In the cross-cultural adaptation process in China, the main challenges for foreign teachers were language barriers; a lack of supportive relationships; and conflicts in perceptions related to teaching, privacy, and boundaries. Useful coping strategies included seeking interpersonal interactions that provided emotional and instrumental support, developing localized teaching models, and maintaining connections with the culture of origin. Under circumstances with convenient living facilities and supportive interpersonal relationships, these strategies promoted the adaptation of foreign teachers with functional personality traits. The potential correlations among these different themes and the influence of their interactions on foreign teachers’ adaptation experience were also discussed. The themes that emerged in our study can help clinicians and university administrators develop therapy methods and support systems for foreign teachers who work in Chinese universities.The aim of this study was to explore foreign teachers’ experience of cultural and life adaptation in China, including the difficulties, emotional stress, and challenges they confronted, as well as the useful coping strategies and resources that facilitated their cultural adaptation. Ten foreign professors who taught in China were recruited from three Chinese universities. Semi-structured interviews on the participants’ experience of cross-cultural adaptation in China were conducted. Thematic analysis of the transcribed dialogs was performed, and five core themes emerged:  With the constant development of the Chinese economy and against the background of globalization, an increasing number of foreign teachers are coming to China. The number of foreign teachers in China reportedly reached 157,076 in 2015 (with most of them coming from America and Europe) and has been increasing over the past few years, especially in Chinese universities . The impHowever, the recruitment of more foreign teachers in eastern Asia has also been accompanied by challenges for these foreign educators related to their daily lives and cultural adaptation. For example, some prior cross-sectional studies used self-designed quantitative inventories to assess the daily challenges faced by foreign teachers in China. They found that the challenges foreign teachers regularly faced were complicated and diverse and included language barriers; differences in diet, living habits, and weather; conflicts in cultural perspectives of interpersonal boundaries; conflicts regarding teaching methods and models; problems with the administration patterns of Chinese schools; and feelings of loneliness and isolation, homesickness, and culture shock . SimilarMeanwhile, previous literature has also indicated diverse emotional and cognitive responses of foreign teachers who confront such challenges. For instance, The results of the above studies, although mostly based on quantitative surveys lacking exploration of the vivid and subjective experiences of participants, provided a general framework for understanding the daily problems of foreign teachers who teach in a culture that is not their own. Meanwhile, despite very limited information, these previous studies also provided preliminary insight into foreign educators’ corresponding emotional reactions and perspectives. However, this information is still not sufficient for the construction of a complete, systemic understanding of the mechanism of foreign teachers’ cultural adaptation. According to previous research on cultural adaptation among other populations, other potential factors affecting foreign educators’ cross-cultural adaptation may include the effective or dysfunctional coping strategies they adopt, variables related to their personal traits and flexibility, and variables related to their social and family environments , 2017.The influence of such factors on foreign teachers’ adaptation to and assimilation into a different society remains underexplored. Although some scholars have tried to examine the strategies subjects adopt to cope with stress due to cross-cultural adaptation, their results have been based more on individual case reporting rather than on an empirical analysis of the subjects’ experience. For example, With respect to the potential personal and environmental factors affecting foreign teachers’ cultural adaptation, some researchers have shared subjective perspectives based on their experience communicating with foreign teachers. The ideas they have proposed are diverse and complicated. For instance, based on the experience of daily interactions with foreign teachers who worked in a Chinese university, A review of the limited literature on foreign teachers’ adaptation to a new culture indicates several gaps. Firstly, most previous studies provided only simple phenomenological descriptions of the cross-cultural difficulties that foreign teachers confront and their emotional responses and were based on quantitative surveys without an in-depth examination of foreign teachers’ subjective experiences. Secondly, with respect to the potential factors affecting foreign teachers’ cultural adaptation and the coping strategies that they adopt to deal with daily challenges, prior literature has been limited to the subjective experiences of the researchers, case reports, or quantitative surveys and lacked an in-depth exploration of the participants’ own experience using an empirical approach. Thirdly, most prior studies focused only on a single area of foreign teachers’ cultural adaptation without threading different aspects, such as the challenges they experience, their emotional responses, their methods of coping and the factors that facilitate or hinder their adaptation, and their potential interactions, into a complete story. Fourthly, the only phenomenological analysis of foreign educators’ experience of adaptation in Asian countries was restricted to the discipline of nursing. The subjective experiences of foreign teachers who work in other specialties remains unexplored. Lastly, most previous research has explored the adaptation process without distinguishing foreign teachers teaching at universities from those working in primary and middle schools. This oversight affects the targeted application of the results to the corresponding population.Hence, to address the research gaps mentioned above, the current qualitative study explored the subjective experiences of foreign teachers working at Chinese universities in terms of the difficulties, emotional stress, and challenges they faced during the process of cultural adaptation in China. Special attention was also paid to the useful strategies that subjects used to cope with these challenges and the potential factors, such as their personal traits, environmental variables, and possible resources, affecting their adaptation processes. In other words, based on an empirical and qualitative approach, we aimed to create a more comprehensive picture of foreign teachers’ cultural adaptation experience by incorporating the diverse dimensions mentioned above.From March 2019 to May 2019, 10 foreign professors teaching in China were recruited from three universities in Zhejiang Province and Shanghai. The sample inclusion criteria were as follows: (1) holds a formal teaching position at a university; (2) has no diagnosed medical or surgical condition or mental disorder; (3) is not a native speaker of Chinese; and (4) has not lived in China for an extended period. All the subjects participated in this study voluntarily. See We released the subject recruitment advertisements through the university Bulletin Board System (BBS) and administrative offices of diverse colleges. Foreign teachers who were willing to participate in the study contacted the researchers by e-mail or phone. Then, the purpose, content, process, and principle of confidentiality of the study were introduced to the potential participants in accordance with standardized instructions. For foreign professors who decided to participate and met the inclusion criteria, the researchers first invited them to the research office. Their future questions were answered, and their willingness to participate was confirmed again. Then, the participants signed the formal informed consent form, and the researchers then made an appointment for a formal interview. The research proposal received ethical approval from the ethics committee of the universities that were responsible for the management of this study.The interview was a semi-structured one in which the interviewers asked the subjects questions according to a predesigned outline. The interview outline was designed according to the topic of this research, i.e., foreign professors’ adaptation and coping in China. The interviewers tried their best to ask open questions during the interview and made necessary inquiries to clarify any vague answers, such as “Could you tell me more?” or “What exactly does that mean?” In addition, few comments or guiding statements were made to ensure the continuity and spontaneity of the interview process. The interview outline was as follows: (1) Please describe the challenges you have experienced since you began teaching in China. If possible, please provide some details. (2) How did those challenges affect you at that time? If possible, please provide some details. (3) How did you handle that situation? Please detail the issue and evaluate your solutions from your current perspective. (4) Were there any people or resources that supported you in that situation? (5) If you encounter similar challenges in the future, what could be some potential resources for you?The formal interview time for each subject varied from 1 to 1.5 h, and the interview was conducted in a separate, quiet, and confidential room. The entire interview process was recorded with a digital recording pen. The interviews were completed by the second and third authors of this paper, who both have received at least 3 years of formal social psychology research training and have 2–4 years of psychological counseling experience. Both are fluent English speakers; hence, there were no language barriers during the interview.Thematic analysis was used to analyze the transcribed data following the guidance provided by Verbatim transcriptions of the digitally recorded interviews were conducted by the researchers. Then, the researchers read through the transcribed materials repeatedly. The accuracy of the transcriptions was checked. Meanwhile, 4 months of training was conducted on the research topic, analytical methods, and guiding ideology. This process also encouraged the researchers to immerse themselves in and become familiar with the data.During the second stage, each interview transcript was reread. Then, initial codes identifying a feature of the data (semantic or latent content) that appeared relevant to the research topic, i.e., foreign professors’ adaptation and coping in China, were developed and assigned. These codes referred to the most basic segment or element of the data that could be assessed in a meaningful way regarding the research topic. The initial codes were added to any word, sentence, or paragraph that the researcher considered noteworthy. The initial codes are shown in After obtaining the initial codes, the researchers repeatedly compared the primary codes with the text content and with each other. Conceptually related and similar codes were sorted into higher-level themes, and all the relevant coded data extracts within the identified themes were collated. As suggested by internal homogeneity and external heterogeneity. Themes without sufficient data were abandoned. Overly complicated themes were divided into multiple themes, and similar themes were merged into each other. When the candidate themes adequately captured the contours of the coded data, the validity of the individual themes was considered in relation to the entire data set to determine whether the themes reflected the meanings evident in the data set as a whole and told a convincing story of the data. At the end of this phase, saturation of the themes was also reached.This phase involved checking and refining the candidate themes against the coded data extracts and the entire data set. The researchers made comparisons between the candidate themes in accordance with the dual criteria for judging categories: During this stage, the researchers defined and refined the themes by returning to the collated data extracts for each theme and organizing them into a coherent and internally consistent account with an accompanying narrative. A detailed analysis of each theme was conducted, and the scope, definition, and story of each individual theme were determined. Any potential subthemes were also identified. The title of each theme was designed to be concise and effective to immediately convey the meanings of the themes. This phase of analysis was recursive until the final theme map could build a complete story that was consistent with the research objectives.This final phase involved organizing the fully developed themes and corresponding data extracts and writing up the reports. The themes were woven together with the analytic narratives and most representative quotes that could capture the essence of the themes. Finally, a report that could illustrate the whole story of the data was completed.For qualitative studies, analysts themselves are tools of the research. The impact of their biases on the research process and results should not be ignored. To bolster the study credibility and dependability, research meetings were held for at least 2 h every week during the entire research process. Any questions, confusion, and ideas about the study were discussed and resolved in a timely manner. Especially during the data analysis stages, the codes and themes that any one analyst produced were regularly reviewed by the other three researchers. Meanwhile, the emerging themes were reviewed by the four analysts together during every research meeting. Any divergence of opinions relevant to the coding, searching, definition, and naming of themes were fully discussed. Finally, consensus on the results, including the final thematic map presented here, was achieved.multiple challenges, mixed negative emotions, active coping and insulation, rich supportive resources, and personal traits—among which, there were 19 subthemes “(A cashier) just asked me, you know, do I need a bag? But of course, it was in Chinese, so I didn’t know what she was asking me, and I kept looking for the bags at the end of the counter.” (P2)“There were also differences in daily life, such as the cumbersome procedures of banks or even the toilet facilities, which made them feel uncomfortable, as the following quotations show:This should be transparent to the bank on this, because a Chinese group can transfer money just by going online; a foreigner, you have to go, and you have to prove your final balance, and they will not say that sometimes you can, you do not need to do that, and they will force you, or they will recommend you to do all the same things every time when you are trying to change some things that are not the same thing.” (P4)“The toilets, I mean, the holes in the floor, I can’t do; that is a cultural thing, I understand, so you know, whenever I go places, I will ask, “Is there a sitting toilet?” (P3)“The conflicts about teaching concepts and methods mainly focused on the following aspects. In terms of teaching methods, both P4 and P1 thought that China attached more importance to English reading and writing while ignoring listening and speaking.I think that’s also challenging because the level of (English) listening is really one of the problems in China. People don’t really teach listening to the same degree because there’s a focus on reading and writing. When you stand in a class as a native speaker trying to communicate to students in English, you realize that they don’t really get 80% that is beyond their understanding.” (P4)“In addition, P3, P1, and P2 all mentioned that Chinese students were accustomed to silence in class, which was quite different from the teachers’ original style of frequent teacher–student interaction and inspiring students to think through discussions.One of the things that I was not prepared for was how quiet the students are, and so when you ask a question in the kind of traditional education fashion, we wait for an answer, but the answer does not come.” (P3)“There were also some differences in the understanding of teaching concepts. Traditional Chinese teaching emphasizes that teachers should follow the whole teaching program designed by the teaching committee and management department of the university. This teaching style conflicted with the teaching concepts of some interviewees, who thought that teaching plans should respect teachers’ own wishes.Let me think about it in the concept of teaching. When I first came to China, I only had a small introduction to the idea of teaching. I first thought that their wishes (those of the management department of the university) were secondary to the requirements of the course. But now, it’s different. You should follow their instructions and plan. You are just an addition to the university.” (P4)“The interviewees experienced certain cultural differences in the way interpersonal communication occurred. Most Chinese people like to communicate with people they are familiar with. P4, P8, and P9 all mentioned this relatively closed communication mode, which was difficult to adjust to when they first came to China.I knew I needed to create a social network that wasn’t closed, because often that was what was happening here. And when I first came, I had a friend, and groups were brought into a friend group, and always, maybe I could call it the KTV phenomenon, your friends and you go to KTV, and nobody else comes into that group. So, unless someone is invited in from some other thing, then that group is quite closed. And I felt that there was this very closed culture within ordinary Chinese socializing.” (P4)“The ways of building relationships mentioned above also made new teachers in China feel disconnected, lonely, and frustrated. Some subjects even felt a lack of control over their interpersonal relationships and a low sense of self-worth, as P8 mentioned.At the beginning, I didn’t really feel connected with my colleagues. I really had this huge gap in communication between me and my colleagues. I just felt lonely and, hum, frustrated. I even sometimes wondered if I was worthy of being recognized and associated with others. I felt like I was losing the internal and external locus of control.”“Some participants described the way that Chinese people, including their colleagues, attach great importance to parent–child and family relations. The way that Chinese people socialize with family and friends also made them feel different and awkward.(I think) friends are more important than family when you become an adult, but in China, it has been the complete opposite. People obviously take families to be closer and, hum, much more important. You know, it looks like a closed loop. No matter what they do, the first groups to consider and trust are families and acquaintances, even if sometimes a friend or colleague may be the better choice. But most of the time, people would take the places (of their friends), but it was always their kids or relatives.” (P9)“Some participants felt that boundaries regarding the respect and control of privacy in China were different from those they were used to in their native cultures and mentioned behavior such as taking and sending photos of others without the permission of the party concerned, being followed and lectured by others on the street, or being asked personal questions during a job interview.I don’t like using WeChat , as some of these WeChat groups are too open; it’s pretty large. There’s my picture with some other people already, and that gets sent to another group in another group.” (P1)“Like interviewing candidates for jobs as new faculty members, ‘Are you married?’ You cannot ask that question. This is my personal thing, right? Personal information. ‘What race are you?’” (P10)“In addition, in daily life, some people felt uncomfortable when their identity as foreigners was given too much attention or taken advantage of.I will always be considered when I am in China as a foreigner; they will go and say “foreigner!” In the States, I would never dream of calling, if I see an Asian person, saying that they are foreigners.” (P9)“I think they (the Chinese people who tried to contact the subject) are more interested in practicing English with me, yeah, just talking, but not making friends with me. Yeah, because lots of people in China are just interested in English. That’s the reason for communicating with you. Sometimes I feel like I’m being used.” (P4)“Additionally, some subjects mentioned that, in the Chinese university administrative system, people tended to interrupt each other when communicating, and the boundaries of individual utterances were easily confused, which made them feel uncomfortable. For example, P1 mentioned,You know, a high-level meeting. This person will try to dominate the conversation. We’ll try to just talk over the person who’s already speaking. And that’s where I’ll just step forward and say, “Would you please? He’s speaking, give him a chance to speak.” I’m just telling them essentially to shut up. I don’t say that; I guess I need to learn to tolerate those people better.”“In the process of adaptation in China, the participants had different levels of emotional arousal when encountering different challenges. Frustration, embarrassment, and anger were common emotions. However, it was difficult for these emotions to be expressed, understood, and responded to.Frustration was the most common emotion of the participants when they met challenges, including language and life barriers, conflicts in teaching, and interpersonal insulation. For example, P1, P2, P3, and P4 all indicated that they felt frustrated when their Chinese students did not like to speak to answer questions in class.”I was frustrated for the first week, two weeks; I was trying to find ideas to get them to open up.” (P1)“We wait for an answer, and if an answer does not come, then we wait some more; eventually somebody will finally answer the question, at least in country Y (P3’s motherland), but here in China, it doesn’t get answered. That’s been a little frustrating.” (P3)“The participants mentioned that they felt embarrassed when their status as foreigners was given undue attention or when they experienced difficulties brought about by language and life barriers. For example, P2 mentioned the following:I just know that I’ll be looked at, and I just know that four hundred people are saying, ‘Foreigner,’ you know, ‘the foreigner’s here,’ and I get my picture taken sometimes.” (P2)“When diverse problems and challenges could not be solved effectively, some participants occasionally felt anger. For example, P2 indicated that, when he was in class, if the students repeatedly ignored his instructions and if he tried several ways to deal with the situation but not succeed, he felt offended.I find it offensive, almost personally offensive, that you are coming to class to ignore me.” (P2)“That’s how I know it’s anger because it’s VPN technology, on my computer; I try it once, twice, three times, another way. It’s not because I didn’t get supported—the IT helped a lot, but it’s the fact that I have to use another Internet, virtual private network, to reach some webpages which I can easily open in other countries.” (P7)“In the process of adaptation in China, finding a method of coping with challenges was common, whether it was a positive response or isolation, and helped participants to further adapt to the situation in China to different degrees. These coping strategies were functional interaction, localization, emotional insulation, and keeping in touch with the culture of origin.Functional interaction refers to some participants’ efforts to have as many interactions with Chinese people as possible to seek assistance in teaching and daily life when encountering challenges in China. Some of the subjects benefited from communication with Chinese friends or students who could speak English. They helped foreign teachers become familiar with the Chinese culture and manage other Chinese students.”So, I make Chinese friends who speak English, and they interpret a lot of cultural things for me; it’s through their English-speaking ability, so they help me know lots of Chinese culture.” (P7)“In addition, P3 also mentioned that, even though some Chinese people could not speak English, they were very enthusiastic and sought to help through gestures or other means. For example, P3 related the following experience when he was in the hospital:One Chinese gentleman of course talked to me in Chinese, so I gave him my business card, and he read it; when I tried to get up, he jumped up to help me to stand, because my leg hurt. Chinese people, they are very kind, very gracious. They look out for each other. They look out for foreigners.” (P3)“In addition to improving their interpersonal relationships, some participants also made adjustments by actively accessing the interpersonal resources around them. For example, P7 mentioned that, when she felt lonely in China, she joined an online cooking group.I can trust their food, because that chicken is more trustworthy; it can help me to deal with my frozen chicken and shrimp. The online group supported me a lot, not only in the cooking part but also, more importantly, the connection with other people.”“Some participants mentioned that, when they felt depressed or heartbroken, they would seek help from local psychological counselors.So, all, everything that I was feeling, like all this negativity, all this, I just talked it out; you find a psychologist, and you talk with that person.” (P8)“Localization refers to participants’ gradual alignment of themselves more with China’s national conditions and their adoption of local methods to improve a situation or resolve problems associated with teaching or life challenges they faced in China. For example, in dealing with the conflicts regarding teaching concepts and methods, P3 and P4 made necessary adjustments to the interactive mode of their classes, the grade evaluation system, teaching multimedia, and other aspects to bring them more in line with the habits of Chinese students, such as by taking the initiative to call roll, linking grades to classroom speech acts, and using video in their teaching. As mentioned by P3,Any students will not respond to a stranger; they will not invest in you unless you invest in them, so I get their names, I tell a lot of jokes, I explain it to them, and I get a couple of chuckles.”“Television covers interesting topics, so it will already contain complex topics. So, they’re also getting introduced to new language environments.” (P4)“In addition, P2, P3, and P6 all mentioned that they handled language problems by maintaining certain fixed lifestyles, such as by taking the same bus at the same time and going to the same restaurant.I get on bus X (pseudonym for the bus number) and go to market X (pseudonym for the market). See? No problem. Two and a half yuan from, um, I always have the card where I want to go so I won’t get lost or confused.” (P3)“Some participants (P1–P3) solved difficulties by downloading software and apps that made life in China easier.How you, you know, when you go to make, say you need to like, buy something, but they (the products) are all labeled in Chinese; I’ve got another app. Maybe it’s our no, no. Um, um, it’s that one also where there is a camera, ah, so you can scan, and I can take a picture of it or scan it, and it comes up in English.” (P3)“Several foreign teachers solved their language problems by looking more carefully at the appearance of products in supermarkets and being sensitive to new information in their surroundings.Even this is a challenge, just, I have to look really closely and realize, oh, that is what I’m looking for. I just didn’t know. And I mean of course, I have to rely on what I’m seeing because I can’t read the description. They are all in Chinese.” (P2)“In addition to the positive responses, some participants, such as P5, P1, and P6, said that, when problems could not be reconciled, the appropriate suppression of their own needs to accept their reality was an important way to adjust their physical and mental states.I see maybe some foreign teachers, and they’re acting, they’re degrading the people there, complaining about some things being dirty or you know, just shut up, don’t say anything. This is culture; this is the way it is, except if you don’t like it, don’t come here. Go home and enjoy your little apartment to live in, but don’t say anything.” (P1)“However, for some participants, it seemed that excessive suppression of their emotions or needs for interpersonal connections stood in the way of their adaptation.When I feel lonely, I usually just have these internal conversations with myself. So yeah, I usually think I just internalize a lot of a lot of things without thinking too much.” (P2)“People speeding or you know, really, I cannot do anything, I just close my eyes because it makes me vomit.” (P6)“The participants mentioned that staying connected to their native cultures and customary living habits helped them better adapt to living in China. For example, they tended to retain their customary patterns of making friends, cooking at home, and communicating with people from the same country. These connections helped them build a relative sense of continuity and promoted their adaptation to their new lives in China.I realized that in community groups, I created an English corner. And because I had an English corner, British people then who all spoke English, I created this social network. I knew I needed to create a social network that wasn’t closed, because often that is what was happening.” (P4)“I know the store, and I also learned how to bake my own bread. Whenever I have time, I bake my own bread at home. I am a picky person, not the kind of person who would eat everything.” (P6)“During the process of adapting to life in China, six of the participants  actively or passively solved problems themselves using software and the surrounding facilities and local or cross-cultural resources. There were four subthemes: convenient apps and facilities, help from local agencies and local people in China, multicultural competency and life experience, and stable intimate relationships.P4 and P6 mentioned that there were many Western-style supermarkets and restaurants in China, such as KFC and McDonald’s, where participants could buy food and daily necessities that suited their own tastes and habits.I go to supermarket O (pseudonym for an import supermarket) because that chicken is more trustworthy. I can trust their food. Their whole wheat, those dark breads. So, I’ll buy those because that’s all I eat.” (P4)“Several participants mentioned that with smartphone apps, it was very convenient to access local resources.I do have this app, the kind where I can talk in English, and it translates to Chinese. So that’s helped a lot, so I’ve learned that works as long as I have a signal to do it.” (P1)“They had this app called Didi (a popular transportation app in China). I didn’t know why I’d never heard of it, that they put in something, and the car rolls up there.” (P10)“P3, P6, P7, P9, and P10 mentioned that obtaining local resources, such as the service support provided by their work unit and help from native people who could speak English, helped them adapt more quickly. P3 mentioned that his school had a service and consultation office set up specifically for foreign professors.A lot of people, when you meet challenges, and the Chinese staff in the training building, they’re the best I have ever seen. So efficient, and things get done like that. I’m just amazed. We don’t have that at university X (the university where P3 worked). So, it’s been wonderful.” (P3)“In other cases, when participants had difficulties in daily life, the related agencies would provide active assistance quickly.The landlords wouldn’t even care to fix things in the apartment, so it’s our university that sends the repair person to the apartment to fix things.” (P6)“In addition, it was very helpful to know some local Chinese people who could speak English. As P7 mentioned,They spoke English quite well; they help us with technology, they help us with food advice, they help us shop.”“Some of the participants had many successful experiences in life and teaching. They thought that these rich life experiences had promoted their cultural adaptation process in China. For example,I am the faculty with the most teaching expertise. My experience tells me (when coming into a different culture and having contact with new people) the first thing you need to do is smile. The second thing you do need to do is bring enthusiasm, have passion, and never get angry.” (P3)“P1, P6, and P10 also mentioned that their cross-cultural experience increased their resilience as they adapted in China.I am an experienced traveler, so I have been in many places in the world, so I am a little bit more adaptable and resilient to all these sort of things.” (P6)“P1, P3, and P9 had lived or worked in other cultures before coming to China to teach. They reported that these cross-cultural experiences in Asia, Europe, and other places made their adaptation process in China smoother.I was in Vietnam for over a year, and I’ve been to, I’ve been to other Asian countries. I’m not saying, um, I’m used to everything, but um, I’m accepting, I accept other cultures at equal value.” (P1)“We’ve been to China before, so we knew what we were getting into. Um, and again, this is the fourth country I’ve lived in. So, we have the same thing. When I lived in Japan, we had the same thing when I lived in Europe.” (P3)“Having a stable intimate relationship helped participants to better face challenges. P3, P6, and P8 were all in China with their partners. P3 mentioned that it eased his frustration to just go home and rest and have his home life.When I go home, I’ve had a long day, I’m tired. Um, I either watch a little television. Usually, what happens is I could have a bite, and I just go to sleep.” (P3)“My life without my boyfriend was only work, so he helped a lot. He has a different style. He is not a workaholic like me; he is more of a laid-back person and kind of drives me crazy. He does help in terms of relaxing; we are going to do something different, not just your work beloved work, but movies, hiking something else.” (P8)“Different personality traits also helped or influenced the participants’ adaptation in China to different degrees. This core theme mainly consisted of three parts, namely, the trait of positive thinking, avoidance coping, and low flexibility.Some participants were full of yearning and expectations for a new life and environment. Even when they encountered different cultures and conflicts, they tended to treat such problems as challenges or differences, to actively face them and to live in the present. This coping style facilitated their adaptation in China.There are no problems. We have challenges, yes. Um, and I try to tell that to students; all the time, students say, ‘We have a problem.’ I say, ‘No, you don’t have a problem; you have a challenge. We will take care of it.’ And that’s the way I see myself also.” (P1)“It is more that I appreciate, began to appreciate the challenge of it; it’s an opportunity for me to practice my competence. I actually feel empowered about this.” (P8)“Some participants loved the Chinese culture. This positive impression of China improved the participants’ experience in the country. As P5 mentioned,The culture, my gosh, the culture is simply incredible; no wonder Chinese are so proud. Probably the most beautiful culture in the world.”“However, some participants, before coming to China, had been accustomed to dealing with problems by isolating themselves, which helped them avoid some conflicts, but also led to some emotional difficulties. For example, P2 and P6 mentioned the following:I would not say my adaptability is great, because a lot of it is just avoidance. That is, what I worry about is I adapt by avoiding many situations.” (P2)“Although I have a lot of experience traveling and living in other countries, I have to say, hum, in fact, I’m still quite used to avoiding problems. Sometimes I feel upset, but I’m not used to expressing it. Although sometimes it helps me avoid trouble, it also brings some problems, which makes me feel bad.” (P6)“Maintaining one’s customary way of life may help an individual stay in touch with his or her culture of origin and promote stability, but if an individual constantly seeks stability, he or she can easily become inflexible. For example, P2 refused to use a mobile phone, even though he knew that using a mobile phone would decrease the difficulty of adapting to life in China.The problem is, I don’t have a phone; I mean, I don’t have a smartphone. I am aware of some of these apps; for me, it would probably be bad because I would be even more isolated.” (P2)“P6 was overly concerned about the safety and hygiene of food, insisting on cooking or obtaining food in his own way.I don’t trust the food, like that it’s healthy, unless I know that it is, like salmon, for instance, I know salmon you have to go to the ocean to catch salmon rather than in the river.” (P6)“To the best of our knowledge, this is the first study exploring foreign teachers’ cross-cultural adaptation processes in China based on a qualitative analysis of the participants’ subjective experiences. The five themes that emerged provided an initial and comprehensive theoretical framework for understanding the challenges, emotional responses, coping strategies, resources, and personal traits influencing foreign teachers’ adaptation to Chinese culture.The first theme that emerged from the data was multiple challenges. Among the multiple challenges that teachers faced, the most common was the language barrier, which affected the daily communication and lives of foreign teachers. However, most of the participants did not learn Chinese systematically. This result is consistent with data reported in previous studies , suggestComparatively, the conflicts between Chinese closed-loop interpersonal interactions and Western individual-to-individual communication patterns seemed more troublesome for foreign teachers . The culWhen coping with the challenges mentioned above, most foreign teachers adopted strategies such as trying to interact more with local people, seeking help from bilingual colleagues and students, maintaining connections with the culture of origin and with compatriots, and visiting a psychotherapist . The common feature of these coping styles is the establishment of interpersonal connections providing mutual understanding and emotional and instrumental support. This finding suggests that supportive interpersonal relationships may play an important role in the process of cross-cultural adaptation for foreign teachers . Other pIn addition, some foreign teachers  chose relatively fixed living habits, retaining some of their old living habits and maintaining regular connections with their culture of origin and compatriots, to reduce the stress of cross-cultural adaptation. The participants’ use of both this strategy and the functional interaction coping strategy suggests that relative stability and certain changes may be equally important for the cross-cultural adaptation of foreign teachers. In other words, attention should be paid to the connection with the culture of origin as well as to the acceptance of and participation in the current new culture . This opIn contrast, some participants responded to challenges and emotions using insulation. Interestingly, we found that subjects with avoidant personality traits  were more inclined to adopt this coping strategy. In addition, these foreign teachers seemed to be more vulnerable to negative emotional experiences such as embarrassment and anger. This finding suggests that foreign teachers’ personality characteristics and their automatic coping styles may both play important roles in their cultural adaptation . NeverthDifferences in privacy and boundary concepts in interpersonal communication were also among the main challenges faced by foreign teachers. Our analysis suggested that sensitivity and the definition of privacy protection among foreign teachers and Chinese people differed, and this difference led to corresponding emotional reactions and conflicts. Aside from isolation, the participants in this research did not seem to have developed any other effective coping strategies. Interestingly, the excessive attention foreign teachers received from local Chinese residents seemed to make them uncomfortable, but also became a resource, as our analysis suggested, that their identities as foreigners caused teachers to receive special treatment on some occasions. However, follow-up research and exploration are needed to determine how to better use this “foreign” identity to promote foreign teachers’ adaptation to life in China.With respect to conflicts related to teaching modes, the inducing factors may vary. On the one hand, conflict may arise due to Chinese teachers’ use of the one-way transmission method in education and the tradition of attaching importance to curriculum content and academic achievement. On the other hand, conflict may also occur due to the traditional Chinese Confucian cultural emphasis on seniority and the use of caution when speaking and acting in the presence of authority figures such as teachers . InteresWhen facing the above challenges, foreign teachers mainly felt emotions such as frustration, embarrassment, and anger, and these emotions were rarely expressed, understood, or processed. This result has rarely been reported in previous literature. Our analysis also demonstrated that these emotions were related not only to the challenge of adaptation itself but also to some of the foreign teachers’ negative orientations and self-deprecation. This suggests that it may be necessary to pay attention to and address the negative emotions that arise during foreign teachers’ adaptation processes from three angles: personal characteristics, practical challenges, and strategies for coping with stress.Three other core themes emerged in our study: mixed negative emotions, supportive resources, and personal/family-of-origin traits. Our analysis indicated that these themes may have interacted with each other and with the first two themes during the subjects’ adaptation. The participants primarily mentioned diverse resources that facilitated their adaptation processes. However, we found that not all the participants adopted these resources. For example, although the results suggested that help from local Chinese people, smartphone apps, and convenient living facilities played important roles in foreign teachers’ adaptation, there were participants who were not used to using these facilities, especially those who had more personality traits associated with avoidance coping, low flexibility, and negative thinking . Meanwhile, it seems that the teachers were more inclined to adopt dysfunctional coping strategies such as emotional insulation, self-sealing, and maintaining a fixed lifestyle. Thus, their ignorance of resources and adoption of avoidant coping may have made them more vulnerable to negative emotions , b and mIn contrast, for some other foreign teachers , a more virtuous cycle appeared. These teachers were more inclined to exhibit positive thinking, to evaluate themselves as worthwhile, and to be more willing to interact with the people around them and adopt accessible resources. As demonstrated by the results, this functional interaction strategy not only improved foreign teachers’ cultural adaptation experience but also made their adaptation smoother. They were more inclined to regard difficulties as challenges and opportunities, and they experienced more positive emotions. This finding is partially consistent with the idea of cognitive behavioral therapy that the way individuals think about problems sometimes plays an important role in coping with problems . The finAdditionally, regarding the resources supporting the subjects’ cultural adaptation, help from local agencies and local people in China as well as stable intimate relationships played an important role in foreign teachers’ adaptation, suggesting that interpersonal relationships provided ample emotional communication, mutual understanding, and instrumental support, which were factors that allowed foreign teachers to more smoothly complete their cross-cultural adaptation processes in China. This finding suggests that Chinese colleges and universities should consider establishing interpersonal connection programs or services that could provide more emotional and instrumental support for foreign teachers. Furthermore, similar to the views of This study has several limitations. We did not distinguish between different periods of cross-cultural adaptation when analyzing the experience of foreign teachers. As Our analysis demonstrated that during the process of cross-cultural adaptation in China, the main challenges for foreign teachers were language barriers; differences in living habits; a lack of supportive relationships; and conflicts in perceptions related to teaching, privacy, and boundaries. When coping with those challenges and the corresponding negative emotions, useful strategies frequently adopted by the participants included seeking interpersonal interactions that provided active emotional and instrumental assistance, developing localized and integrated teaching models, maintaining connections with the culture of origin, and being sensitive to new information. Under circumstances with convenient living facilities and supportive interpersonal relationships, these methods promoted the cultural adaptation of foreign teachers who had cross-cultural life experiences, stable intimate relationships, higher psychological resilience, and positive attitudes. The themes that emerged in our study can help clinicians, university administrators, and other relevant parties develop more comprehensive, humanized, empathetic, and detailed therapy methods and support systems for foreign teachers who work in Chinese universities.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by the Tongji University and Wenzhou-Kean University. The patients/participants provided their written informed consent to participate in this study.XX and NW conducted interviews with the participants and transcribed the data. LL and SY developed the interview outline and took the main responsibility in drafting the manuscript. All authors contributed to the recruitment of patients and analyzed the data.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Recently WHO has characterized COVID-19 as a pandemic. Diagnosing the disease accurately and decreasing misdiagnoses and missed diagnoses is very important for management. Therefore, we have analyzed the seven versions of China's national guidelines to examine how the diagnostic criteria roadmap has developed and evolved, in order to share our experience worldwide. In this article, we present the developments from the first to seventh versions, involving changes of case classification, changes to “suspected case,” changes in “confirmed case,” changes in clinical classifications, changes in “severe case,” and unchanged criteria. We have also discussed the reasons and implications for these changes and are looking forward to providing suggestions for worldwide understanding and management of this pandemic. A nucleic acid test is currently accepted as the gold standard method to confirm diagnosis. In addition, imaging examination and epidemiological history should also be considered as auxiliary diagnosis methods. Since December 2019, a new disease caused by 2019 novel coronavirus (2019-nCoV) has resulted in a worldwide outbreak . The disDiagnosis and Treatment Guidelines for COVID-19, which have been issued by the National Health Committee of the People's Republic of China (http://www.nhc.gov.cn/) up to 5 March 2020. The first to seventh versions were included and the data necessary to estimate the changes in diagnosis of COVID-19 were extracted. Two authors independently reviewed the full text. Discrepancies were resolved by discussion and consensus. Besides extracting all the context of diagnostic criteria, the issued data, clinical classification, and definition of severe disease were also collected.We searched for all versions of the All changes have been compared and presented in a separated table for suspected cases, confirmed cases, and severe cases. Other changed and unchanged items have also been described. All analyses used Microsoft Excel and PowerPoint 2019.The first version was issued on 16 January 2020, and the seventh version on 3 March 2020. The criteria for case classification developed considerably over time. In the first edition, three types were described: observed case, confirmed case, and critical case; however, from the second edition onwards, the term “observed case” has been changed to “suspected case,” and the criteria for “severe case” has been added. In the third edition, more clinical manifestations were added, and were classified as moderate, severe, and critical according to the severity of clinical symptoms. In the fifth edition, the form “mild” was added. Hence, in the seventh edition, the types were suspected case or confirmed case, with four clinical levels of severity: mild, moderate, severe, and critical cases.In the fifth edition, the term “clinically diagnosed cases” was defined for Hubei Province. In Hubei Province, the suspected patients who had imaging features of pneumonia were designated as clinically diagnosed cases. However, this type was merged into “suspected case” in the sixth and seventh editions.The term “observed case” used in the first edition was changed to “suspected case” in the second edition. For a patient to be diagnosed as suspected this had to be based on the epidemiological history and clinical manifestations. From the second to fourth editions, it had to include any two epidemiological history features in addition to clinical manifestations. However, from the fifth to seventh editions, a comprehensive analysis was required which included epidemiological history along with clinical manifestations; cases without clear epidemiological histories were added as a criterion judged by the presence of clinical features.Epidemiological history initially included direct or indirect contact with related markets in Wuhan, which was mentioned in the first edition. However, this item was deleted from the second edition onwards, but “a history of contact with patients with fever or respiratory symptoms from Wuhan city within the last 14 days before symptom onset, or with a cluster of confirmed cases” was added. Then in the fourth edition, the contact scope was enlarged to include other places where COVID-19 had spread and also included an epidemiological relationship with 2019-nCoV infected cases.For clinical manifestation, “symptoms without obvious improvement or with progressive severity after 3 days of standardized antimicrobial therapy” was mentioned in the first edition. However, this was deleted from the second edition onwards, and it only included fever, imaging features of COVID-19, and total white blood cell counts showing normal, decreased, or reduced lymphocyte count. In the fifth edition, the fever symptom was expanded and respiratory symptoms added; the criterion of “suspected case” was divided into inside Hubei Province and outside Hubei Province. The suspected patients having imaging features of pneumonia were designated as clinically diagnosed cases.In the first edition, to define the case as “confirmed,” it was necessary to collect the respiratory tract sample for viral whole genome sequencing, and this needed to show high homogeneity to the known novel coronaviruses. The real-time PCR test for nucleic acid in the respiratory tract or blood samples was added in the second and third editions. The pathogenic detection via blood samples was added in the fourth and fifth editions; the serological evidence was added in the seventh edition.In the seventh edition, if “the specific IgM antibody and IgG antibody of 2019-nCoV are reported in serum as positive,” or “the 2019-nCoV specific IgG antibody in serum changes from negative to positive, or rises ≥ 4 times in the recovery phase above that in the acute phase,” this is also diagnosed as COVID-19.There was no clear clinical classification in the first three editions. In the first edition, it specified a clear criterion for “critical case,” and the criterion for “severe case” was added in the second and third editions. The clinical stages were added in the fourth edition, which divided confirmed cases into moderate severe and critical stages; the mild stage was then added in the fifth to seventh editions. The mild stage was defined as persons having slight clinical symptoms without any imaging features of pneumonia.2)/fraction of inspired oxygen (FiO2) for patients from high attitude areas” was added. In the seventh edition, “severe cases” were defined and divided into children and adults.The criterion for severe case has evolved since the second edition. Compared with this edition, “Oxygen saturation during inhalation ≤ 95%” was modified to “Oxygen saturation during inhalation ≤ 93%” in the third to seventh editions; additionally, the descriptions of rapid Sequential Organ Failure Assessment (qSOFA) score, CURB-65 score, and coalescent pneumothorax were also deleted. The “other combined clinical conditions that necessitate hospitalization” in the second and third editions was also deleted in the latter four editions. The description “pulmonary imaging shows leafy lesions or progressive lesions > 50% in 48 h” was deleted in the fourth and fifth editions but was reincorporated in the sixth and seventh editions. In the sixth edition, “the necessity to adjust the arterial partial pressure of oxygen , from the second version to the fourth version it increased by 2.8 times , and from the fourth version to the fifth version by 4.2 times  . After aAlthough the use of radiological evidence to confirm viral pneumonia may be an important alternative to the diagnosis and monitoring of COVID-19, it also brought some problems. This procedure may include some patients with common pneumonia; hence criteria for clinically diagnosed patients also needs to include the nucleic acid results at a later stage to correct the actual number of cases. In addition, with the surge of patients, it was necessary to have enough hospital beds quickly to ensure the early diagnosis and treatment of patients. This requires more funds, equipment, and medical staff input, which poses a challenge to the country's regulatory and economic capabilities .The nucleic acid test is currently used as a confirmed diagnosis method. In addition, imaging examination and epidemiological history should also be considered as auxiliary diagnosis methods. We suggest approaching COVID-19 diagnosis with caution, doing as much as we can to reduce misdiagnosis and missed diagnoses, exploring and combining different methods, and actively seeking new methods, especially for screening asymptomatic patients and also identifying people who retest as positive again after recovery.All datasets generated for this study are included in the article/supplementary material.X-TZ and X-QR: conceptualization. B-HL, TD, and L-LM: writing-original draft preparation. X-TZ, Y-HJ, and X-QR: reviewing and editing. All authors have read and agreed to the published version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Apportioning credit for completed joint undertakings has always been a challenge. Academic promotion committees are faced with such tasks regularly, when trying to infer a candidate’s contribution to an article they coauthored with others. We propose a method for achieving this goal in disciplines (such as the author’s) where the default order is alphabetical. The credits are those maximizing Shannon entropy subject to order constraints.In attributing individual credit for co-authored academic publications, one issue is how to  More and more published research is a collaboration of several researchers . AbIn this paper, we focus on disciplines where the default order of authors is alphabetical . Thus, not changed unless the difference in contributions, in favor of the alphabetically latter author, is deemed to be larger than Suppose there is a disciplinary standard maximal (Shannon) entropy approach, reflecting the most diffused contribution distribution that satisfies the implications of the limited information given by the order. Constrained maximal entropy has been used, among other applications, in physics [We shall make use of the constrained  physics  and fina physics , where tStart with two authors (A and B), with the respective unknown expected contributions mas 2006 ). We shaFor three authors A, B and C, and respective unknown mean shares C’s contribution, Note that B, C, A), the solution is average the above order-dependent shares with equal shares. Thus, for example, the order  will result in For , the solutions is For , the solution is four authors, whose mean contributions Consider now the case of For , the mean contributions need to satisfyFor , the mean contributions need to satisfyIf Note that in all cases, the expected contributions are either independent of Dirichlet . That iWe have andandAs we wish to allocate the whole credit to the authors, we have So Note that if we have already estimated (inferred) the mean relative contributions How does the number of authors affect the relative contribution of one of them? Consider, for concreteness, A’s contribution in orders where he/she is last:We see that, in the case of three authors, A’s relative contribution depends on the order of B and C; in 3a, C needs to be rewarded for “overtaking “ B (as well as A), which reduces A’s contributions.Now, for 3b and 4a, the relative contribution of A is:The former ratio is larger than the latter for, and only for, For 3a and 4a, For 4b, the former ratio is larger if n authors in alphabetical internal order with A at the end, A’s contribution is For In this paper, we attempted to quantify the significance of deviations from some “natural“ or “default“ order of authors. We assumed that the unknown relative contributions maximize entropy subject to constraints reflecting default order reversal.Future study could further demonstrate and validate the proposed method by empirical and data-driven methods. For example, a comparison could be made of academics’ rankings by the H-index (or some other measures), compared to authors’ rankings by their total fractional journal paper contributions. Another option is to apply this study to journals where the authors’ contributions are required and published, while comparing it to the order of the authors’ names. Clearly, a survey could be conducted over some well-cited papers, asking the authors to ascribe their fractional contributions, while comparing them to those determined by the proposed method.We note that the proposed measure, if and when it will be used for personal evaluation and promotion, should be combined with qualitative assessments, as often done in T&P committees. Otherwise, “automated” evaluation metrics alone could encourage game-playing among collaborators, which would be an uninvited outcome.Finally, let us note that several related applications could use, with required modifications, the proposed method—for example, for assessing the contribution of programmers and AI agents in tasks distributed and published over the Internet. One scenario with some similarity to the considered problem is the following.In sports, some media “power rank” (PR) teams during the season. The PR is usually consistent with the number of wins the teams have achieved, but not always .Therefore, suppose that the number of wins of two teams A and B If


We fully agree that, in analyzing social tipping interventions (STIs) for accelerating a global transformation to carbon neutrality by 2050 , there iWe also fully agree that coalitions of people and organizations are needed that mobilize around a common cause, eventually reach a critical mass, and produce a momentum for change that in turn legitimizes politicians to build their own coalitions that lead to government action. Indeed, as Otto et al.  argue, t


Across North America, the opioid overdose epidemic is leading to increasing hospitalizations of people who use drugs (PWUD). However, hospitals are ill-prepared to meet the needs of PWUD. We focus on illicit drug use while admitted to hospital and how PWUD and health care providers describe, respond, and attempt to manage its use.Using varied purposive methods in Toronto and Ottawa, we recruited n = 24 PWUD  and n = 26 health care providers  providing care to this patient group). All n = 50 participants completed a short, socio-demographic questionnaire and an audio-recorded semi-structured interview about receiving or providing acute care in a hospital between 04/2014 and 05/2015. Patient participants received $25 CAD and return transit fare; provider participants received a $50 CAD gift card for a bookseller. All participants provided informed consent. Audio-recordings were transcribed verbatim, corrected, and uploaded to NVivo 10. Using the seven-step framework method, transcripts were coded line-by-line and managed using NVvivo. An analytic framework was created by grouping and mapping the codes. Preliminary analyses were presented to advisory group members for comment and used to refine the interpretation. Questionnaire data were managed using SPSS version 22.0 and descriptive statistics were used to describe the participants. Many but not all patient participants spoke about using psycho-active substances not prescribed to them during a hospital admission. Attempts to avoid negative experiences  were cited as reasons for illicit drug use. Most tried to conceal their illicit drug use from health care providers. Patients described how their self-reported level of pain was not always believed, tolerance to opioids was ignored, and requests for higher doses of pain medications denied. Some health care providers were unaware of on-site illicit drug use; others acknowledged it occurred. Few could identify a hospital policy specific to illicit drug use and most used their personal beliefs to guide their responses to it .Providers highlighted gaps in institutional guidance for how they ought to appropriately respond to in-hospital substance use. Patients attempted to conceal illicit drug use in environments with no institutional policies about such use, leading to varied responses that were inconsistent with the principles of patient centred care and reflected personal beliefs about illicit drug use. There are increasing calls for implementation of harm reduction approaches and interventions in hospitals but uptake has been slow. Our study contributes to this emerging body of literature and highlights areas for future research, the development of interventions, and changes to policy and practice. Across the world, rates of opioid related overdose vary with the United States and Canada reporting rates four times the global average and Australia and New Zealand combined reporting twice the rate of the global average –4. The mMutual distrust between health care providers and PWUD has been documented to influence therapeutic interactions in hospitals and impacts the quality of care delivered , 17. In Hospital settings have been characterized as risk environments , 20 wherData from a Vancouver study showed that 43.9% of PWUD who had been in hospital reported ever using an illicit drug during their hospitalization . To add This qualitative, descriptive study is located within a broader program of research about the experience of receiving or providing hospital care to people living with HIV and/or hepatitis C virus (HCV) who use substances , 23. TheFor the patient population, eligibility criteria included self-reported: 1) HIV and/or HCV infection; 2) current or past use of substances, such as alcohol and drugs in ways that were not clinically indicated, harmful to wellbeing and/or illegal; 3) hospital admission for HIV, HCV and/or drug or alcohol related problems in the past five years; and 4) residing in Toronto or Ottawa, Canada. Patient participants were recruited using poster and electronic advertisements and word of mouth at local AIDS service organizations and community health centres.Eligibility criteria for health care providers included: 1) currently working in a general hospital in Toronto or Ottawa as a physician, nurse, social worker or other allied health professional; and 2) providing hospital-based health care to this patient group. Physicians on the research team contacted their colleagues at acute care hospitals via personal email and email listservs to provide information about the study and encouraged those interested to contact the study coordinator directly to learn more about the research. With these methods,Patient participants were asked to complete a brief questionnaire and an audio-recorded, face to face, semi-structured interview. The questionnaire included items about socio-demographic characteristics, health status, and substance use. During the semi-structured interview, patient participants were asked about their experiences of accessing acute care in a general hospital, the quality and nature of interactions with hospital-based clinicians, how they negotiated/managed their substance use while admitted to hospital, if and how they used substances while admitted, and what could be done to improve the experience of patients who use substances in acute care settings. Provider participants also completed a brief questionnaire with items about workplace characteristics, work role/position, demographic characteristics, and prior training in addictions and harm reduction. During the audio-recorded, face to face or telephone, semi-structured interview, provider participants were asked about their attitudes and experiences of providing care to this patient population, experiences prescribing opioids, benzodiazepines and psycho-active substances, the management of on-site substance use, procedures for patients leaving against medical advice, any hospital policies pertaining to on-site use of substances that were not prescribed, and recommendations to improve acute care for this population. As compensation, patient participants received $25 CAD cash and return transit fare and provider participants received a $50 CAD gift card for a bookseller.Audio-recorded interviews, lasting 10–60 minutes, were conducted between 04/2014 and 05/2015 by SR, SCC, AG or CS for patients at the University of Toronto or community organizations where recruitment took place and for providers at the hospital or by telephone. Audio-recordings were transcribed verbatim by a confidential transcriber, verified, corrected, and uploaded to NVivo 10. Using the seven step framework method, team members used line by line coding on several transcripts to identify pre-existing and emergent concepts, collectively discussed codes, developed a code set to be applied to subsequent transcripts, used an iterative approach to re-code transcripts to capture new codes, used Nvivo to capture the codes for each transcript, grouped codes into categories to create the analytic framework, charted the data by transcript and topic , and mapped connections between categories to identify and interpret themes in the dataset . Themes For this study, we recruited 24 participants living with HIV and/or HCV who were mostly male, Caucasian and housed; ranged in age from 33–56 years old and reported use of opioids, cocaine and/or many other legal and illegal drugs see . We alsoIn this analysis, we trace how lack of institutional policy regarding on premise illicit drug use created an environment where individual clinicians developed informal policies to guide their decisions. These informal policies, based on clincians’ personal beliefs and values, were powerful and for some patients created a risk environment that reproduced stigma and led to hospital admissions characterized by pain and discomfort, early discharge and drug-related risk. To understand what behaviours and situations these informal policies were designed to address, we begin first with a description of what motivates on-premise illicit drug use, what substances are consumed, and how they are consumed.If you're a drug addict on the street, you're a drug addict in there. You know? You're not going to stop using ‘cause you're in the hospital. (laugh)” (Ottawa patient-33). Attempts to avoid negative experiences such as withdrawal, boredom, sadness, loneliness and/or pain were commonly cited as reasons for using drugs that had not been prescribed. Exemplifying this are the remarks from Toronto patient-24 who had tried to stay:”high every day. That's dealing (with) boredom and making sure I don't get sick [experience withdrawal], because heroin's physically addicting”. Others spoke to the negative experience of sitting idle in the hospital and “after, … I had, sort of caught up with my sleep, then it became really boring … loneliness, sadness… You just want to not feel like that. So, it just, that urge just is sometimes overwhelming” (Ottawa patient-39).Many patient participants spoke about using psycho-active substances not prescribed to them during a hospital admission: ““It was hell getting…my pain meds. [Medical staff] were like ‘You're on forty five milligrams three times a day? I find that hard to believe [that you are still in pain]’”. These experiences discouraged patients from seeking future health care in a timely fashion: “I'm afraid to go, because I don't want to have pain. . . .So for me, if I knew it was guaranteed that my pain would be looked after in the hospital, I would go. But otherwise, I'm not going to go.” (Toronto patient-27).Patients described how their self-reported level of pain was not always believed, tolerance to opioids was ignored, and requests for higher doses of pain medications were disregarded and labelled as drug-seeking attempts. Toronto patient-21 recounted: Some patients used the drugs they possessed when admitted. Others left the hospital to buy drugs, including Toronto patient-29 who described going out to buy drugs to cope with acute pain:“It happens all the time, almost every visit that I've been there, whether it be me or my partner, always going out and getting morphine or what have you, to increase the pain medication and so on….I could cite the time my partner was in … for ten hours, and in severe pain…I literally went out, picked up the morphine, came back [to the emergency department] and was administering it to her, as the nurse opens the curtain, 'What are you doing?' And I'm like, 'Well, you don't want to deal with it, so I'm dealing with it.' Surprisingly, they didn't really do anything about it.”How did I manage my pain? …Walked out of the hospital and right to the park…. the drug dealers sit in the park, all day, all night, so … you just go out and buy it”. Patients, including Toronto patient-29, noted that dealers had gotten ‘wise’ to the potential to buy and resell drugs at premium prices: “You can make a killing in the hospital. (laugh)…So, there's people that actually do sit out front of the hospital, all day long and … hustle people and see if they can buy their meds from them… there's huge money in morphine and that.” Others relied on friends to bring drugs as recounted by Toronto patient-21. “When you're in isolation, they have an alarm on your door… So I couldn't get out. So my friends had to bring it in.”Participants noted it was easy to obtain their drug of choice given the proximity of the hospital to parks as reflected by Toronto patient-26: ““it's not fun to party when you don't feel good”.Those who abstained from using drugs while in hospital did so because they faced barriers to using drugs, which included: having been too sick to use substances, lacking money to buy substances, and inability to leave their rooms to buy drugs and/or to have substances delivered to them in hospital. Some attributed their abstinence to personal principles noting ‘it was not right’ to use while in hospital or noted as Toronto patient-27, a stimulant user, I’ll just walk in with my sunglasses on. They won't even notice. I am pretty good at disguising my personality when I'm high.” (Ottawa patient-39). Some patients said that they would “sneak in the bathroom. Not smoking, injecting and do it and quickly and where no one can see you. lock the door to the bathroom… you don't leave evidence behind.” (Ottawa patient-32). Others described waiting until the evening when fewer staff were present: “I didn't do it during prime time. …The first time I… did use, and then the nurse came in… And that's when I realized, 'There's no way I can use during the day. I'm going to get caught.'” (Toronto patient-15). Patients mentioned that it was easier to disguise the use of opioids because stimulants, such as crack cocaine, could lead to more discernible changes such as anxiety, aggression, restlessness, irritability and/or twitching. Others concealed use, not to avoid hassles, but to show respect for others in the hospital: “I also used some cocaine… after the surgery I had … for my fibula. . . . I was very discreet. I had this room to myself. . . .I think it's best not to make a scene, not to make your drug use everybody else's problem too.” (Toronto patient-23). Toronto patient-26 described sneaking out to conceal her use “So, I’d wait until nobody was at the front… I’d hear the other people’s bells going off.” However, this participant also remarked that she did not always conceal her use and that health care providers were aware of her use “Trust me, they know…. They’d be standing at the door and I’d do my toke and… be like WHAT? (laugh)… They just ignored me for some reason.” (Toronto patient-26).To avoid hassles, reprimands, and/or discharge, many patients spoke about trying to conceal their substance use from health care providers: ““I don't know if I ever saw this [substance use] in the hospital” (Toronto physician-32). Others acknowledged substance use happened during hospitalizations and suggested it was often well concealed by the patients: “I agree that [patients use substances], you know, especially for substances that don't cause such an acute cognitive change, like, you know, for example, cannabis. Like, yeah, it's very well hidden sometimes, yeah.” (Toronto physician-5).When asked, some of the health care providers interviewed said that they were unaware of on-site substance use. A physician said: I just don't know what our policy is here” and Toronto patient-27 remarked: ‘I don’t think there are. They have mean security guards. That’s about it I think.” Only one of the hospitals where we recruited clinicians had an addiction consulting service (ACS). None of the clinicians interviewed from this hospital noted that they had sought assistance from this group to address illicit drug use. One of our participants was a member of this service and also noted that there was no formal policy in place. In the absence of formal policies, responses to observed or suspected illicit drug use were determined by individual health care providers. Their responses varied from attemptsto enforce abstinence, to efforts to mitigate the risks of illicit drug use, to prescribing medications to manage withdrawal and other symptoms. Toronto physician-5 remarked, “I've seen a spectrum of different approaches. You know, one is to call the police, right? A second is to get some addictions help. Third is to cut off their opioids.” The type of response could vary between health care providers, across shifts and as such, patients could experience varied responses across a single admission.With two exceptions, none of the participants–patient or provider–could identify a hospital policy specific to substance use. For example, a Toronto social worker-11 said: “Ah no. Oh. Yeah, well in the psych ward they do…I can’t remember exactly [what they said] but they basically read you the riot act. They warn you severely.” Ottawa patient-38 spoke about being told once when he was 14 years old that “if I was caught in my room either drinking or smoking, smoking anything, that I would be arrested depending on what was found, and have to leave.” For patients, awareness of so-called ‘policies’ only happened after they were caught or suspected of having used an illicit drug. When asked if prior knowledge of ‘policies’ might influence their behaviour, Ottawa patient-34 exemplified the sentiment amongst those who had used while admitted: “No, I would have done it anyway. So when I really want to get high, I want to get high…it wouldn’t have helped too much.”Toronto patient-22, the first exception, remarked when asked about a hospital policy: ““I certainly know that when a patient hits a certain level of belligerent and difficulty…then the management will step in and … have a more serious talk … infer that they don't need to be in hospital if they're not going to play by the rules… put a bit of the fear in them.” One patient participant, admitted for a broken mandible, was discharged when his illicit drug use was detected: “Yeah, I got my girlfriend to bring me morphine… they kicked me out of the hospital really, because of it.” (Ottawa patient-33).The strategies used by health care providers to enforce abstinence included: immediate discharge, threats to discharge if drug use continued, increased behavioural monitoring, behavioural contracting to enforce abstinence, confiscating drugs and/or use equipment to prevent future use, and/or reduction or termination of prescription medications. Discharging patients found to be using illicit drugs was justified by personal beliefs that hospital environments should be drug-free and further defended as a measure to reduce risk to staff and other patients. Toronto social worker-11 described how patients would be threatened if they used drugs: You know, if you are going to smoke crack in the washroom again, we're just going to discharge you, regardless of how sick you might be, because that's not tolerated… It actually puts other people at risk and themselves at risk…if this activity were to persist that it would be grounds for discharge.'”Lack of institutional policy allowed health care providers to determine if they would discharge a patient following the first detection of substance use or after a warning as exemplified by the remarks by Toronto physician-4 “‘patients have…smoked crack or were caught with alcohol…. that's just physically removed from them.” (Toronto dietician-31). Ottawa nurse-22 described a gradual escalation of responses to suspected drug use:Increased monitoring of patients and confiscation of drug use equipment were other methods used to discourage illicit drug use: ““Obviously, I would start by asking the patient. And you know, sometimes, you know that they're lying to you, because the signs are there, that they're all of a sudden high and they weren't when you went in, let's say, fifteen minutes earlier. So…the doctors are the first to call. And then, sometimes, we've had to have security come and search the room and their belongings, unfortunately, because they've stashed stuff in secret places in the room.”Everywhere I went, I’d turn around… and she’d [hospital worker] be there …. I just started sneaking around her eventually.” Ottawa patient-33 noted: “So they kicked me out [for using]. They monitor you a little more closely when you're a drug user, right? Like, they test you more often for …drugs… before they test you for what they're actually looking for.” Ottawa patient-33 and others noted that not only were they monitored more often but also that physicians and nurses “Just the way they talk to you and that, they're a little more stern and that. You know? There's not, there's no, like, you can't bicker…it turns into an argument, but it's like, there's no changing their mind.”About increased monitoring, Toronto patient-16 said “It makes us, ah, less engaged with them; a lot more careful about, you know, their privileges off the ward or provision of narcotics or, benzos for anxiety …cause of the violation of the agreement or the trust between us, absolutely changes.” (Ottawa physician-23). Not all physicians, including Ottawa physician-36, agreed with cancelling prescriptions because they worried that patients would leave against medical advice:Some physicians feared the consequences  of prescribing medications to patients who were not honest about their illicit drug use during the admission and cancelled medication orders for pain, anxiety, and/or depression: ““Well, the flip side… I talk about that story where somebody was not swallowing his oral morphine. And he was crushing them in the washroom. He had a syringe hidden in the ceiling and then he was injecting himself. They found him. They make the rules even harder. And the guy left. Had endocarditis and he left… I wouldn't be surprised if he's dead by now … What I dislike about it is instead of facing the situation of 'Okay, you have an addiction problem and you need to take morphine and how can we handle that while you're in hospital?' It was kind of a conservative approach of 'Oh no, you're a criminal and we'll make your life harder’.”blind eye to things” and Ottawa physician-16 spoke about allowing patients to go for “a smoke break. They need to get some fresh air. . . . you don't usually get in their way.” This physician also noted that after going outside “They come back and they're all relaxed and ah, and you know, they'll often apologize for being a pain in the ass, and they're fine until they need their next hit.” (Ottawa physician-16). Ottawa patient-33’s comments were supportive of this approach “It would be helpful if they accepted the fact that it was going to happen… staff that could adjust to that.” Toronto patient-15 expanded further saying “I think they should have more of an open approach… Well depending on the behaviour of the person. If you are rowdy, if they using and it’s not affecting anybody, why not let them use?.” Toronto patient-26 also hoped that clinicians would: “just ignore it… if it doesn’t bother anybody, I don’t see what the big problem is” but this hope often came with a worry that they might receive a lower standard of care: “And you're a drug user… they forget about your meds…they're later with you or run to the other patients before they run to you. . . .”In contrast to health care providers who used discharge and increased monitoring to enforce abstinence during hospital admissions, others tried to mitigate the risk of early discharge. Acknowledging the lack of official policies and lack of expertise about how best to help patients, these health care providers prioritized keeping patients in the hospital. Toronto nurse-8 said she would turn: “a If I were to find them using, I would probably just say 'You know, you really can't do that here. The hospital, first of all, doesn't permit drugs in the hospital that aren't prescribed…Go out, do what you have to do and then come back.'” Toronto physician-3 also said he would encourage patients to “smoke them outside. Don't smoke them in the bathroom… it creates a whole bunch of other issues that I can't actually, I have limited powers.”Although not commonly discussed, some providers, including Toronto nurse-6, tried to help patients manage their use of drugs: ““I tend to try and take the easy route and try and provide them what I think they need, what they crave. otherwise… they leave hospital against medical advice …And if that means giving them drugs, then so be it, you know?” (Ottawa physician-23). Ottawa physician-24 remarked: “In the cocaine using, withdrawal's less of a concern. I might calm them down with some Ativan, just acutely. Usually they just sleep it off.” Ottawa physician-23, although uncomfortable with providing substitution dosing, remarked about a street- involved woman living with HIV and HCV who was admitted with endocarditis:A small number of physicians believed that efforts to force patients to be abstinent would not lead to long term change for the patient and instead they tried to prevent withdrawal, manage cravings, and/or to manage pain and reduce patient and provider conflict: “We need to treat her for six weeks. We cannot do this safely as an outpatient… let's get her on a dose so that she does not crave it… she was in isolation. She was also MRSA positive. And got three times daily… MS Contin or something like that…it was six weeks of kind of, swallowing what feels wrong, that is, basically giving an addict what they're addicted to. On the other hand, it is realistic and we're not going to change the world with a short admission like this. And addiction's a little bit more complicated than just denying someone their drugs, so.”If somebody was smoking in the hospital, they cannot smoke. You give him a patch…Somebody is using morphine in the street and, or heroin and he goes in the hospital, you give him nothing. Right? … we should have at least the same standards for smokers and for people using other substances.”Substitution dosing was justified as a measure to ensure consistency of approach across patients, as exemplified by the remarks of Ottawa physician-35: “It can work, one of two ways. It can be helpful, or I think push the patient away from the clinical aspect.” (Toronto patient-20).Others hoped that the response might include a conversation about drug treatment and about what might happen next “In this study, patient participant accounts of substance use in hospital rooms and bathrooms as well as outside of the facility while admitted align with existing literature and reinforce that common reasons for in-hospital substance use include avoiding physical withdrawal and managing pain during hospital admissions , 25. PatA contributor to on-premise use is the real and perceived lack of access to appropriate pain management. Fear of pain results in delays seeking medical care, leading to worsened health problems as has been documented here and elsewhere , 20. PrePast studies have also shown that providers have negative perceptions of PWUD including labelling them as ‘drug-seeking’ or believing patients will sell their prescription opioids, resulting in reluctance to prescribe , 37. WhiOur study contributes to the small, but growing, body of literature and theory about drug use in hospitals and the role of harm reduction by illuminating the relational, affective, temporal, fluid, and ambiguous elements, as well as acts of resistance. First, our study provides both provider and patient perspectives, and highlights relational issues which affect care such as behaviour following use, and affective issues related to fear, anger, anxiety, and disappointment from both patients and providers. The relational is extended into the narratives of patients who supported each other by sharing drugs in hospital with friends and loved ones, and providers who turned a blind eye to these strategies. In addition to the embodied experience of drug use and withdrawal which is well documented in the literature, our findings highlight the temporal elements and how time passes when people are unable to use and the devastating impact of boredom and isolation. Despite the perception of the hospital as fixed, patients moved between the hospital and surrounding community drug using spaces, and dealers moved from those spaces into hospitals, with relative ease making for fluid borders. While much attention has been given to discriminatory and punitive polices in hospitals, we heard about the absence of policy and what this void enables or constrains. Such policy ambiguity empowers some care providers to subject patients to searches and expulsion while it empowers others to provide substitution dosing on a case by case basis. That is, we heard accounts of resistance from both patients and providers. Hospitals are indeed risk environments, but where there is risk there is also opportunity, including for developing client centred care approaches. We invite others to take up these theoretical threads in future research that recognizes the complexity of managing substance use in hospitals. Such an orientation invites thinking about drug use in hospitals as an assemblage of relations, bodies, drugs, affects, temporalities, and policies .While our study illuminates important patient and provider perspectives, there are limitations to consider in its interpretation. Our study findings are based on qualitative data collected about experiences in academic hospitals in two large cities in Canada. Given that participants spoke about experiences that took place in the five years preceding the interviews, their recall of experiences may be influenced by time and other subsequent events. In addition, we recruited people living with HIV and/or HCV and who also use illicit drugs people, a very specific sub-population of people who use drugs whose experiences may not reflect those of PWUD without these infections. Additionally, we recruited people who reported the use of any illicit substance without a prescription and our sample precluded sub-analysis by substance type and/or route of administration. Eligibility for provider participation included delivering care to those living with HIV and/or HCV and this provider group may have different perspectives and attitudes compared to other specialists or general medical providers. While the findings are subject to these limitations and the extent to which the data can be generalized across place and time are not clear, our findings to add to a growing literature that reports similar experiences in other settings suggesting that these experiences are more generalized than specific to person, place or time , 25.There are increasing calls for implementation of harm reduction approaches and interventions  in hospitals , 42 but