particle interferometry, where Alice and Bob each are equipped with an interfering device and receive one of the counter-propagating particles from their common source. If Alice during the time-of-flight of the particles changes her device by making with suitable mirrors one of the interferometer arms longer than the other, this constitutes an immediate switching from one vacuum landscape to another, with the standing waves of the zero-point field now reflecting the new experimental arrangement. In other words, the ’s group , this vielations ,30.With our two-momentum approach to an emergent quantum mechanics we have shown that one can in principle base the foundations of quantum mechanics on a deeper level that does not need wavefunctions. Still, one can derive from this new starting point, which is largely rooted in classical nonequilibrium thermodynamics, the usual nonrelativistic quantum mechanical formalism involving wavefunctions, like the Schrödinger equation or the de Broglie–Bohm guiding law. With regard to the latter, the big advantage of our approach is given by the fact that we avoid the troublesome influence from configuration space on particles in real space, which Bohm himself has called “indigestible.” Instead, in our model, the guiding equation is completely understandable in real coordinate space, and actually a rather typical consequence of the fact that the total current is the sum of all particular currents, and the total intensity, or probability density, respectively, is the sum of all relational intensities. As we are working with Schrödinger  particles, accounting for differences in particle statistics is still an open problem.As shown, we can replicate quantum mechanical features exactly by subjecting classical particle trajectories to diffusive processes caused by the presence of the zero point field, with the important property that the probability densities involved extend, however feebly, over the whole setup of an experiment. The model employs a two-momentum approach to the particle propagation, i.e., forward and osmotic momenta. The form of the latter has been derived without any recurrence to other approaches such as Nelson’s.is to be digested from our model is the fact that the relational intensities are nonlocally defined, over the whole experimental arrangement . This lies at the bottom of our deeper-level ansatz, and it is the only difference to an otherwise completely classical approach. We believe that this price is not too high, for we obtain a logical, realistic picture of quantum processes which is rather simple to arrive at. Nevertheless, in order to accept it, one needs to radically reconsider what an “object” is. We believe that it is very much in the spirit of David Bohm’s thinking to direct one’s attention away from a particle-centered view and consider an alternative option: that the universe is to be taken as a totality, which, only under very specific and delicate experimental arrangements, can be broken down to a laboratory-sized relevant environment, even if that laboratory might stretch along interplanetary distances. In our approach, the setting up of an experimental arrangement limits and shapes the forward and osmotic contributions and is described as vacuum landscaping. Accordingly, any change of the boundary conditions can be the cause of nonlocal influences throughout the whole setup, thus explaining, e.g., Aspect-type experiments. We argue that these influences can in no way be used for signaling purposes in the communication theoretic sense, and are therefore fully compatible with special relativity.The one thing that Accepting that the vacuum fluctuations throughout the universe, or at least within such a laboratory, are a defining part of a quantum, amounts to seeing any object like an “elementary particle” as nonlocally extended and, eventually, as exerting nonlocal influences on other particles. For anyone who can digest this, quantum mechanics is no more mysterious than classical mechanics or any other branch of physics.


Background: Currently, there is abundant research indicating that smoking and alcohol consumption have significant impacts on morbidity and mortality, though little is known about these behaviors among Canadian health care workers. The objective of this study was to examine health and coping behaviors, such as smoking and alcohol consumption as well as stress management techniques, among health care workers consisting of gendered, racialized, and immigrant employees. Methods: Drawing on a single-case, mixed-methods study in Ontario, Canada, this paper presents under-researched data about smoking practices, alcohol consumption, and stress management techniques among health care workers in labor-intensive, high-stress, high-turnover environments. In particular, it identifies the various mechanisms for maintaining health and well-being. Results: The findings suggest that 7.7% of survey respondents reported smoking while 43.4% reported alcohol consumption, which were reported more frequently among immigrants than among non-immigrants. Participants also reported health-promoting activities in face-to-face interviews, such as mindful breathing techniques and drawing upon social support, while a few respondents reported alcohol consumption to specifically cope with sleep disturbances and job stress. Conclusions: Although smoking and alcohol consumption were both connected with coping strategies and leisure, they were predominant in immigrant groups compared to non-immigrant groups. Smoking and alcohol consumption can have problematic consequences on human health and they also impose economic costs to society. Smoking is responsible for more deaths than obesity, physical inactivity, or hypertension , resultiAs with the case of smoking, indicated above, alcohol consumption can also pose problems. Alcohol consumption is associated with esophageal cancer, liver cirrhosis, liver cancer, as well as toxicity, and accidental deaths, among other things ,12. It iPrevious research suggests that certain health behaviors, coping strategies, and defense mechanisms are often adaptation processes in response to stress, and include escaping, avoidance, disengaging behaviors, and diminished health-promoting behaviors such as reduced adherence to health-promotion practices, dietary restrictions, and smoking cessation . Indeed,While it has been well known that both smoking and alcohol consumption can be utilized as coping mechanisms to stress responses ,21, littThis study was derived from a larger project that utilized a single-case research design, which involved qualitative interviews, observations, and a survey for quantified description of LTC workers . The sitThe site had a total of 176 workers. Sampling and recruitment for this study was broad and included non-VMs and men in order to compare and contrast experiences. The recruitment methods were snowball techniques and direct purposeful recruitment by the principal investigator. Ethics approval was received from York University’s Office of Research Ethics (ORE) (STU2016-139), and participant consent was obtained in writing and signed.An ethnography was the primary data collection technique in which the sources of evidence were from direct observations and in-depth, key informant interviews. Observations and interviews were carried out by the researcher over two and a half months at a single LTC site between the hours of 6:30 a.m. and midnight, which were opportunistic times to observe the workers’ scheduled shift changes that occurred at 7 a.m., 3 p.m., and 11 p.m. Observations were conducted in secure, locked and unlocked units/wings at the site; in public spaces within the facility; and at the reception area. These spaces included hallways and dining areas on the individual units, a recreation space of the atrium located on the ground floor, an employee break room located at the mezzanine level, and spaces outside meeting rooms that were located in the basement level of the building. Fieldnotes were generated during observations, which documented preliminary thoughts, assumptions, and the physical setting. Observations sometimes included workers who had already participated in interviews. This was a way to trace and track the status of workers, e.g., immigrant/non-immigrant.Face-to-face, in-depth, semi-structured interviews were conducted with participants and digitally recorded. The semi-structured interview guide was broad and asked standard questions about the participants’ background; how participants started work at the LTC facility; how participants dealt with stress, either in their job or family life; and how participants felt after a day’s work. In addition, various probes and prompts were also utilized after responses to these questions. For example, participants were asked to indicate how they cope, how they unwind, and/or to elaborate and tell the researcher more about the topic of interest after they discussed their response.The goal of conducting observations and interviews was to gather rich data about the participants and their routines. For the quantitative component, an exploratory, paper-based pilot survey was distributed as well as a separate demographic questionnaire following each interview. The inclusion/exclusion criteria were that individuals must work within the health care sector in ancillary, support, or direct services, the worker’s roles must be directly related to the residential LTC facility. In all, 92 respondents filled and returned the survey, i.e., a response rate of 52% was achieved. One survey was excluded because the worker was not responsible for work that was related to any aspect of the LTC home. The purpose of the survey was to examine descriptive data such as smoking and alcohol consumption and the effects of sex or birth/immigration status. The survey asked participants whether they smoked cigarettes daily, occasionally, or not at all. The rationale was to assess whether or not tobacco use was light or heavy. Light or intermittent smoking was interpreted from the response “occasionally”, and heavy smoking was interpreted from the response “daily”. One person did not respond and was, therefore, excluded from the analysis. Mann–Whitney U tests were also conducted to test whether the distribution of being a cigarette smoker and the distribution of alcohol consumption was the same across categories of sex, immigrant status, and VM status. The survey also asked about alcohol consumption. Respondents were instructed to choose how often they drank alcoholic beverages over the past 12 months. There were seven choices to choose from, including an option to choose “not at all”. The rationale was to assess whether or not alcohol consumption was light/mild, moderate, or heavy. Light/mild alcohol consumption was interpreted from the responses “less than once a month”, “once a month”, “2 to 3 times a month”, while moderate consumption was interpreted from “once a week or 2 to 3 times a week”, whereas or heavy-alcohol consumption was interpreted from responses “4 to 6 times a week” or “every day”. One person did not respond to the survey and was excluded from the analysis. For the qualitative component, multiple units of analysis were organized by worker characteristics such as sex, job titles or roles, VM status, and employment type.The term VM was used instead of non-White for several reasons. Firstly, the use of dichotomous terms such as White/non-White has been criticized in the research literature . SecondlAlthough qualitative and quantitative data collection was carried out concurrently, there was “separate data analysis” . For theWorker demographic data from the interviews and survey responses are indicated in n = 83/90) of participants were non-smokers; however, 5.6% (n = 5/90) indicated “daily” smoking, and 2.2% (n = 2/90) indicated smoking “occasionally”  of participants reported not consuming alcohol at all (n = 13/90), followed by less than once a month , which were light/mild patterns of consumption. No one reported consuming alcohol 4 to 6 times a week; however, one person reported consumption every day, which was interpreted as heavy consumption.The survey results also indicated that 56.7%  (p < 0.006) (The results from the Mann–Whitney U tests indicated that while the distribution of being a cigarette smoker was the same across visible minority status (data not shown), it was not the same for sex   and immi< 0.006) , which wThe survey responses pertaining to alcohol consumption are listed in p < 0.001) , it was not the same for Canadian-born workers and immigrants  , which wThe qualitative data from observations did not provide significant findings with respect to smoking, alcohol consumption, stress-management techniques, or coping and defense mechanisms. However, interview data indicated that workers were exposed to high-stress environments and often employed a variety of coping mechanisms in order to minimize its effects. Interestingly, few participants disclosed smoking and alcohol consumption behaviors as a coping mechanism during face-to-face interviews. One possible reason for this trend might be that these activities are carried out as leisure activities as opposed to coping strategies. Another possible explanation is that there may be stigma associated with smoking and alcohol consumption, which may be perceived as socially unacceptable practices to discuss in workplace settings. The latter is important, especially given that the study was conducted in a health care environment, which could evoke additional pressure or stigma related to the health-related harms of smoking and alcohol consumption. This may have diminished disclosure among some interview participants during face-to-face interviews.The data suggest that various health-impacting practices that may be utilized as coping, defense mechanisms, or stress management techniques were widely practiced by employees in the LTC home. For smoking and alcohol consumption, only a few participants reported these activities during interviews, e.g., Participant 5 , Participant 26 . Participant 37 , indicated consumption of alcohol to cope with a sleep disorder rather than taking prescription medication whereas Participant 40  indicated consumption of alcohol for work-related stress management.One worker indicated that sometimes she used a dramatic method to regain her peace of mind:A: “Sometimes when I get too stressed, I go in the washroom and scream. Well it relieves me.” .Another worker took brief timeouts to practice mindful breathing when work became too stressful because she said she was becoming unhealthy and had chest pain:A: “I got sick of the stress. I had a lot of chest pains and I’m like, ‘No. I can’t not [sic] have stress get to me.’ When I close that door at 2 o’clock, I just have to let it go. And if I see something bothering me, I’ll just have to breathe […] Take my just two-minute break. I’ll just have a two minute.” .When a support staff worker was asked about coping with stress, they indicated the practice of mindful breathing:A: “Well, I take deep breaths, breathing technique, you know, and then sometimes I need like fresh air or cold air on my face, you know. I don’t know, probably to brush it off, but and just to be quiet, you know, and eat.” .Mindfulness and meditation practices were sometimes ritualized:A: “I love reading. And then, I have a little ceremony. When I know that I’m feeling stressed, I have a—you know those candles, like [laughs] are they stress free or something, stress free candle. I have music. And I just lie down, just let loose of your body. Lie down, don’t think of anything. It’s a [sic] very good, like, yeah, meditation.” .A nurse used solitary contemplation to cope with stress:A: “I don’t really meditate but I really just like to be on my own sometimes and just sit quietly in a room and not think about anything. I guess that’s my way of meditating, or just lay on the bed and just look at the ceiling, and just relax for like 10 min. Sometimes I fall asleep, sometimes I don’t.” .While the above participants used meditation and mindfulness as strategies of resilience, others indicated alternative strategies. When asked about how one deals with stress, a manager indicated that she would have moments where she would just break down and cry. The participant also said she listened to music, prayed, and had the support of her family. She reflected on religion in order to achieve a sense of purpose and perspective when confronting difficulties:A: “I think I cope. I try to cope. There’s moments when I just break down and cry. Crying for me is a good thing. […] I pray. Prayer for me is a big thing. When I feel I’m too stressed, I pray. Praying helps a lot. Pray and music. […] And family support. I mean my parents, very, very supportive. My husband, great support.”Many interview participants reported that they used solitary recreation as a coping strategy and indicated that they engaged in five forms of solitary recreation, including: watching television, reading, listening to music, engaging in a hobby , and traveling. When a nurse was asked about relaxation, she said the following:A: “As soon as I get home I just have to eat, watch my movies or watch my TV series for a little while and I’ll be fine. I’m back to myself.” .A manager watched movies on the home television and watched YouTube videos to purge negative emotions:“Sometimes I put a movie, like a drama movie that I want to cry or watch YouTube videos that I just break in tears. Always my kids watch me […] they just look at me, ‘Okay, she’s going to cry now.’ They don’t know the stress of my day. I like music. Sometimes I just pump it so loud in the car and it just give [sic] me this relief” .An ancillary worker said: “for mental repression I watch TV” . A PSW said she liked to listen to music and watch movies to de-stress:I: “You said you listen to music. Is that cultural music or—”A: “Yeah, yeah. I’m [cultural background]. You know, movie—we have the movies. I love to listen some music; same time, I have our religious song, too. That’s especially Friday.” .A nurse said she took short vacations when work-related stress became intolerable:A: “I go away when it gets too much, I’m off somewhere, I’m just like itching, I need to get away. When I’m stressed I start to be very irritable […] I get tired, that’s when I get tired because I’m just like I’m done, I need a break and when that happens I know I need to go take time off or take a trip, I just need to get away because I’m boiling.”I: “You like to go particular places or do you go any —?”A: “Niagara Falls or take a trip to the [overseas country] or just stay home, take a—for a couple days I just stay home, but I can tell when my stress level is not normal, it’s getting—I’m antsy and I’m bitchy and I’m—I don’t do as much of production as if I’m—no I don’t focus and I get mad at every little thing and I—they say and I said be because I’m just fed up—no because it’s bad, I just—I’m stressed.” .While participants used mindfulness, prayers, and solitary recreation as ways to cope, others indicated that they had very little time for those sorts of strategies, and instead drew upon social support from family, friends, and the community as a source of stress relief. For example, an allied health worker reported that time spent with her young son provided her stress relief:A: “My stress reliever’s [sic] my son, you know. I make sure I spend time with him, because if I just, you know, if I went to the gym or go to the gym, you know the time is short that you’re in, you should spend it with your son. You just read when he’s, you know, he’s playing, just read something that you know, self-help.” .A manager used conversations with friends and sisters as a coping strategy. She indicated that previously, her stress levels were so high, it affected her health and sleep patterns, to the point that she eventually resigned from her previous job. She revealed that she was personally against the use of medication because of their side effects:A: “Talking to my friends, you know, sometimes relieves the pressure. Talking and chatting. I have other sisters in other parts, not in Toronto, but you know, sometimes they visit and that kind of lightens the load a little bit. […] 15 years ago, or thereabouts, I had a breakdown, actually. A stressful thing because I was trying to manage everything […] And so, it all got to me, you know? Eventually. And it affected me, and I think also the—you give your best and when sometimes there’s no recognition, I think that also kind of affects your stress levels, you know? Or value given. So, I knew I had to stop. Actually, I stopped working, I actually resigned from my [previous] job. […] And I decided that I had to take care of my health because I had like, I couldn’t go to sleep and you know, I had all of those things. So, I kind of—I don’t believe in medication. Cause I know there are side effects” .For one allied health worker, conversations with friends was helpful and relieved stress:A: “I also—talking just to like my closest friends, sometimes, have [sic] been the best help. They don’t even have to say anything—just listening sometimes, you just get it off. And then, you can forget about [it], right, once you say it.” .A nurse indicated that she took leave for vacations and drew upon support by calling and speaking with friends and coworkers so that they did not feel isolated in their situations in which she would “vent” to upper management to cope with the stress. She also indicated that her coworkers socialized with each other:A: “I go on vacation. I just call up someone and I just vent. Or I vent to these people every day. Every day I see them I say this and this, and we walk in with that. Just to make it seem like we’re not alone. When you feel you’re not alone, it feels better. […] And then you know we’ll buy food once in a while, like when it’s someone’s birthday I’ll get her flowers. Like we’ll do things for one another. I close the door, I’ll sit with my manager, we vent to each other. I listen to her venting and I realize mine is nothing compared to hers. So yeah, it’s just the feeling of not being alone.” .While the above nurse felt she could confide in management, an allied health worker indicated she drew on support from her colleague:A: “There’s one in my department—we’re really close. We support each other all the time. We’re always backing each other up. And whenever there’s a problem with the management, too, we back each other up.” .A trainee also spoke of “venting” to her boyfriend to alleviate stress because she did not have time for anything beyond this strategy:A: “So if anything my boyfriend hears a lot about my stress and usually just venting is enough for me.” .Another worker had friends who worked in other LTC facilities, and they would meet and commiserate to de-stress. Other than this, the participant indicated that perhaps stress was a part of the way she worked and lived now, indicating the level of stress that was normalized in her experience:A: “venting—a lot of my personal—like my friends outside of work all work in long-term care. So, probably 90% of them work in long-term care and we just chat. You know, everybody has a best friend, you call your friend, you chat, you complain about the day. That’s about it. You know, the odd time you get together and over dinner as you meet with friends and everybody has a chance to complain about their job or talk about the funny things that happened at the job, that’s it. Other than that really it is just sometimes the best distress [sic] is just to sleep it away. […] Sometimes maybe it’s just stress is routine which is really scary but when you’re used to being in a stressful job I don’t think you know any different. So, I may not have a tool, I think it’s just the way I live my life now.” .A different support staff worker said he would read a lot and talked with a close friend to “unwind”:A: “I just—I read a lot. […] My roommate is a smart guy too, so we can have discussions about the world, or politics or stuff like that. […] That’s—I guess that’s how I unwind. […] And then there’s some guys that we hang out with on the weekends. Other than that, see the guys from back home every now and again.” .Previous research has suggested that in Canada, immigrants do not report elevated smoking intensity and alcohol consumption as coping strategies in response to work-related stress . The finCanadian studies of immigrants, racialized workers, and women suggest that these groups are often predisposed to high stress, chronic illness ,33,34, aSocial support is one of the key SDoH . The avaThis study is not without its strengths and/or limitations. One of the limitations of this study was that it was conducted with a single-case  investigation. Although such an approach means that the findings may not always be representative of and generalizable to provincial and national data, a strength of focusing on one site means that certain issues can be investigated in a deeper way, with a closer look at context. One of the strengths of this study is from its methodological approach. For example, mixed-methods research design is often rated for higher quality than other methods .Finally, there are several policy implications of this study. Firstly, given that health care workers were found to exhibit various coping and defense mechanisms, it may be useful to conduct further studies to assess their success so that there are opportunities for vulnerable workers who can benefit by learning these strategies to utilize them. Furthermore, sharing this information may be beneficial as a part of the organizational-level recruitment and training process. Another policy option is to minimize stress at its root cause rather than treating stress. For example, workers may be experiencing stress because of the underlying issues of food insecurity, which has been previously reported in the care work literature . FinallyThis work contributes to critical, interdisciplinary health scholarship by contextualizing social and behavioral health practices and coping mechanisms of workers in high-stress environments. The findings fill knowledge gaps in the health literature, while also suggesting typical health and lifestyle behaviors. For instance, workers reported smoking and alcohol consumption. However, these were rarely communicated in face-to-face interviews, possibly due to either stigma or because such consumption was not a coping mechanism but rather was for leisure or pleasure.This study reveals the tension and high levels of stress found in LTC workers in the region of study as well as coping strategies that could promote health and wellness. Given that chronic stress and illness are strongly connected to each other, it would be beneficial to explore further follow-up studies in order to assess the effectiveness of chronic stress management. Another opportunity for future studies would be to further explore culturally unique practices for health and well-being. Furthermore, given that this study was small in scope, future research might include a survey with a wider scope and scale that includes other provinces and jurisdictions across Canada, and also seek to understand what types of assistance care workers may need, both within and outside of the home.The evidence from this study demonstrates several important points. Firstly, it demonstrates that workers in the site of study often rely upon particular resources for support, such as for solitary recreation, in order to deal with the hazards stemming from their stressful, labor-intensive positions. The analysis also indicates that workers draw upon support from a variety of sources, including their co-workers.While work stress and workloads in the LTC sector are known to be overwhelming, strategies to address these issues are often limited to behavioral modification, such as diet and physical activity interventions, rather than including a holistic approach, which considers income, employment, education , social support, and other SDoH. In order to manage care and care work , it might be helpful to utilize particular initiatives that address and include SDoH, such as Total Worker Health©. Total Worker Health© initiatives aim to improve the health and well-being, of workers ,43,44,45


Parental nutrition was a stronger predictor of children’s intake of fruit, vegetables , and soft drinks . There was no mediator effect of PSE. However, outcome expectancies were associated with PSE . In conclusion, interventions should promote self-efficacy, outcome expectancies, and healthy nutrition for parents as well in order to strengthen the healthy eating habits of children.Overweight and obesity, as well as their associated risk factors for diseases, are already prevalent in childhood and, therefore, promoting healthy eating is important. Parental self-efficacy (PSE) and early health-promotion can be helpful in promoting healthy eating. The aim of this study was to examine the influence of PSE on children’s nutrition behavior and identify PSE as a mediator between an intervention and children’s nutrition. The kindergarten-based health-promotion program “Join the Healthy Boat” was evaluated in a randomized controlled trial with 558 children  participating at both times. Linear and logistic regressions as well as mediation analyses with potential covariates such as parental outcome expectancies or parental nutrition were carried out using questionnaire data. In children, PSE was positively associated with fruit and vegetable intake ( Non-communicable diseases such as cardiovascular diseases, cancer, or diabetes are one of the main causes of global deaths . The risIn 2017, an unhealthy diet was the cause of 11 million deaths and 255 million disability-adjusted-life-years . IncreasA healthy diet is vital for children because, on one hand, it contributes to a healthy cognitive development ,11,12 orThere seems to be a stagnation or even a decline of childhood obesity in developing countries, which public health programs have contributed to ,17. HoweEven though genetic predispositions play a role in the development of risk factors, family and  environment can affect children’s eating habits . ParentsIt has been suggested that parental self-efficacy is a predictor for children’s adjustment , and it On the other hand, parental self-efficacy has been shown to be helpful for a positive parent-child relationship, parental competence, educational quality, and  parental health, as well as child development and adaptability ,32,33. ABeside parental influence, kindergarten has been shown to be an ideal setting for health promotion because most children in Germany visit kindergarten during the period from birth to school entry . There, “Join the Healthy Boat” is a health promotion program for kindergarten children. Implemented in 2014 in southwest Germany, it aims to promote healthy eating, increased physical activity, and meaningful leisure time activities using behavioral and structural prevention aspects. The program was developed using the intervention mapping approach  and is bIn order to gain more theoretical knowledge about the potential of the construct of parental self-efficacy as well as predictors of children’s nutrition behavior, the aims of this study were to examine whether parental self-efficacy affects children’s nutrition, such as fruit and vegetable intake, as well as their consumption of sugar sweetened beverages.To date, there is limited research available on parental self-efficacy and early health-promotion in the kindergarten setting. The health promotion program “Join the Healthy Boat” offers an intervention that intends to positively influence children’s nutrition behavior, but by including the family environment, the intervention potentially affects parents’ self-efficacy as well. In addition, this study tried to identify parental self-efficacy as a potential mediator between the intervention “Join the Healthy Boat” and children’s nutrition.The kindergarten intervention “Join the Healthy Boat” was developed using the Intervention-Mapping-Approach . Based oSimilar to the associated primary school intervention , the keyBespoke materials for parental work were designed appealingly, were drafted in easy and plain language, and offered specific action alternatives as well as health-related information. Kindergarten staff were provided with ideas and opportunities  to present health relevant information to parents without them having to feel imposed upon.Data used for this study was retrieved from the evaluation study of the kindergarten program “Join the Healthy Boat”, which is a prospective, stratified, cluster-randomized longitudinal study with a control and an intervention group. Sixty-two kindergartens were randomized equally into a control or an intervention group. After baseline measurements, the intervention was implemented into the daily life of the kindergartens in the intervention group for one year. Follow-up measurements were conducted after that year, after which the kindergartens in the control group also implemented the program. More details of the evaluation study on recruiting, stratification, etc., are described elsewhere .The evaluation study was registered in the German Register of Clinical Trials (DRKS-ID: DRKS00010089). Ethics approval was obtained from the university’s ethics committee and the Ministry of Culture and Education and was carried out according to the Declaration of Helsinki. Parents gave their written informed consent for the study, and the children gave their oral assent on site .At baseline, 973 children in 57 kindergartens aged 3 to 5 years  participated. The final distribution of the intervention and the control group was 30 to 27 kindergartens, respectively, due to the drop-out of 5 kindergartens. At follow-up, a total of 558 (57%) children aged 4 to 6 years  participated and were used for data analysis. More than half of the children were male (52.3%), 1/3 had a migration background (33.4%), and almost half of the children came from families with a high education level (48.7%). The following instruments and methods were used for the data analysis of this study; other instruments of the intervention study are described elsewhere . Using aMigration background was operationalized as a dichotomous variable with one level as “Children with at least one parent born in a foreign country or children who were spoken to in a foreign language for the first three years or their life” based on the definitions of the Federal Statistical Office  as well To include the potential specificity of self-efficacy beliefs , parentaThe scales regarding the effects of parental self-efficacy on children’s intake of fruit and vegetables as well as on children’s consumption of sugar sweetened beverages were assessed with six items each  and wereThe scales for parental outcome expectancies on children’s intake of fruit and vegetables as well as sugar sweetened beverages were assessed with six items each and conceptualized as, for example, “If my child drinks less sugary sweetened beverages, it is good for their teeth” with a seven-point Likert scale. More detailed information on the scales are shown in The dietary intake of children, mothers, and fathers were assessed with four items each, querying the portions of fruit, raw and cooked vegetables, and vegetable juice consumed during the week (“never” to “three times per day or more”). The intake of sugar sweetened beverages was assessed by one item each, asking if sugar sweetened beverages were consumed “never” to “repeatedly during the week”. To have a better comparison, mothers’ and fathers’ dietary information was combined and calculated as parental intake. Fruit and vegetable intake was calculated as a metric variable whereas consumption of sugar sweetened beverages was calculated as a dichotomous variable, with one level as “sugar sweetened beverages once a week or more”. Multiple linear regression analyses for the metric dependent variable “children’s fruit and vegetable intake” were carried out. Logistic regressions were used to analyze associations between parental self-efficacy and children’s intake of sugar sweetened beverages at least once a week or more. Several requirements for regression analyses ,55,56 haTwo different analyses tested whether parental self-efficacy is a predictor of children’s intake of fruit and vegetables or sugar sweetened beverages, respectively. It was controlled for age, gender, migration background, family education level, parental intake of fruit and vegetables, and parental consumption of sugar sweetened beverages, as well as outcome expectancies on children’s intake of fruit and vegetables and sugar sweetened beverages.To examine a potential mediator effect of parental self-efficacy, the interaction effect between intervention, parental self-efficacy, and children’s intake of fruit and vegetables as well as sugar sweetened beverages was tested for significance. The mediation analyses were carried out with PROCESS . PROCESSThree different regression analyzes for each dependent variable  were carried out using the control variables of age, gender, family education level, migration background, and parental outcome expectancies. To identify the potential effect of the intervention on parents or children, parental self-efficacy and children’s nutrition values at baseline were used as control variables as well. One analysis examined the effect of the intervention on parental self-efficacy, the other two examined the role of the intervention on children’s nutrition with and without the mediator as a control variable.Based on these calculations, a significance test for the indirect effect using the bootstrapping method and its generated confidence intervals was performed. Preacher and Hayes  recommenp = 0.031 and p = 0.028, respectively).Children’s and parents’ characteristics are presented in ß = 0.237  p < 0.001) as well as parental intake of fruit and vegetables  were positive predictors of children’s intake of fruit and vegetables, even though parental consumption has a slightly higher standardized regression coefficient. No other variable had a significant effect on children’s fruit and vegetable intake  0.728  p = 0.002) as well as tertiary family education level , and being female  had an inverse effect on children’s intake of sugar sweetened beverages. On the other hand, if at least one parent consumed sugar sweetened beverages at least once a week or more, the chance that children consumed sugar sweetened beverages at least once a week or more increased significantly  on children’s intake of fruit and vegetables. There was no effect of the intervention on parental self-efficacy  or children’s intake of fruit and vegetables . The non-standardized indirect effect between the intervention, parental self-efficacy, and children’s fruit and vegetable intake was −0.008 with a 95%-confidence interval of −0.029 to 0.003, which shows no significant effect either. Individual analyses showed no significant effect of parental self-efficacy , and parental intake of fruit and vegetables had an effect on children’s intake of fruit and vegetables . Some baseline control variables affected variables at follow-up . There was no significant effect of the intervention on the mediator parental self-efficacy  p = 0.592) nor on children’s intake of sugar sweetened beverages . The non-standardized indirect effect between the intervention, parental self-efficacy, and children’s intake of sugar sweetened beverages was −0.020 with a 95%-confidence interval of −0.064 to 0.123, which showed no significance either. In the individual analyses, a significant effect of parental self-efficacy on children’s intake of sugar sweetened beverages could be observed . There was no significant effect of gender or family education level, compared to the first analyses. Some baseline control variables affected variables at follow-up  the effect of parental self-efficacy on children’s fruit and vegetable intake can be confirmed with reservation.Family education level and children’s gender showed significant associations with the consumption of sugar sweetened beverages, but not with their fruit and vegetable intake. Similar findings were observed in the KiGGS-study, which found significant gender differences in fruit and vegetable intake in 11- to 17-year-olds, but none in 3- to 10-year-old children . In contMoreover, it has been shown that children from families with low socioeconomic status are more likely to consume less fruit and vegetables and to drink more lemonade . This coAge, migration background, or parental outcome expectancies did not affect children’s nutrition at follow-up. In an Australian study , the levIt is known that migration background can impact on children’s nutritional behavior . HoweverIn diabetes patients, outcome expectancies combined with the self-efficacy of those patients were the strongest predictors of their own nutritional behavior . TherefoIt should be noted that parental intake of fruit, vegetables, and sugar sweetened beverages has a significant to a highly significant effect across all analyses and, in contrast to other influencing variables, has the highest contribution to children’s intake of fruit, vegetables, and sugar sweetened beverages. Parents’ own consumption can be seen as an example of what to eat, but will also reflect what is available at home. Both components are key influences for children’s nutrition ,23,24. SParental self-efficacy could not be identified as a mediator between the health promoting intervention and children’s nutrition, which might be explained by the disappearance of the significant influence on fruit and vegetable intake, as well as by the fact that the intervention had neither a significant effect on the mediator nor on the children. In the evaluation study of the program “Join the Healthy Boat” , no signThe intervention had no significant effect on parental self-efficacy, which could be due to parental involvement only through letters and parents’ nights; there was no so-called family homework as implemented in the intervention for primary school children ; therefoIn order to correctly interpret the results discussed, the strengths and limitations of this work should be considered. One strength of this study lies in the underlying data from the evaluation study. With its cluster-randomized waiting control group design, valid statements can be made about causal relationships in relation to the predictors of children’s health behaviors. The high and diverse sample, as well as the recruitment across the southwest of Germany, strengthens the study. However, the southwest is rather well-off compared to other states, which is also reflected in the high proportion of families with tertiary education levels in the sample, so that a generalization to other federal states is not necessarily possible. Furthermore, a selection bias cannot be ruled out, because mostly kindergartens with an affinity for health promotion as well as health-conscious and well-educated parents agreed to participate in the study. In terms of method, it should be noted that the measures are based on self- and external assessments of the parents regarding their own and their children’s behaviors, which were not tested again for reliability and validity. A source of error could be social desirability as well as the wrong estimations of children’s nutrition while being at kindergarten.The mediation analysis with PROCESS should be mentioned as a strength, because the problems with the practice postulated by Baron and Kenny  can be rAnother point that should be noted positively is the consideration of parental self-efficacy in relation to children’s individual behaviors because this enables differentiated statements about the effect and potential influence of the construct of parental self-efficacy. However, as mentioned at the beginning, parental self-efficacy poses a definition difficulty. Because it is derived from the general theory of self-efficacy without having its own theoretical framework , it is gThe operationalization of individual variables should be changed for future research. For example, no further distinction was made between mothers and fathers. The level of family education was only considered in two categories and was used as the only indicator of socioeconomic status. Therefore, it would be important to differentiate the consumption, self-efficacy, and outcome expectancies between mothers and fathers because other studies showed special influences of the mothers ,38. For In conclusion, in spite of the work’s limitations, parental self-efficacy can be seen as a predictor for children’s intake of fruit, vegetables, and sugar sweetened beverages. As a recommendation for the intervention ”Join the Healthy Boat” and other health promoting interventions, parents should be included more intensely. The focus should include parental nutrition, parental self-efficacy, and parental outcome expectancies, as this can have direct and indirect effects on children’s nutrition. Gender, age, migration background, and family education level had inconsistent or no effect, but this could be because differences appear later in life, which highlights the need for early prevention. In future research, parental self-efficacy on children’s physical activity in kindergarten children could be discussed to specify the potential effect and use it for the intervention “Join the Healthy Boat” and other health promoting interventions.


To explore the introduction of an evidence-based information intervention – the ‘Caring for Someone with Cancer’ booklet – within home care and end-of-life care, to inform future implementation and practice development within this setting.Family carers’ contribution is crucial to enable care and death of people at home. The ‘Caring for Someone with Cancer’ booklet received positive responses from family carers and District Nurses and is an evidence-based intervention designed to support carers to deliver basic nursing tasks. Further feasibility work was required to establish how it should be implemented. Little is known about how to successfully translate interventions into practice, particularly within home care settings and end-of-life care.Implementation of the ‘Caring for Someone with Cancer’ booklet, utilising a qualitative case study approach, in four home care sites. Semi-structured interviews, informed by Normalization Process Theory (NPT), were undertaken at implementation sites in May 2016–June 2017. Participants were generalist and specialist nurses, managers, and Healthcare Assistants (HCAs). A framework approach to analysis was adopted.“just getting through the day”. Implementation was successful in sites with explicit management support, including proactive implementation attempts by managers, which legitimatised the change process, and if all staff groups were engaged. To encourage uptake of evidence-based interventions in home care settings, practitioners should be given opportunities to critically reflect upon taken-for-granted practices. Future implementation should focus on work pertaining to the NPT construct ‘Collective Action’, including how staff interact and build confidence in new practices.Forty-five members of staff participated. Failed implementation was associated with organisational-level characteristics and conditions, including workforce composition and predictability of processes. Unstable work environments meant home care providers focused on short-term rather than long-term goals, precluding practice development. Staff’s perceptions of the time available to engage with and implement the intervention inhibited adoption, as many participants were  NPT focuses on the process through which new ways of thinking, interacting, and organising work are embedded, sustained, and ‘normalized’ in practice  actively implement the booklet intervention with home care providers using NPT and (2) identify barriers and facilitators for a successful implementation of the booklet intervention, including contextual factors that influence adoption to inform future implementation of evidence-based interventions in this setting.et al., et al., Due to the issues raised in the feasibility study . Four cases  within the case study area were purposefully selected to actively implement, and evaluate the implementation of the intervention Table .Information sessions, led by the researcher (AM), were used to ‘kick start’ implementation  took part in one interview (pre- or post-implementation). Reasons for this included work commitment, staff rostering, participants leaving the organisation, or site withdrawal from the study.Interviews were conducted by one researcher (AM). Topic guides were tailored to individual case study sites and were informed by NPT Box  The provision of information/support for relatives and participants’ end-of-life care training (Coherence and Cognitive Participation)Initial impressions of the intervention (Collective Action)Implementation strategies, delivery processes, and implementation work (Reflexive Monitoring)Evaluation of the intervention and its implementation ?Has your understanding of your role in supporting relatives changed? Why/why not?All staff members who had access to the booklet, or could provide information about its implementation, were eligible. Internal Facilitators initially contacted potential participants who, with their permission, were introduced to the researcher. All participants had time to consider their involvement, and interviews were arranged at a time convenient to them. Snowball sampling techniques, whereby participants were asked to suggest potential informants, were used once data collection was underway Coyne, .Interviews were held in private rooms at the case study sites. Interviews averaged 46 min in length. All interviews were digitally recorded, transcribed verbatim, and anonymised. Written informed consent was obtained from participants prior to each interview. All participants received a ‘Certificate of Participation’ in exchange for their time, which were thought to be an incentive for skilled staff to include in their professional development portfolio and/or contribute to revalidation.Forty-three females and two males participated, spread across the four case study sites . This was widely stated as the reason for failed implementation attempts, and was recognised as a potential barrier to other areas of practice development: ‘you don’t want to start a research project with somebody that’s going to leave’ (HaH01 Site 4).Organisational changes within the NHS in general and specifically within the organisations, in conjunction with demands on staff, possibly due to competitive tender, appeared to result in a number of staff leaving across case study sites. All participants, with the exception of Hospice@Home, discussed the high turnover of staff and current ‘I don’t really know how things are going to pan out in the future. It’s like the million dollar question’ (CHS1 Site 1). This suggests there was an absence of ‘change efficacy’; the shared belief in the staff’s collective capability to execute actions involved in implementation . Despite evidence to suggest the booklet intervention could save clinical time .Similarly, the District Nurse site was undergoing a turbulent period due to staff shortages. The District Nurse team was understaffed for the study’s duration and relied upon agency staff. District Nurse participants discussed the challenges associated with everyday practice, and it was considered an inappropriate time to introduce and integrate something new: ‘otherwise it’s like trying to ice a cake that’s not been baked’ (TS01); with a lack of continuity inhibiting adoption.A stable workforce was thus considered an important facilitator when implementing new practice: ‘“ We’ve had different nurses…when [name of nurses] were here they’d say “I’ve just given such and such that book”…the [nurses] we’re getting now, they’re not here on a regular basis…the one we have on today might not be on for another couple of weeks… so it’s not the same communication” - CHS3, Site 1The availability of support from other staff members was a key factor in ensuring the successful implementation of the booklet, particularly within the nursing home settings. Specifically, the lack of continuity with nurses in this setting, who were perceived as leading the intervention, and the reliance on agency nurses, resulted in individual adoption, which was haphazard:upset’ and ‘disheartened’ by the absence of manager support, suggesting there was a disconnect between the manager’s perception of the change process and staff’s morale, and that belonging to frontline staff. This often resulted in staff leaving the organisation, which had an impact on subsequent practice development:“If I was the owner of a factory and suddenly all my senior staff or very experienced carers were upping and leaving, I would have been down on the shop floor saying “what’s going on?”, and that’s what we didn’t get. And it was soul destroying.” – CHS1, Site 1When reflecting upon past practice development, many participants discussed the lack of direction from managers and few allocated resources to support staff adjusting to change, resulting in staff feeling ‘abandoned’ and ‘alienated’. Participants claimed they were ‘sweeping’, or if there was a lack of communication from managers regarding developments. For example, HCAs in nursing home settings usually became aware of changes to practice through ‘word of mouth’: ‘One day when you’re off it just comes, this is a new thing, you have to go and do it’ (CHS204 Site 2). Thus, HCAs appeared to be ‘kept in the dark’ regarding current or future changes. Conversely, nurses were informed of practice developments, which was then cascaded down to HCAs:“I: When something new is introduced, how are you told about it?Email or you get told by the nurses. They get the information first and they pass it on to us.” – CHS209, Site 2Staff’s sense of ‘abandonment’ was exacerbated if the changes were perceived to be ‘New practices were therefore largely adopted and normalised by nurses, whereas HCAs’ adoption was often delayed.do anything extra’ as they were ‘just getting through the day’; thus, prioritising other tasks over implementation work. However, the time required to deliver the booklet was minimal, suggesting the reported lack of time was instead a consequence of family carers having more information and thus asking nurses more questions. By claiming to ‘be busy’, nurses may restrict patients’ and family carers’ ability to ask for, or access, additional support  and there was ‘never a break’ (CHS9 Site 1). One participant compared her increasing workload to being on a ‘rollercoaster’, unable to fulfil all her duties within the time available during a shift. Consequently, nursing home staff had to prioritise their workload. Nursing home participants claimed residents care ‘comes first’. Therefore, work related to the resident’s care including new admissions, death of a resident, and communication with relatives was perceived as tasks that required immediate action and were thus prioritised, delaying implementation work.Similarly, in the nursing homes, participants discussed the chaotic nature of their work, claiming there was ‘demands of modern auditing’ (CHS1 Site 1), which was compounded by staff shortages and the use of agency staff, nurses were unable to interact with relatives, which may involve delivering the booklet.In addition, scheduled tasks within the nursing home settings took priority. For example, medication rounds consumed the majority of nurses’ time and could be considered a ‘scheduled task’, as they occur at the same time every day. Documentation presents another demand on nurses’ time, which precluded their involvement in implementation and practice development. Documentation makes the invisible visible, which arguably improves communication and continuity of care , limiting their engagement in practice development. Overall, the hospice, in which the Hospice@Home team was based, was perceived as ‘an open culture for change’, which aimed to ‘develop and share’. Consequently, Hospice@Home staff were given time to participate in the research and were encouraged by the manager. It is likely that Hospice@Home participants had ‘more time’ to engage in implementation work compared to other sites, most notably District Nurses.Successful implementation required the organisation to be conducive to change, whereby sufficient resources to support the change process were allocated. Across the sites, a variety of perspectives were expressed regarding research and changing practice. Some participants emphasised the need to ‘fell by the wayside’ because the two Internal Facilitators left, who were perceived as influential local champions. Leadership, including the influence from senior nurses as role models, therefore facilitated the implementation of the booklet intervention.Leadership was considered a crucial factor in potential adopters gaining the confidence to use the intervention. For example, in Nursing Home 1, there were persistent claims that implementation ‘hub’, who engaged in work to keep the intervention visible. In turn, the Clinical Service Manager supported the Hospice@Home Coordinator in her role as Internal Facilitator, describing herself as a ‘leader’ rather than a manager who is ‘more hands on than most people’ (HaH08 Site 4). Participants suggested that the characteristics of a ‘good leader’ includes being knowledgeable of patients, residents, and their families; and taking a ‘hands on’ approach yet giving staff the freedom to organise and develop their practice. Furthermore, constantly communicating with staff, being a ‘port of call’ and approachable were perceived as characteristics of a ‘good leader’. The abovementioned ‘good leader’ was a facilitator in this study.In contrast, HCAs in the Hospice@Home team had clear leadership and role models in the service co-ordinator and staff nurse. Participants perceived the Hospice@Home Internal Facilitator as the ‘As end-of-life care was the main remit for the Hospice@Home team, the intervention was considered relevant to staff within this site, and thus potential adopters perceived engagement in implementation work to be a legitimate use of their time. The team was, therefore, open to the change process and the booklet was successfully integrated into their routine practice. In contrast, some participants at other sites – where end-of-life care was only a partial remit – considered the innovation to be incompatible with their norms, values, and perceived needs of family carers. These participants resisted adoption and did not deliver the booklet.The Hospice@Home participants also demonstrated that they worked as a team, and staff felt supported by their colleagues. In contrast to the nursing home sites, there was a sense amongst the Hospice@Home participants that each member positively contributed to the team’s work, and the booklet’s implementation. Specifically, participants discussed the knowledge and expertise within the team, which was accessed when supporting family carers. Consequently, not only was the booklet intervention applicable for staff within this site, but also staff were able to adapt the innovation by providing additional support – with help from colleagues – to meet the needs of their service users; facilitating implementation and encouraging adoption.HCAs within the nursing home settings claimed they did not feel confident delivering the booklet, as they may disclose prognosis or may be unable to answer relatives’ questions, indicating a ‘Closed Awareness’ ; indeed, they needed to be ‘told what to do’. This suggests leadership is not only needed to support staff adjusting to change, but is also important in giving potential adopters the authority to change their practice. That is, not the autonomy to introduce changes without approval from the manager, rather directing staff on how to change their practice based on decisions they have made:“I think… giving out these books, we can’t do that. We need our management to tell us, we can do it” – CHS207Hospice@Home staff, compared to HCAs within the nursing home settings, were autonomous; not only in the management of their caseload but also within practice development, including the adoption of the booklet. According to one participant, nursing home HCAs required ‘In this study, we aimed to better understand the implementation of evidence-based interventions in home care settings by exploring adopters’ experience of implementing the ‘Caring for Someone with Cancer’ booklet in four case study sites. We identified a number of contextual factors, which inhibited or enabled practice development in home care settings, including workforce composition and predictability of processes; management and peer support; time management; and organisational ethos, leadership, and culture.et al., et al., et al., ‘Context’ is widely recognised as a contributing factor to implementation in the theoretical literature  supports this view, and highlights the importance of assessing organisational context when implementing evidence-based intervention and planning for practitioners’ disengagement. A companion paper also highlights the importance of the facilitator role in terms of ‘leverage’ within the team, communication skills and styles, and supporting peers  research has shown, leadership in the form of registered nurses as role models, can facilitate HCAs’ learning regarding the principles of palliative care and the development of knowledge and/or practice.It has been recognised for over 15 years that management support is particularly important to the success of change processes, as managers often dictate how resources in an organisation are used  and encourage engagement. However, research suggests that setting time aside alone is not adequate  was also relatively limited (6–12 months). Furthermore, only 10 participants across the four sites took part in both stages: pre- and post-implementation interviews. A future study could explore the sustainability of the booklet intervention, and further test the facilitators identified in this study, to encourage the uptake of other evidence-based interventions in home care settings.few tweaks’ the booklet would be suitable for any life-limiting conditions. Specifically, participants that attributed worth to the intervention acknowledged there was a gap in service provision and family carers require more support to fulfil patients’ preferences to be cared for and die at home. The booklet was considered a means to pass on some of the knowledge required to fulfil this; specifically, on ‘what to expect’ when the patient approaches the end of life. The intervention was received positively by family carers across all sites, which encouraged many members of staff to use it.Notwithstanding the study’s limits, the findings make an important contribution to implementation literature, both within the area of home and end-of-life care as: (a) it is one of the first to use NPT to drive the implementation process, (b) provides an in-depth exploration of implementation, solely utilising qualitative methods, and (c) provides evidence that, despite the booklet being originally developed to be used as an adjunct to district nursing, it could be used within nursing home settings, both to support relatives and educate staff members. Furthermore, by exploring the delivery – or not – of the booklet, this study provided further justification for use of the intervention in palliative home care for cancer patients, and revealed with a ‘This study reveals unique challenges experienced by home care providers and researchers when attempting to change practice within this setting, including turbulent change and a focus on short-term rather than long-term goals. At the time of this study, care in the community appeared to be in crisis, as a result of underfunding and high staff turnover Drennan, . Partici


Previous literature has explored the underrepresentation of women in surgery. However, this research has often been quantitative or limited by considering only the perspectives and experiences of women at more advanced career stages. Here, we use a qualitative methodology and a sample of women and men across the career continuum to identify the role that gender plays in the decision to pursue a surgical career.We audio-recorded and transcribed semi-structured interviews conducted with 12 women and 12 men ranging in their level of medical training from medical students to residents to staff surgeons. We used Braun and Clarke’s six-step approach to thematic analysis to analyze the data, maintaining trustworthiness and credibility by employing strategies including reflexivity and participant input.Our findings suggested that the characteristics of surgery and early exposure to the profession served as important factors in participants’ decisions to pursue a surgical career. Although not explicitly mentioned by participants, each of these areas may implicitly be gendered. Gender-based factors explicitly mentioned by participants included the surgical lifestyle and experiences with gender discrimination, including sexual harassment. These factors were perceived as challenges that disproportionately affected women and needed to be overcome when pursuing a surgical career.Our findings suggest that gender is more likely to act as a barrier to a career in surgery than as a motivator, especially among women. This suggests a need for early experiences in the operating room and mentorship. Policy change promoting work-life integration and education to target gender discrimination is also recommended. A greater representation of women in surgery may increase patient-centered care, particularly for women patients,9 and improve working conditions for the profession as a whole.10Gender is a significant determining factor in career selection, with fewer women interested in a surgical career than men.11 a lack of role models and/or appropriate mentorship,7,12-16 experiences with sexual harassment and/or gender discrimination,12,14,16,17 and perceptions about the challenges of a surgical lifestyle and a lack of parental leave or childcare.10,12,14,18,19 However, a large number of the existing studies on gender in surgery are quantitative in nature, which may not fully capture the nuances of why and how these challenges are experienced. Furthermore, with the exception of work by Brown and colleagues,10 much of the work on gender in surgery focuses exclusively on the perspectives of women. While this is important to amplify and legitimize the voices of those who have historically been marginalized, we believe that gender equity can only be attained through a concerted effort from the surgical community as a whole, which includes individuals of all genders.In order to improve gender equity in surgery, a necessary first step is to understand the factors that contribute to individuals’ career choices. Existing literature on this topic has uncovered a variety of explanations for the lack of women in surgery, including the association of surgery with traits that are normatively masculine,The goal of our research was to address the following research question: “What role does gender play in the decision to pursue a surgical career?” We approached this question using interviews that considered the experiences of both women and men across the career continuum, including medical students, residents, and staff surgeons.20 to our research as career choices are often complex and multi-faceted; thus, speaking directly with participants allowed us to develop a more nuanced understanding of how individuals decide upon a career in surgery and the role that gender plays in this process. We opted to use interviews over focus groups to respect the personal and potentially sensitive nature of some of the interview questions.20We chose a qualitative, interview-based approach20 generated an initial list of potential participants that included medical students, residents, and staff surgeons from two academic centres in Ontario, Canada. We included both women and men in our sample. We also attempted to recruit non-binary individuals; however, we were unable to identify any such individuals who were interested in or pursuing a career in surgery. Although participants were from Canadian centres, some participants’ backgrounds allowed them to speak to their experiences both within and outside of Canada, providing us with a rich data set. We reviewed our initial list of participants and filled any gaps using online department lists to ensure a sample that was representative of the various surgical specialties and levels of training/seniority within each participant category.After receiving ethical approval from the Hamilton Integrated Research Ethics Board (HiREB-0629), we purposivelyWe contacted 30 potential participants via email and, if they agreed to participate, obtained written informed consent. We subsequently asked participants to complete a demographic questionnaire and scheduled an interview at a time and location of their choice.We conducted semi-structured interviews with medical students, residents, and staff surgeons between February and June 2017. A sample interview guide is provided in A graduate student in health professions education (AA) and a research assistant (JW), both trained in qualitative research methods, conducted the majority of interviews in this study. On occasion, other research trainees also assisted with the interviews under the guidance of these researchers. Each interview lasted approximately 20 minutes (range: 10 to 50 minutes). No further themes arose after approximately 18 interviews; however, we continued sampling until we had an equal number of participants in each training category, and an equal number of women and men in our sample. The additional interviews helped to confirm themes and reinforce our conceptualizations of the data.21 to thematic analysis to analyze the data. Thematic analysis is a flexible approach to qualitative data analysis that allows researchers to generate a rich, nuanced account of a phenomenon of interest.21 We began by familiarizing ourselves with the data by transcribing each interview and reading the resulting transcripts in their entirety several times. This was followed by the generation of initial codes, which identified features of the data that were relevant to our research question. We then grouped related codes into themes and generated a thematic map in order to further scrutinize the themes developed from the data. Once this process was complete, we defined and named the themes and used them to produce a written account of the data.We used Braun and Clarke’s six-step approachA graduate student in health professions education research (AA) and an undergraduate research trainee (KM) performed the data analysis. Both are non-MDs and therefore brought an outside perspective to this work. The research team corresponded frequently to discuss our conceptualizations of the data and to construct themes. We employed a number of strategies to help ensure the trustworthiness of the data, including reflexive journalling, documenting the analytic process, regular debriefing with more experienced clinical and non-clinical researchers, and seeking input from participants on the themes developed from the data.Twenty-four individuals (12 women and 12 men) participated in the study. Participants came from two academic institutions, with one providing the majority (21) of participants. An equal number of medical students, surgical residents, and staff surgeons were included in our study. Collectively, these individuals represented seven surgical specialities. Participants had varying levels of training and experience in surgery. All medical students had experienced at least one surgical rotation and/or elective but had differing views on their likelihood of pursuing surgery. Five were clearly interested in a surgical career, two were clearly uninterested in a surgical career, and one was undecided and hesitant about a surgical career. Residents ranged from first to fourth year, while staff surgeons varied in their experience from newly appointed to approximately 20 years in clinical practice. A summary of the sample characteristics is provided in Participants’ initial explanations of why they had chosen a surgical career did not explicitly make mention of gender-related factors. Instead, their responses focused on factors such as the characteristics of surgery and early exposure to the profession.Characteristics of surgery: Alignment between participants’ personal strengths and the characteristics of surgery was an important determining factor in their career choices. Participants emphasized the “doing” as opposed to “thinking” and “procedural” rather than “diagnostic” nature of surgery, which catered to individuals’ interests in a hands-on approach to medicine. One participant explained: “I really liked the hands-on aspect. I really like to be able to see the problem, diagnose the problem, and then fix it and see the results right away” . Others highlighted the appeal of immediately visible outcomes, often leading to a sense of immediate gratification: “The first case I saw was a cancer case, so the patient walks into the room with cancer and they walk out, and it’s gone. That kind of immediacy … that’s what was really exciting to me” .Another appealing aspect of surgery was the ability to address a variety of complex health challenges as part of a team: “The teamwork is amazing. I just love it” . Other described the “adrenaline rush” associated with high-acuity surgical cases, which some participants believed attracted “a very specific personality type. It’s the same type of people who would like certain high-adrenaline sports, and … become marathon runners” . Participants also enjoyed the day-to-day variety inherent in a surgical career, both in terms of the cases encountered and the tasks performed.Early exposure: Early exposure to the profession was also an important factor in participants’ decision to pursue surgery. Participants listed classes with professors specialized in particular surgical specialties; electives, rotations, and observerships; and targeted programming as particularly influential in instigating interest in surgery. While positive experiences in surgery were influential in motivating trainees to pursue a surgical career, negative experiences could serve as a deterrent. For example, one participant described how his clinical clerkship made him feel that surgery was an intimidating environment: “Some of the trainees that were in that surgical specialty … gave me the sense that you needed to eat, breathe, and sleep only [surgery] in order to survive” .Previous academic and life experiences could also incite excitement in surgery. These experiences ranged from personal injuries to non-medical undergraduate and postgraduate backgrounds in construction, engineering, illustration, and sports. In other cases, however, participants’ interests directed them away from surgery. For example, a medical student with an interest in public health explained that he did not intend to pursue surgery because it “is so far away from everything that I am interested in” .Gender-based factors: Although gender was not explicitly mentioned by participants when describing their motivations for pursuing surgery, most participants viewed it as a challenge that needed to be overcome when deciding on a surgical career. We elaborate on the various gender-based factors discussed by participants below.Lifestyle and becoming a parent: Issues around the surgical lifestyle and becoming a parent were the most prominent career-related challenges mentioned by participants. While participants did not always explicitly indicate what they meant by the term “surgical lifestyle,” common sentiments included the lengthy training period and long working hours that could sometimes preclude individuals from focusing on other areas of their lives . While both women and men acknowledged these challenges, they were seen to disproportionately affect women. One participant explained, “I think that at a cultural level, at an instinctive level, people still have biases for who’s supposed to be at home raising the children” . Another remarked, “Gender doesn’t become a challenge until you actually become a mother. That’s where it becomes much more challenging” . Participants described a variety of challenges related to becoming a parent including the challenges of pregnancy and breastfeeding while performing surgery; the social stigma associated with taking pregnancy and/or parental leave; challenges accessing childcare; fear of skill decline; and longer-term impacts of parenthood on career advancement, such as a longer time spent in residency training or fewer women in higher-ranking academic positions.Lifestyle challenges were exacerbated when both spouses had demanding careers: “I think [in the past] the surgical lifestyle was based around the premise that you had a single-income family, where you had a spouse who was essentially at home … helping out with a lot of the … day-to-day work” . Surgeons with spouses who had more flexible careers, on the other hand, were more likely to consider their partner an important source of support in maintaining a family life: “My husband decided not to work anymore, or at least not to work full-time, to be with our kids” . Along similar lines, both the women and men in our sample acknowledged the importance of non-childbearing  leave in more equitably distributing childcare duties between genders. However, many participants found it hard to fully take advantage due to social stigma. For example, one participant recalled overhearing a senior surgeon say: “‘He’s losing money to raise a kid. … You should have your wife around to help you raise your kid.’” .Stereotyping and gender discrimination: Additional challenges were related to stereotyping and gender discrimination, including sexual harassment, when interacting with colleagues and patients. Stereotyping among women was common, with many women reporting that they were often mistaken for nurses or medical students and could be met with resistance from nursing staff or allied health professionals when giving orders: “I find that they’re not necessarily coming to me with issues. They will come to the male juniors or … I’ll get a lot of resistance” . Women participants also shared numerous examples of inappropriate comments made by patients or colleagues, for example: “‘I never thought I’d have … a beautiful young woman examine me like this’”  or “‘If I was your dad, I wouldn’t have let … my daughter, go into general surgery’” .Gender discrimination was not exclusive to the women in our sample, although these challenges presented themselves differently in men than in women. A controversial finding was men in OB/GYN reporting on the difficulty of gaining clinical experience with sensitive procedures: “I think gender … played a big role in my learning. Just because patients didn’t want a male to come in and … do an exam” . While some men felt that this was an example of gender discrimination that could affect their educational experiences in certain specialities, one might question the extent to which a woman’s autonomy to choose her care provider during sensitive procedures is actually discrimination or patient autonomy. Nonetheless, we chose to include this finding here given its prevalence in men’s responses. Some men also felt that they received harsher feedback compared to their women colleagues or were socially isolated because they did not conform to traditional, gender-based stereotypes. As described earlier, participants frequently commented on the social stigma that men choosing to take paternity leave could face from their colleagues, which served to reinforce traditional gender-based stereotypes of men as providers and careerists and women as stay-home caregivers.Specialty interests: The extent to which gender-based challenges affected participants’ career choices often depended on their specialty interests. Challenges tended to be attenuated in surgical specialties in which participants were better represented  due to a greater number of role models and mentors. For example, one general surgery resident commented that the rumors she had heard about surgery being incompatible with a family were “exaggerated. … I don’t think it’s unmanageable to have a family. … I’ve seen quite a few … female surgeons who have children, who have families, who have hobbies, and are able to make all those things work” . Specialties in which there were fewer women, on the other hand, were perceived to “deter females from being interested in it. … The attitude [is] that surgery [is] not a specialty for women” .Positive effects of gender: It is important to note that gender did not always negatively influence participants’ decisions. In some cases, the effect was positive. For example, one resident felt that her identity as a surgeon was particularly important because “A lot of women really want a female urologist. … [They] don’t want to talk to men about [sensitive health issues]” . Another participant felt that women bring the benefit of being “more compassionate [and] nurturing, [which] lends itself to caring in medicine” . For other participants, the growing presence of women in surgery was seen to be making the field more humane, which would ultimately benefit everyone: “I think there’s been a lot of change because [women] have demanded that surgery … doesn’t kill your lifestyle, so that you can still be a human being and also do surgery” .This study explored the role that gender plays in the decision to pursue a surgical career using a sample of Canadian medical students, residents, and staff surgeons. While a small number of participants found their gender to be a motivating factor in their decision to pursue surgery, the majority of participants perceived gender as a challenge. Responses centred on the surgical lifestyle, becoming a parent, stereotyping, and gender discrimination, all of which were felt by participants to disproportionally affect women interested in a surgical career.11 This view may be represented in our interview data, which focus on action-oriented characteristics of surgery such as the “doing” as opposed to “thinking” and “procedural” rather than “diagnostic.” It can also be seen in participants’ perceptions that one must “eat, breathe, and sleep” surgery in order to survive in the profession. While some women—particularly those who have selected surgery as a career—may find themselves aligned with these characteristics, others may find them alienating or intimidating. The “masculine” nature of surgery may also affect the extent to which women receive positive early exposure to the field, as there may be differences in how women and men participate in, and experience, surgical encounters in the operating room.11,22 Moreover, since there are currently more men than women in the field, it may also affect the extent to which new trainees are exposed to mentors who are women.When discussing their main motivations for pursuing surgery, participants described an alignment between the characteristics of surgery and their personal interests, as well as early exposure to the profession. Although not explicitly mentioned by participants, each of these areas may implicitly be gendered. For example, scholars have argued that the surgical identity is constructed from a set of traits normatively identified as masculine.23 In our study, some participants were driven by their passion for surgery and appeared unphased by any gender-related challenges, despite being aware of and/or having experienced them. Others found their gender much more salient and “visible.” A number of participants reported an interest in surgery but were not fully comfortable with the perceived sacrifices, particularly around the surgical lifestyle and having children. These individuals were much less certain about the decision to go into surgery, and in some cases, had ruled out the profession entirely relatively early on in their training.The specific manner in which the factors uncovered in this study intersected with one another to inform career decisions depended on participants’ circumstances, experiences, identities, and values. Although participants did not explicitly use the term “intersectionality” when describing their experiences, the notion that multiple identities and experiences can impact people in different and complex ways is important to consider yet has received very little attention in research on gender in surgery thus far.10,12,14,18,19 A Norwegian study substantiated the impact of family life on career selection, finding that the more children a woman has, the lower her chance of becoming a specialist.24 Increasingly, however, lifestyle-related challenges are becoming important considerations for both women and men,10,25 and may help explain the decline or stagnancy in applications to more demanding specialities such as surgery.12,26 Our findings confirm the challenges associated with balancing the demands of a surgical career with raising a family and underscore the importance of policies around parental leave for both childbearing and non-childbearing parents. Not only must these policies exist on paper, but they must also be supported at all levels in order to be effective. Our study revealed gaps in this area, particularly with respect to non-childbearing  leave, as many participants found themselves supportive of, but unable to fully take advantage of this option due to social stigma and logistical challenges .Prior research has shown that work-life integration is a primary concern when making career choices because it affects well-being and informs the sacrifices that individuals must make.27 our findings suggest that speciality decisions are often solidified before medical school. This is often rooted in students’ desires to be competitive for their speciality of choice and can thus shape future experiences, such as the electives they choose to take. Positive experiences in surgery through observerships or targeted outreach programs may be influential in cultivating an interest in surgery.12,28 Furthermore, the presence of positive role models in surgery may increase a junior physician’s likelihood of indicating interest in surgery.29 Role models, mentors, and sponsors provide the necessary support and guidance trainees require to navigate their professional lives, which may be especially important for women and other minorities.7,12-16 Observing a woman surgeon balance her career with family life implies that work-life integration is possible. More importantly, having a greater number of women role models in surgery helps create a culture in which it becomes appropriate and typical to discuss gender-related topics, such as family planning and parental leave.It is also critical to pay attention to students’ early experiences in surgery. Consistent with other studies,12,14,16,17 Our findings attest that gender discrimination is common in surgery, particularly among women. This may be especially problematic among medical students who do not necessarily have the same agency as more experienced professionals to navigate these challenges.30 Prior research has also shown that abusive acts are not always recognized and dealt with appropriately, in part because of the “machismo” culture of surgery.11,31 Thus, policies, education, and cultural change are imperative in order to clearly underline that gender discrimination is not tolerated among and towards healthcare professionals.Social challenges including poor interactions with patients, peers, and staff can also deter students from a career in surgery. Experiences of stereotyping, gender discrimination, and sexual harassment, can be particularly influential in the decision to pursue (or not to pursue) a career in surgery.This study was limited to the perspectives of participants from primarily one academic centre in Ontario, Canada. However, our sample contained three participants from a second academic institution who did not report any major institution-specific differences. We also did not uncover any major institution-specific differences from residents or staff surgeons who had completed earlier parts of their medical training at other institutions. Nonetheless, there remains room to expand the diversity of perspectives included in this, and other gender-related work. For example, our sample was not very ethnically diverse, nor did it include the perspectives of those who do not identify with binary conceptualizations of gender. Finally, our work considered the perspectives of only those at academic centres; in community centres, some women may hold leadership roles despite not having an advanced level of academic recognition.Given that nearly 60% of graduating physicians are women, medicine has made significant strides towards a more representative workforce. Yet, in surgery, women continue to represent less than 30% of the workforce and are not moving into leadership roles at the same rate as men. This suggests that the current “wait and with time, they shall come” strategy for attaining gender equity in the profession does not appear to be effective. In addition to addressing concerns around work-life integration and gender discrimination, surgical programs should actively target prospective applicants earlier in their training to ensure that they have a chance to experience the profession and benefit from exposure to role models and mentors occur before career decisions are made.