Little is known about the challenges MLTs faced in keeping up with the unprecedented demands posed by the pandemic, which contributed to the notable staff shortage in the profession. This study aims to identify and understand the stressors of MLTs in Canada and the lessons learned through their lived experiences during the pandemic. (2) Methods: In this descriptive qualitative study, we conducted five semi-structured focus groups with MLTs working during the pandemic. The focus group sessions were audio-recorded and then transcribed verbatim. Thematic analysis was used to inductively code data and identify themes. (3) Results: A total of 27 MLTs across Canada participated in the study. Findings highlighted four key themes: (i) unexpected challenges navigating through the uncertainties of an ever-evolving pandemic; (ii) implications of staff shortage for the well-being of MLTs and quality of patient care; (iii) revealing the realities of the hidden, yet indispensable role of MLTs in predominantly non-patient-facing roles; and (iv) leveraging insights from the COVID-19 pandemic to enhance healthcare practices and preparedness. (4) Conclusion: The study provides in-depth insight into the experiences of MLTs across Canada during the pandemic. Based on our findings, we provide recommendations to enhance the sustainability of the laboratory workforce and ensure preparedness and resiliency among MLTs for future public health emergencies, as well as considerations as to combating the critical staff shortage.  Coronavirus disease COVID-19) brought unprecedented challenges to the healthcare system. It placed a significant burden on healthcare professionals working on the front lines, increasing workplace demands on healthcare professionals, along with the heightened risk of exposure to the virus 9 brought. In a reAmong these healthcare professionals are medical laboratory technologists (MLTs), who work primarily behind the scenes. MLTs conduct medical laboratory testing and analyses to assist in the diagnosis, treatment, monitoring, and prevention of disease . MLTs woThe pandemic highlighted the critical role of MLTs, underscoring the importance of their work in the healthcare system. Their expertise facilitated the surveillance of the virus and supported public health efforts to prevent its spread . HoweverThe impact of the pandemic has been extensively studied as to visible healthcare workers, such as physicians and nurses ,6,24. HoThis qualitative study aims (1) to identify and understand the stressors of MLTs working during the pandemic and (2) to identify the lessons learned from the COVID-19 pandemic, with emphasis on well-being and how to optimize healthcare delivery. The insights gained from this study can contribute to promoting resilience among MLTs and address existing gaps in the laboratory workforce to ensure workforce sustainability and enhance the preparedness of the healthcare system for future public health emergencies. The present study explores the stressors of MLTs and lessons learned on a national scale, building upon previous work by authors B.G. and B.N.-K. on the same population within a provincial context . For thiThe focus groups were conducted virtually through Microsoft Teams Version 22.08.1  from JulEligible participants were medical laboratory technologists in Canada working during the pandemic. Participants were identified through a multi-faceted approach. We partnered with various associations and regulatory bodies across Canada, including the CSMLS, the Medical Laboratory Professionals’ Association of Ontario, the British Columbia Society of Laboratory Science, the College of Medical Laboratory Technologists of Alberta, the College of Medical Laboratory Technologists of Manitoba, the Nova Scotia College of Medical Laboratory Technologists, and the Newfoundland and Labrador College of Medical Laboratory Science to help facilitate the recruitment process. Participants were also recruited using social media platforms . In addition, a snowball sampling technique was applied by asking existing participants to assist with recruiting potential participants. To minimize the risk of fraudulence, participants’ names were verified through the public registry of their respective provinces before participating. Participants received a $50.00 Amazon gift card for their participation in the study.We obtained ethics approval from the University of Guelph’s Research Ethics Board (22-03-001). Before participating in the study, participants were informed about the purpose, risks, benefits, confidentiality of information, anonymity, and voluntariness of the study. Written informed consent was obtained from each participant. To maintain privacy and confidentiality, participants were asked to refrain from using any identifying information that others might recognize. Participants were reminded that the session would be audio-recorded for the accuracy of data collection.A semi-structured interviewing method was applied, guiding the discussions with open-ended questions . Follow-The focus group recordings were transcribed verbatim. To ensure accuracy and improve credibility, two researchers (P.D. and M.G.-D.) reviewed the transcripts while listening to the audio recording. Data analysis was guided by Braun and Clarke’s six steps of thematic analysis , using QWe reached data saturation after conducting five focus groups. A total of 27 medical laboratory technologists across Canada participated in the study, with 22 participants identifying as women and five participants identifying as men . The parFour key themes emerged from our data: (1) unexpected challenges navigating through the uncertainties of an ever-evolving pandemic; (2) implications of staff shortage for the well-being of MLTs and the quality of patient care; (3) revealing the realities of the hidden, yet indispensable role of MLTs in predominantly non-patient-facing roles; and (4) leveraging insights from the COVID-19 pandemic to enhance healthcare practices and preparedness . Figure Our findings revealed that MLTs experienced fear and anxiety due to the uncertainty of the pandemic. Participants defined the fear of the unknown as a significant contributor to the stress which they had experienced, especially at the beginning of the pandemic, due to the limited knowledge and understanding of the COVID-19 virus. FG-80: “So, I found the, the biggest stressor for me at least, like for, for the first wave, when it first started, was the unknown. So, you sort of like, everyone in the public had we don’t know what the effect of this is, we don’t know how contagious it is. We don’t really know what’s going on.”FG-89: “Uh, I think in the beginning it was, it was really the uncertainty of the pandemic like, um, yeah, just you don’t know what’s gonna happen next.”The fear of infection emerged as a prominent stressor during the pandemic. Due to the high-risk nature of their work, which involves handling potentially infectious patient samples, participants expressed their profound fear of contracting the virus. Some participants whose duties included phlebotomy and sample collection expressed heightened concerns about contracting the virus. The risk of exposure to COVID-19 created a sense of unease and concern among participants for their own personal health and safety. This fear of infection felt by MLTs was intensified as they found themselves ill-equipped to work safely due to the shortage of personal protective equipment (PPE) during the early stages of the pandemic, which increased their susceptibility to the virus. Participants described the manner in which the lack of adequate PPE compromised their safety and their ability to safeguard their well-being, which added a layer of stress to their already-demanding jobs. FG-104: “…just anxiety about catching COVID and going to work and having to put myself at risk while this maximum workload was still being placed upon us, so like my own health and safety.”FG-79: “…there was a shortage of masks and we wanted to reserve the masks to the nurses and doctors or other professionals who interacted with the patients directly.”Participants’ concerns extended beyond the workplace. A cogent stressor among participants was the fear of infecting their family members, including children and those who were immunocompromised. During the initial wave of the COVID-19 pandemic, the pervasive lack of comprehensive information about the transmission of the virus was a constant source of fear and distress. Participants described the ways in which the stress of not knowing how to protect themselves and their families heightened their anxiety. This fear was particularly pronounced for participants with young children and those who lived with family members who were more vulnerable and at higher risk from COVID-19 infection, such as elderly parents and immunocompromised family members. Participants described taking strict precautions, such as disinfecting personal belongings, showering, and changing clothes immediately upon returning home from work before interacting with their families, demonstrating the lengths they went to minimize the risk of transmission.FG-53: “…in the first wave and especially at the beginning was, was the fear of infection and the fear of, worse, the fear of bringing it home. I, I, I don’t know many people who in, in health care, who weren’t experiencing that, the fear of bringing it home… especially in the beginning when we didn’t have enough information about transmission and modes of contact and means of managing containment. We didn’t have any of that.”FG-85: “Like for me, I had a brand-new baby at home and I had a, a child in school and coming home and not like, trying not to bring it home. I was like scrubbing down and showering, going straight down, stripping my scrubs off and putting them in the, um, wash… And so, then I was changing at work and then coming home and so, it was a lot of that stress and just not knowing, and trying to keep your, your family safe. Even knowing that you’re, you’ve just walked into a, a positive room and like, “How do I not bring this home to my brand-new baby? How do I not bring this home to my, my husband and, and little son?”FG-80: “My husband is also exposed to patients and, and my kids go to school so, there was also, you know, that. And I have, you know, my mom’s in her 70s and we’re worried about her and, you know that kind of stuff?… And you know, when you go to work and then you worry about bringing it home.”FG-82: “I also live with someone who’s immunocompromised, and our lab was right beside the intensive care unit, so I was a bit concerned about bringing anything home.”Participants also expressed their concerns about inadvertently infecting patients, recognizing the far-reaching consequences and the potential implications for immunocompromised patients, including vulnerable populations. They acknowledged their responsibility as healthcare workers to adhere to infection and prevention-control measures to ensure the well-being of their patients. FG-79: “Because we didn’t know much about COVID such that how it’s spread, etcetera, I was hoping that I will, I was not spreading the virus to patients by coming to work.”The rapidly evolving nature of the pandemic contributed to the stress and anxiety felt by participants. Participants described the unpredictability at work during the pandemic, when each day brought uncertainties and new challenges, which caused ambiguity in navigating the workplace. Due to the rapid development of knowledge about the virus, MLTs were tasked to adapt to frequently modified health and safety protocols. These changes included the use of PPE, infection prevention, and control measures. Participants noted that the changing protocols and inconsistent communication caused confusion among MLTs. As an added stressor, management expectations changed rapidly, causing a sense of ambiguity as to their roles and instability in their work routines, thus elevating their stress levels. Participants also highlighted the challenge of keeping up with the rapid advancements, which included learning new testing methods and novel technologies.FG-80: “And then just every time we went to work, there was a change. So, one day it would be like, okay, well, you have to wear a mask all the time, well, you do this, and now it’s you have to wear an N-95 and now it’s, okay well, we want you to wear an N-95 and a face shield and then, oh, well, you don’t really need any of that. So, every day when we went to work, there was something new, there was a new procedure to learn, there was a new protocol to follow, and it’s just, we sort of had these, like, debriefings every day.”FG-97: “Um, I will say for us one of the biggest stressors would be a heavy workload which increased exponentially for us, especially during COVID because our lab was very much involved in the COVID testing. And with that, the need to adapt to change very quickly and then like, to learn new processes and new testing methods in a very short period of time.”FG-11: “…I found during COVID there was a need for a lot of, um, adaptability and there was a lot of changing just kind of happening in a very short time scale and a lot of lab[s] just weren’t prepared to take that on.”The pandemic also presented challenges to resource availability. Specifically, the pandemic created a surge in demand for testing supplies, causing disruptions and delays to the supply chain, which significantly strained the availability of these resources and impacted the efficiency of laboratory operations. Participants described situations in which the shortages of essential supplies and resources affected laboratory operations, further contributing to their stress as managements’ demands remained high. Participants expressed the belief that due to the supply shortages, they had to be resourceful by using the resources available to them and exploring alternative options. Consequently, this increased the time required to complete their tasks, consequently adding to their workload. Participants also described the fact that much of their equipment had become outdated or broken and needed replacement. The limited availability of the necessary equipment hindered the quality and timeliness of laboratory testing processes. These challenges further contributed to the burdens experienced by MLTs.FG-105: “I just wanted to also add the strain of supply chain, um, where our current, like most common supplies are often running out with no alternative to replace. Um, and for the lab, it means a lot because we actually have to validate new reagent, new test tubes. And this is just increasing workload to already stretched workforce, um, and we’ve never seen this in the past.”FG-96: “And then the final stressor that I thought of that was touched on was just supply issues, but not only COVID-specific supplies but even things like our gold top tubes. At one point, we were very near to the point of sending our patients to another location because we had to save the very few  tubes that we had in case we had stats, in case we had emergencies, that sort of thing, um, because we just could not source it. We’re a small clinic. We were not on the top priority list for the supplier. So, it took a lot to be able to get a hold of the supplies that we needed, even for things that weren’t COVID-related.”FG-107: “There’s a lack of equipment required to do our, our job with, you know, sometimes a lot of the instruments are getting older.”The pandemic increased testing demands, significantly increasing the work volume of MLTs. This placed a significant strain on MLTs, as they were tasked to process a larger number of samples in a shorter time. Participants reported working longer hours, sometimes foregoing breaks, to keep up with the escalating demands. This strain was further compounded by a notable staff shortage that existed before the pandemic. The increased workload and prolonged hours along with the limited human resources exacted a toll on the physical, mental, and emotional well-being of MLTs. Unsurprisingly, this work environment led to a notable rise in workplace injuries and an increased incidence of sick leaves and absences.FG-104: “…you know, you had three night shifts, then one day off then had to work seven day shifts in a row and you never got to see your spouse or you had to work stat holidays.”FG-94: “There’s been injuries at work and with how we have staff shortages and increased load, people are trying to push harder, work faster so those injuries are happening more often.”FG-107: “It was a, a big stress on me because I, I needed to get everything up and running because people’s lives were, um, on the line. So, that was, it was so bad that I actually ended up in the hospital with a cardiac event. And stupid me thought, okay, well, uh, I should just go back, I’m okay now, I’m gonna go back. So, I tried for a few more months and the stress, it just didn’t, it didn’t stop, like it just kept actually rising. So, I ended up going on medical leave.”The overwhelming workplace pressure and insufficient staffing led to heightened levels of stress, which led to retention challenges. The cumulative stress resulted in burnout among many MLTs, causing them to leave the profession or retire early, exacerbating the staff shortage. As a result, this substantially increased the workload for the remaining MLTs.FG-89: “Like my experience in my workplace was that a lot of the staff burnt out during the pandemic… Uh, our sample load increased dramatically and there was a lot of people that weren’t adjusted to that to, um, that kind of workload…they ended up retiring early because they couldn’t take the, they couldn’t take the workload… because it was just, like it was just too much work. And then so that, that caused our staff to be in a little bit of a crisis because suddenly there was many people leaving our lab.”FG-104: “Before COVID, we didn’t necessarily ever have staffing shortages because it would be like one tech got hired and one tech would retire and it was sort of this ongoing trade off and it wasn’t too bad, but we found with COVID we had a lot of techs, uh, for about halfway through 2021, we had a lot of retirees and a lot of people leaving permanently due to stress leave, so we were really running out of people because so many people were leaving.”The increased workload and limited staffing imposed on the remaining staff had a negative impact on the overall job satisfaction and well-being of MLTs. As a result, some participants expressed intentions to leave the profession and consider alternative career paths at some point during the pandemic. Also, some participants revealed that the workload pressure led them to make the decision to leave their previous workplace and seek employment in less-demanding settings.FG-105: “For me, I often had to re-evaluate if I wanted to retire because I’m actually at an age where I can retire. Uh, so I did have quite a few times where I would just wanted to give up because on a daily basis, I just deal with problems, like everyone was so negative, and problem-solving all the time and having to find all the solutions.”FG-89: “I actually like reconsidered my profession many, many times. I would think it was such a mistake to get into healthcare, that I just wanted out, that I wouldn’t recommend this health -, this profession to anyone…”FG-51: “Even before the pandemic. I think we had maybe half a year or a year when I first started where we were fully staffed, and it was, uh, sort of a steady decline from there on out and it got much, much worse to the point where I actually left that lab and moved to a different lab because it was too short staffed and the demands were still the same or a little bit more, and it ended up putting a little too much strain on people who are left.”Participants explained that senior MLTs who retired during the pandemic were replaced by newer and less-experienced staff. This increased the burden on the remaining staff members, as they had the added responsibility of training the new MLTs in addition to their existing workload, further straining an already-stretched workforce. Participants noted that new MLTs found themselves confronted with an overwhelming and highly stressful work environment, leaving them unable to handle the pressure. As a result, some newly recruited MLTs left the profession. Reportedly, while facing a shortage of qualified MLTs, the turnover of newly trained staff worsened the situation, making it increasingly difficult to fill the workforce gap.FG-89: “…since we had, um, uh, since it was so stressful at our lab, people would come and be trained and then leave immediately after finding a new job just because, just the workload that they were thrown into was so, was so high that they just looked for, for a new job.”FG-49: “…it’s stressful and I can’t imagine being a new person and having expectations … You don’t wanna make mistakes and there’s a lot of pressure to make sure that what you’re putting out is accurate and correct and, on both sides, I think from our new hires, and that’s why we’ve actually had a lot of new hires leave because it’s so chaotic, they, they just can’t take the environment.”Participants reported increased rates of laboratory errors due to the high influx of testing. They explained that the pressure to meet demands and turnaround times led them to sacrifice the rigor and quality of their work. Participants reported instances in which they were instructed to ‘cut corners’ to expedite the testing process. However, participants expressed their concerns about these shortcuts in testing procedures which could potentially compromise the quality and integrity of test results and, in turn, pose risks to patient-safety outcomes. Deviating from standard protocols weighed on the participants, as they felt that their professional integrity was being compromised.FG-39: “I feel that when you are constantly under stress, sometimes I, I might have and I, I might have and so many other MLT’s when they were under so much stress, they might have accidentally made any transcriptional errors in the reporting the critical results. Some results might have been missed to call, which could affect the patient care, because those patients are waiting for those results so that they, their, their treatment could begin and stuff like that, but there were there were situation where the sample was too old to be loaded onto the analyzer. But we were told to cut corners and not to reject the specimen and just continue processing them, which directly implements the patient care. Because if the patient was actually a positive but now that the specimen integrity has lost, that patient might come out as a negative. So, there, there were so many cut corners from the management.”Participants also highlighted the fact that the lack of training contributed to the occurrence of errors. As new protocols were rapidly introduced and implemented during the pandemic, they had to quickly learn and adapt to the changes to meet the high testing demands. Additionally, there were reportedly more errors due to inadequate training for newly hired MLTs during the pandemic. Participants explained that due to the limited staffing, there was reduced capacity to provide proper training for new MLTs. The lack of proper training and mentorship for new MLTs reportedly contributed to an increased likelihood of errors.. Correcting these errors was a time-consuming and labor-intensive process, as they often required recollection, retesting, and reanalysis of samples, which further compounded the workload of MLTs. Participants reported that these errors and the subsequent corrective measures caused delays in diagnosis and treatment, impacting patient care and health outcomes.FG-95: “Just to add on, I want to say that I feel that, that training, the training period was inadequate for a lot of the processes that were being implemented just because due to COVID, it needs to be implemented very fast and very soon. So, not only is the training inadequate, but staff wasn’t- staff weren’t sure what they were doing and there’s a lot of corrective reports that went out. So, I think it added on to a lot of stress that was in my workforce…”FG-98: “So, if we are, yeah, um, so if we’re putting out like grads who are not fully trained or they may not know certain things, then when we put them out to the workforce and they have the, the employer has these expectations like you have to x, y, z and they don’t know those things, it may require like a recollection from a patient if they collect the wrong tube, whether that be like blood or if it’s a microbiology sample if they plate the, if they inoculate the plates incorrectly, stuff like that. And we have seen cases like this pop up, so it requires a recollection from a patient, which will just ultimately delay patient care.”FG-95: “Uh, I know that there was a lot more mistakes that were made. And then, there was a lot of corrective reports just because of the burnout and it was just small mistakes that were missed that ended up being reported out. And then we’d have to phone and correct it. So, there was implications at the end of it.”Our findings revealed MLTs experienced moral distress and guilt as they worked during the pandemic. Participants were placed in morally distressing situations, in which their test results could have potentially affected life-saving decisions. They understood the immense responsibility that came with their work and expressed the emotional weight of knowing that their actions had direct consequences for patient outcomes. Participants also reported that because of the high priority and large volume of COVID-19 testing, other tests, such as cancer testing, were delayed. These delays added to the moral burden experienced by MLTs as they were aware that this could potentially delay diagnosis and treatment for patients. FG-53: “And so, you ended up with this backlog or you were having conversations about whether or not to do this test this month and whether or not the patient could wait a month or the next month for the test and there was conversations that should never be had that were being had and it left me as a professional feeling inadequate, which I think really wore on all of us. And that was through start to finish. There wasn’t a time where that wasn’t a problem.”FG-53: “…during the 2nd and the 3rd wave, some of the testing panels we were performing in my particular area were looked at as a possible means of determining who would be ventilated and who would not be ventilated, in the case where a lack of ventilators became possible. And both in the 2nd and the 3rd waves, those conversations were definitely happening. And knowing that the numbers you were generating would literally determine the fate of a human being, was incredibly stressful, way more than I had ever signed up for in my career.”The findings also revealed that MLTs often experienced feelings of guilt. Participants expressed feelings of guilt for taking breaks, because they felt a sense of obligation to deliver timely results. This guilt was further intensified by the high-pressure work environment, where they constantly strove to meet demanding deadlines. Participants expressed reluctance to leave unfinished work for fear of overburdening their coworkers. Participants also reported working unpaid overtime to ensure that tasks were completed before passing them on to their colleagues.FG-39: “We also needed a break but you can’t. You badly want to go on your coffee break, but when you actually go on your coffee break, you cannot enjoy your coffee break, because now you’re constantly thinking about going back and calling all those critical results. You could imagine how you must be feeling at 3:00 AM in the, in your night shift, where you have so much work to do. And sometimes we were even asked to handle the bacteriology side as well when there was no support of a lab assistant during night.”FG-95: “When you’re, when, during our testing, we finish, we usually try to finish the whole process and not leave it to someone else because it’s just very difficult to hand off sometimes. So, um, unpaid overtime, meaning that a lot of times to finish it before the shift ended, we wouldn’t take our break times. So, we would just skip our breaks entirely or we would just take an extra 10 min to finish resulting the samples. And it wasn’t something that was forced, it was just that a lot of people, it was just so busy that you just want to finish your work and go home and have no conscious about it and not take that work home. And then you just didn’t want to leave thinking that, um, you know, that you didn’t hand off properly, it was rushed, and it was just a lot of just emotional kind of, you didn’t want to leave home thinking about work.”Participants expressed that they had felt guilty when considering sick leaves or absences, as they were aware of the already-existing staffing challenges. They were concerned about the impact their absence may have on the remaining staff and leaving their colleagues with an even greater burden. This fear of overburdening their colleagues created a sense of obligation to remain at work, even when they were unwell and needed some time off.FG-89: “…You would see on the schedule, um, that they’re working short that day and then yeah so, I had uh, yeah, even, even myself like, I would, I would always like triple think even, even trying for one, because you just know that it wouldn’t be possible. Yeah, and even some people who are genuinely sick, like they would feel so guilty about calling in sick to work because they just know it’s, it’s just gonna mean like, an even worse day for everyone.”Given the sense of duty to support their colleagues, some retired and soon-to-retire MLTs were reportedly compelled to continue working to alleviate the staff shortages. Our results revealed that those who had planned to retire chose to postpone their plans, as they were cognizant that their absence would have left an additional strain on their colleagues. Some participants also reported that they knew of retired co-workers who had returned to work to fill staffing gaps and support the workforce. FG-101: “People that had like their retirement plan, like planned out, they had their dinner ready they were like, “yeah, I’m gone.” COVID kind of hit, and they were like, “I’ll stay. I will, like, stay, until this is all figured out.” We had people come back, like it was the opposite here, people that were retiring stayed on to see us through. They’re still working to make sure that we, like, get through this.”Despite the invaluable roles of MLTs in the healthcare system, their efforts and contributions go unnoticed. Participants expressed their belief that there was a lack of understanding of their roles by those outside of the laboratory. As MLTs are typically non-patient-facing, participants noted the limited public awareness and understanding of their profession. Participants expressed the belief that they felt forgotten in healthcare in comparison to other healthcare workers and that they were perceived as a ‘magic black box’ where samples are automatically analyzed and interpreted. They noted that individuals outside the laboratory failed to recognize the complexities within the laboratory. Participants emphasized that the lack of public awareness and understanding of their profession may be attributed to the non-patient-facing nature of their work. They explained that the limited visibility of MLTs may have contributed to the lack of adequate funding for staffing, as the attention and allocation of resources tended to be directed towards more visible areas of healthcare. Participants also expressed their sense of a lack of understanding of laboratory operations among other healthcare workers, in demanding faster turnaround times and expecting immediate responses. This lack of understanding led to challenges in communicating and collaborating with other healthcare professionals. FG-53: “Some of the stressors that I’ve experienced in this profession, for the 27 odd years, primarily boils down to a lack of either understanding and or respect for the work that actually is accomplished within the laboratory. People outside of the lab kind of view us as that magic black box, samples will go, come, go in. Magic happens. Numbers come out, values come out, but what happens in between is magic… I think that’s the single biggest challenge I’ve experienced in my long career…We’re not in the front, to, for the world to see… we’re hidden, and I think that has a lot to do with why we’re not funded to the levels required to achieve the staffing that’s required to make it possible for us to feel not spread thin.”FG-96: “I would say our common stressor is, uh, communication and dealing with other health care professionals who may or may not understand, um, really how our profession works and the, the sort of rules the, um, standards that we need to follow.”Despite their contributions during the pandemic, participants felt that their work was unrecognized and unappreciated. MLTs found themselves with increased work demands and responsibilities without receiving any additional compensation. Participants expressed their frustrations, as they were tasked to assume more responsibilities without receiving any additional compensation for the increased workload. FG-49: “…you’re asked to take on more responsibilities without actually any additional compensation.”Several participants reported they did not receive ‘pandemic pay’ or any additional financial compensation for their efforts and sacrifices during the crisis. This lack of recognition and compensation resulted in dissatisfaction among MLTs, which impacted their work morale and made them question the value of their work. Participants perceived that their efforts were underappreciated and that they were not given the same recognition as other healthcare workers, leading them to question the significance of their roles. They expressed disappointment with the unequal treatment, as they believed that their contributions were just as important, and equal to those of other healthcare workers.FG-84: “And then, um, I know then in Ontario, one of the stressors was they did like a pandemic pay for like nurses and people that work in the, like the dietary people, the secretaries, they were getting a pandemic pay, but then the MLTs and respiratory technologist and diagnostic imaging, they didn’t get that cause they weren’t first, first line workers…Like, we were like right there, but it was never acknowledged.”FG-53: “And then, the lack of pandemic pay hit. And I am sorry, every lab tech in this thing has cried during this pandemic. And then to have that pandemic pay slap in the face hurt. It was like, so it really doesn’t matter what we do, so maybe we should just stop doing it. So, there was that.”MLTs also expressed a belief that they had experienced a lack of support from management during the pandemic. Participants reported that despite voicing their concerns regarding the staffing issues and needing more MLTs, they felt their pleas had gone unheard. Participants expressed their frustrations with their managements’ inaction to their concerns about staffing shortage, which negatively impacted work morale. Participants also highlighted the impact of hearing words of acknowledgement, even when immediate actions to address these concerns might not have been feasible. They expressed their sense that simply acknowledging their concerns and reassuring them that efforts would be made to support them could have helped to boost morale and job satisfaction. FG-51: “There was also that sense of management not hearing us where we were constantly banging on the fact that we were really short [and] we need to hire more people. We need to do something about this and, uh, almost the feeling like the concerns with being brushed off they weren’t even really being acknowledged. Um, and then sometimes even if management can’t do anything, if they say, ‘But our, our hands are tied, we can’t really do anything about it, but we see you, we’ll do what we can.’ Sometimes even hearing that helps, but our hospital didn’t really do that. So that kind of also affected morale.”Participants also reported a lack of regard and respect for their personal lives. One participant recounted the time they had requested a leave of absence due to a family emergency; however, their request was denied due to staffing limitations. The participant expressed dismay and dissatisfaction at the lack of understanding and consideration for personal circumstances. Participants felt they were not supported in their time of need and felt undervalued as an employee. FG-56: “I also had a family emergency during, I think, wave three of the pandemic and I wasn’t allowed to take time off work to deal with that. So, what, management is fully aware of what I was going through, but I was told we’re short-staffed.”Participants also highlighted the challenges of accessing mental health support and services during the pandemic. Participants noted the importance of mental health during the pandemic. Some participants reported a lack of available mental health services. Other participants reported that despite the availability of these services, they were not accessible to them, as they did not have the time to attend them outside of work.FG-99: “…it’s usually really difficult, like, given like how short we are, not everyone actually has the time outside the work to attend these, uh, sessions on their personal time.”Participants recognized the importance of prioritizing their well-being and setting boundaries in the workplace. Working throughout the pandemic, participants gained valuable insights into their own capacities and limitations. The participants recognized the significance of self-care and realized they must prioritize their own health and well-being. Participants noted that by placing themselves first, they are better equipped to care for patients and fulfill their professional duties effectively. They indicated that if they are healthy, both physically and mentally, they can be more productive and are better able to handle the demands of their work.FG-99: “Um, just knowing what my own limits are and just really know how I am and what I can take on is that, you know, as a medical lab tech. And also, how to handle the various stressors either at work or at home, so that, that’s really became, um, I would say the highlight of what I’ve learned throughout this whole pandemic period, to figure out, uh, more of my own, uh, yeah, mental capacities.”FG-94: “…I learned to set up boundaries for myself. I was more of like a yes person before, and even if there were things I wouldn’t [be] uncomfortable with or I didn’t agree with, I would just kind of think of it as a compromise and just let things be. But to me this was a really big deal and I learned to kind of stand up for myself and my family and set up boundaries which, uh, some people were not used to, but it was, uh, it was kind of like, uh, I got a little stronger in a sense, I guess. So, that was, that was kind of the lesson I learned in kind of the good thing that came out of it.”FG-107: “And also, you know, in order to serve the citizens of Manitoba, you know, I, I need, I needed to, to remember that I need to place myself, ensure that I’m placing myself first and I wasn’t doing that… I was just always thinking about somebody else, but it got to the point where I was putting other people first and then it was having its toll on me.”Participants noted the importance of having strong leadership and effective communication for enhancing preparedness and response efforts during a public-health crisis. They recognized that clear and consistent communication is paramount in such situations. Participants underscored that timely and coordinated communication is crucial during public-health emergencies. They noted that effective communication channels should be established to disseminate accurate and up-to-date information, guidelines, and protocols to reduce confusion among staff and ensure that everyone is well-informed. FG-82: “I think a major thing and it’s a tough thing to be able to do, given that, you know, responding to a pandemic is ever-changing but consistent messaging and consistent, um, like a consistent approach from leadership, uh, in enforcing rules or even determining what the rules are, and very clearly and consistently communicating those rules would have reduced some stress.”Participants also highlighted the critical role of strong leadership during a public-health crisis. They emphasized the need for leaders who can provide guidance and support, ensuring that each member of the team understands their role and carries out their responsibilities accordingly. They highlighted their belief that leaders should be responsive to the needs and concerns of their teams and foster an environment where individuals feel valued and supported. By integrating communication and leadership strategies into preparedness plans, healthcare organizations can enhance their response capacities as to future public-health emergencies.FG-81: “…in terms of preparedness, having a plan for future pandemics, I think it’d also be important to emphasize the role of leadership. Who is doing what and where? Who’s taking care of these staff? Who’s taking care of this patient, for that patient? During the pandemic in my region, everybody was their own leader. We were left to a lot of our own devices… So, in the future, knowing that we have certain people we can look up to, and knowing that we can go to them to find what our roles are, know what their roles are, know what we need to do as individuals would better help not just us understand things, help our morale, help our stress, but give the patients better care.”FG-80: “…communication was probably the number one thing that, sort of, wasn’t wonderful for this pandemic and, and also just leadership in general. Like, I think people need to feel like they’re a part of a team, but also that they have someone leading them who actually, I mean, I don’t know what one knew what was going on, but it was, it was, everything was so uncertain. And if they could, like, make clear plans…I think if leadership really made stronger protocols and actually stood behind them, it, it gives you sort of a feeling of where you’re supposed to be because everything was really up in the air, and we didn’t have sort of any kind of leg to stand on.”Participants expressed their belief that having an integrated electronic health-record system would improve communication among healthcare providers. By integrating patient information into a centralized electronic system, healthcare providers can access patient information, including laboratory results, more efficiently. Implementing an electronic health-record system can help streamline workflow and increase efficiency, as less time is spent on administrative tasks, contributing to increased productivity among healthcare professionals. The adoption of such a system can also facilitate continuity of care for patients and help minimize errors, which will, overall, enhance patient care. FG-82: “So, I think, kind of a foundational piece that could be improved across the board is the electronic health record. Um, if that was really seamless with our test results going in and, um, being accessible as soon as they’re ready and, and all of that, I feel like communication between healthcare providers could be improved, patient care could be improved, you know, our workload could be reduced if that was really seamless, just across the board, that would be an improvement. And that could be, you know, a great source of data for epidemiology that would be a little bit more consistent if it was, uh, yeah, more cohesive across Canada or even within provinces, um, between health authorities and between the private and public healthcare, um, like, uh, private lab companies, results being able to come into the EHR in a hospital setting in a simple way would make things simpler.”The purpose of this qualitative study was to identify and understand the stressors of MLTs working during the COVID-19 pandemic and to identify lessons learned from the pandemic. Research on this population was scant even before the pandemic, suggesting the need for further examination. To our knowledge, this is the first national qualitative study exploring the experiences of MLTs during the COVID-19 pandemic. The results revealed several factors that contributed to the stress experienced by MLTs during the COVID-19 pandemic, including exposure to the virus, high workload, extended work hours, lack of recognition and compensation, and lack of management support. These findings are similar to those of a provincial study conducted on medical laboratory professionals in Ontario, Canada by Gohar and Nowrouzi-Kia . This suThe first theme that emerged from the study was: unexpected challenges of MLTs navigating through the uncertainties of an ever-evolving pandemic. The pandemic inherently changed the landscape of the healthcare system, including laboratories, and presented new challenges to MLTs. Our findings indicate that the evolving nature of the pandemic and limited understanding of the virus caused uncertainty and fear among MLTs. The frequently changing protocols and procedures during the pandemic added to the stress and anxiety felt by MLTs, as they had to stay updated with new information and adapt quickly to the rapid changes. This fear of the unknown during the pandemic was seen among healthcare workers in previous studies ,34. Due The second theme of this study outlines the implications of staff shortage for MLTs’ well-being and patient care. Our findings indicate that the increased testing demands during the pandemic resulted in increased workload and longer working hours for MLTs. The pressure to deliver accurate and timely results placed immense strain on MLTs, leading to exhaustion and burnout. This finding is consistent with the results of an Ontario study which shows a high prevalence of burnout among MLTs . High leProlonged burnout can lead to attrition, further aggravating the staffing shortage. Our findings indicate that burnout from the increased workload caused many MLTs to leave the profession and retire early. Recent national data show that burnout (63.2%) emerged as the most commonly reported reason among healthcare workers considering leaving or changing jobs . MoreoveJob burnout also contributed to increased laboratory errors, which can have serious consequences for patient care and safety. This finding mirrors previous research linking burnout to patient safety . PreviouThe study’s findings also revealed that MLTs experienced moral distress during the pandemic. Previous studies on nurses show that moral distress is a significant predictor of turnover intention ,60. The While there are commonalities between the first two themes and other healthcare workers, our third theme identifies stressors that are unique to MLTs as typically non-patient-facing healthcare workers operating in isolated laboratories. Participants indicated that those outside the laboratory had limited understanding of the roles of MLTs and of the laboratories’ operations. This lack of understanding contributed to the MLTs’ stress, as they were expected to increase their workloads with limited human and laboratory resources.This lack of recognition contributed to stress and job dissatisfaction among MLTs. Compared to other healthcare workers, there was a lack of public recognition for the work of MLTs, which left participants feeling undervalued and demotivated. A study on nurses shows that recognizing and appreciating the work of employees promotes job satisfaction . RecogniOur findings also indicate a lack of management support, leading to decreased morale among MLTs. Poor leadership can lead to employees feeling undervalued and unsupported, affecting job satisfaction and motivation ,71,72. RStaff shortage is a concerning and persisting issue in the healthcare sector across Canada and worldwide. Our results revealed that staff shortage, when combined with increased work demands, leads to poorer health outcomes, exacerbating the staff shortages due to sick leaves or employees leaving the profession. This is consistent with a model proposed by Gohar and colleagues , depictiIn addition to the existing healthcare staff shortage, there is an unprecedented concern for Canada’s laboratory workforce. According to CIHI , there aIn response to the critical shortage of MLTs, recent government initiatives have been implemented. In Ontario, steps have been taken to increase laboratory capacity by integrating internationally educated MLTs into the workforce and expanding the number of seats per cohort . Also, aOur results revealed that MLTs recognized the importance of establishing boundaries in the workplace. A clear work–life balance increases job satisfaction, which promotes employee commitment to the organization . SpecifiOur findings also indicate the need for strong leadership and clear communication during pandemics. MLTs reported a lack of clear guidance and communication from their leaders during the pandemic, which made it difficult for them to understand their roles and responsibilities. This finding is consistent with other studies that show healthcare workers navigating the pandemic with ambiguity due to the lack of communication and leadership . ConsistEffective communication for service facilitation was also reported as a method for improving the healthcare system. Participants reported that an electronic health record would improve communication among healthcare providers, lessen their workloads, streamline laboratory processes, minimize laboratory errors, and ultimately improve patient safety. In a study examining job satisfaction and digital healthcare, the authors uncovered the fact that physicians who frequently use digital health experienced greater job satisfaction in comparison to those who did not adopt such technologies . We recoTo increase the recruitment and retention of MLTs, we recommend increasing awareness and public education about the vital role of MLTs and their work in the healthcare system. Increasing the visibility of the profession can attract more individuals who wish to pursue laboratory medicine and can also help increase funding to support the staffing shortage. Further, raising awareness of the profession will lead to more realistic expectations of their work and ensure that their contributions are duly recognized. We also recommend that when offering incentives to healthcare workers, they should be offered more equitably to minimize organizational injustice. An inherent limitation of qualitative research is the difficulty in generalizing the results. Despite the small sample size, our findings were consistent across different provinces. Furthermore, provincial ,21,25 anWorking behind the scenes, MLTs are often unseen, despite their crucial role in the healthcare system. The pandemic highlighted their importance, as they were at the forefront of the response to COVID-19. This qualitative study aimed to identify and understand the stressors of MLTs during the pandemic, and to determine lessons learned for the improvement of employee wellness and healthcare provision. The results identified key themes, including (1) unexpected challenges navigating through the uncertainties of an ever-evolving pandemic; (2) implications of staff shortage for MLTs’ well-being and the quality of patient care; (3) revealing the realities of the hidden, yet indispensable role of MLTs in predominantly non-patient-facing roles; with the fourth theme highlighting the lessons learned. Our recommendations emphasize the need to address the staff shortages in this population due to commonly known issues in healthcare such as high work demands and organizational factors, in addition to Canada-specific factors, including Canada’s aging and growing population and a substantial proportion of MLTs nearing retirement. By implementing these recommendations, healthcare organizations can better support MLTs and ensure the sustainability of the laboratory workforce, ultimately enhancing the delivery of quality medical laboratory services in Canada. The findings of this study could be used by policymakers to strengthen the healthcare system’s capacity to respond to future public health emergencies.


To better understand the social determinants of conceptual knowledge we devised a task in which participants were asked to judge the match between a definition (expressed in abstract or concrete terms) and a target-word . The task was presented in the form of a competition that could/could not include an opponent, and in which different percentages of response rounds were assigned to the participant at the experimenter’s discretion. Thus, depending on the condition, participants were either exposed to a competitive context mimicking a privileged/unprivileged interaction with the experimenter or to a socially neutral setting. Results showed that manipulation of the social context selectively affected judgments on abstract stimuli: responses were significantly slower whenever a definition and/or a target word were presented in abstract form and when participants were in the favorable condition of responding in most of the trials. Moreover, only when processing abstract material, responses were slower when an opponent was expected to be present. Data are discussed in the frame of the different cognitive engagements involved when treating abstract and concrete concepts as well as in relation to the possible motivational factors prompted by the experimental set-up. The role of social context as a crucial element for abstract knowledge processing is also considered. In his famous Dialogues, Plato imagines his master Socrates stating that: “a good decision is based on knowledge and not on numbers”  and involves specific signals aimed at stressing the artificial, non-literary meaning of what is performed  theory  all complied with inclusion criteria and were naive as to the purpose of the study. The number of participants assigned to each condition is reported in Table The study was conducted in accordance with local ethical committee guidelines. All participants gave informed consent before starting the experimental session. Due to the Coronavirus pandemic, the entire experiment was carried out online. Participants were invited to join via advertisements posted on students’ groups on the major social networks . Inclusion criteria were a) Italian as a first language; b) negative history of neurological and/or psychiatric diseases; c) not having taken medicaments interfering with alertness  in the past 24 h. A simulation using G-power  assuming alpha = 0.05 and power = 0.8, suggested a total sample size of 60 participants . Compared to standard laboratory settings, the percentage of dropouts is expected to be larger in online studies because participants are less affected by situational demands  and more likely to abandon the study before completion  on a black background. The definition was displayed in the upper half of the screen, the word in the lower half . More details on word/definition pairs and their selection are given in Appendix 1.Forty words were selected from a large database of Italian words , described the concept mainly by means of perceptual attributes or real-world examples. Conversely, the second definition, i.e., abstract definition (Ad) described the target concept using a theoretical framework or taxonomic relations. For example, the two definitions for ‘freedom’ were as follows: Cd, “Those in prison or in slavery are deprived of it”; Ad, “The condition of a person not subject to constraints”. A pre-test was run to ensure that the selected definitions correctly captured the intended content and that Cd and Ad were perceived as different by the readers (see details in Appendix 1).Of these 80 word/definition pairs , half were combinations in which both the word and the terms of the definition were either Abstract (Aw/Ad) or Concrete (Cw/Cd), the other half were combinations in which an Abstract concept was described by a Concrete definition (Aw/Cd), and vice versa (Cw/Ad). This was done to manipulate the amount of abstract material participants were asked to deal with. Using the same words and definitions, an equal number of pairs was constructed in which the definition did not match the concept described by the word . Again, the accompanying word always belonged in the same category  and was randomly extracted from the same pool as the matching ones. Matching pairs required a “yes” response; Not-Matching pairs required a “no” response (see procedure). Not-matching pairs were introduced to explore RTs relative to both affirmative and negative responses. This was done because if present, differences in latency between the two types of responses may inform the operations leading to the decision.To keep task duration to a minimum, the 160 pairs so obtained were split into two sets of stimuli, each containing 40 matching pairs , and 40 not-matching pairs . Separate t-tests confirmed that words included in Set 1 and 2 did not differ with respect to Length, Familiarity, Concreteness, and Abstractness. The same was true for definitions, which did not differ in terms of Length Word production, Word/definition association, and Concreteness/Abstractness ratings .The software PsyToolkit was used Stoet, , 2017. RAll participants were informed that they would perform a task requiring a decision on the congruence between a definition and a target-word , and the next trial started.A description of the different trials’ structure is given in Fig. b” and “n” keys are located centrally, making it comfortable for the participants to provide both responses without moving the right hand excessively.Participants were asked to respond as rapidly and accurately as possible, as both measures would contribute to their final score (and increase their opportunity to gain points). On the instruction page, it was also specified that the index and middle finger of the right hand should be used to provide respectively the yes and no response, while the index finger of the left hand should be used to press the space bar. On a QWERTY keyboard , the “A between-subjects design was applied to minimize confounds due to repetitive exposure to the test material. Participants were randomly assigned to one of six experimental conditions. A summary of the conditions is given in Table To explore the effects of being involved in direct competition, in three conditions (Opponent +) participants were falsely led to believe that a second player was present and that they were actively competing with him/her. To keep up this pretense, the experimenter presented the task as requiring two players and made as if the rendezvous day and time had to be arranged to suit both participants. On the day of the experiment, before giving the go-signal, the experimenter pretended to check whether the other player was also online and repeated this pantomime when the task had to be resumed after the pause. To test the effect of social support, in all Opponent + conditions, participants were told that turns of response were decided by the experimenter who could choose, trial-by-trial, to whom to assign the next round. It was emphasized that this choice was entirely at the experimenter’s discretion. Three combinations of “response” and “wait” trials were tested in a between-subjects design. In one condition (High), the proportion of “response” trials was high and that of “wait” trials was low: namely, the response round was assigned to the current participant in two-thirds of trials (67%), and to the fictional, second participant in one-third of trials (33%). Accordingly, participants assigned to this condition were unfrequently kept on hold , as if the experimenter supported them by giving them more opportunities to gain points. Conversely, in the complementary condition (Low), participants responded in 33% of trials and were kept on hold in 67% of trials. Accordingly, these participants were less frequently called to respond being kept on hold for longer periods, as if the experimenter neglected and/or obstructed them favoring their competitor. Finally, in a third condition  the response round was assigned to the current participant in 50% of trials and to the fictional second player in the remaining 50% , simulating a fair behavior on the part of the experimenter.In three other conditions (Opponent-), the task was described as involving one participant at a time. This was done to control for possible non-specific effects derived from being involved in a task in which speed and accuracy were emphasized and for the fact of being kept idle for different amounts of time in the High, Equal and Low conditions . The role of the experimenter was presented to these participants as that of a guide or an assistant in case any issue would arise during the task. The same combinations of ‘response’ and ‘wait’ trials described for the Opponent + groups were applied  but—as there was no second player—when kept on hold, participants read a message informing that data were being uploaded to the server.All participants were administered the same number of ‘response’ trials, the difference between the High, Equal and Low conditions referring only to the number of ‘wait’ trials assigned to the current participant . Despite what was told to participants, data uploading never delayed the task and a second player was never present. In both Opponent + and Opponent- conditions the percentage of trials in which they were called to respond was identically manipulated. The only difference between the Opponent + and Opponent- conditions related to the message participants received.For each participant, the program created two files, one relative to the questionnaires (demographic data and debriefing section), and the other relative to the experimental task. The two files were separately analyzed so that the person working on the data was blind as to the identity of the participant and the group he/she belonged to. Throughout the experimental session, the experimenter could not see the participant’s responses.b” for match and “n” for not match). Def-RT was assumed to reflect the time spent reading and processing information relative to the definition, RT the time devoted to reaching a decision on the possible match between word and definition. For both measures, responses faster/slower than the overall participant’s mean ± 2 standard deviations (2%) were removed before entering data in the analyses. Responses to a short set of debriefing session were also collected and explored via descriptive statistics.Responses were considered correct if participants pressed “b” (“match”) when the definition matched the target word, and “n” (“not match”) when the definition and word did not match. The proportion of correct responses out of the total number of presented items was computed for each participant and each stimulus category. Proportions were submitted to arcsine transformation prior to being submitted to parametric analyses. In addition, for each participant, two latency measures were collected, time spent on the definition (Def-RT) and time required to respond (RT). Def-RT was the time elapsed between the appearance of the definition on the screen and the first key press (space bar). RT was the time elapsed between the appearance of the word and the second button press  and Definition  as within-subject factors, and Opponent  and Proportion  as between-subject factors. RTs were submitted to an ANOVA with Word , Definition , and Pair  as within-subject factors, and Opponent  and Proportion  as between-subject factors. Newman-Keuls test was used for post-hoc comparisons whenever appropriate. For all statistics, the alpha level for acceptance was set at 0.05. Bonferroni correction was applied in the case of multiple comparisons.In each trial, participants spent approx. 70% of the time on the definition and the remaining 30% deciding whether it matched the appearing word. This distribution was similar across the different groups , testifying that all participants correctly followed the instruction to carefully read the definition before calling for the word.p = 0.000001 and Definition, F = 7.52, p = 0.008. As expected, accuracy was higher when participants responded to concrete words  than to abstract words , and to concrete definitions  than to abstract definitions . The main effects of Opponent and Proportion were not significant and there were no significant interactions .Overall, accuracy was very high, with correct responses being approx. 95% in all groups . The ANOVA with Word  and Definition  as within-subject factors, and Opponent  and Proportion  as between-subject factors showed only the main effects of Word, F = 45.27, M = 1993 ms, SD = 486 ms). The ANOVA with Word  and Definition  as within-subject factors, and Opponent  and Proportion  as between-subject factors showed the main effects of Word, F = 8.47, p = 0.005 and Definition, F = 6.38, p = 0.014. The related interaction Word x Definition was also significant, F = 14.41, p = 0.0003 as was the higher-order interaction between Proportion, Word and Definition, F = 14.12, p = 0.000006Average time spent reading the definition was approx. 2 s  and if the item involved was a concrete  vs. an abstract word  . The latter, somewhat counterintuitive, finding is better understood if the Word x Definition interaction is considered. Post-hoc tests showed that when concrete concepts were presented, participants spent more time reading their definitions if these were phrased in abstract  than concrete terms . This difference in Def-RTs was not found for abstract concepts . Inspection of the three-way interaction . Conversely, when abstract concepts were involved, a significant difference in Def-RTs was found only for participants in the Low condition (p = 0.0002).In detail, Def-RTs were significantly longer if the definition was phrased in abstract  than concrete terms  to decide whether the word and the definition matched or not. The ANOVA with Word , Definition , and Pair  as within-subject factors, and Opponent  and Proportion  as between-subject factors showed main effects of Word, F = 75.24, p = 0.000001, Definition, F = 23.98, p = 0.00001 and Pair, F = 4.82, p = 0.03. The interaction, Opponent x Proportion x Word x Pair was also significant, F = 6.00, p = 0.004On average, participants required approx. 1 s  compared to concrete , and if the definition was phrased in the abstract  rather than concrete terms . Besides, RTs were significantly longer for matching pairs  compared to not matching pairs . Post-hoc tests relative to the higher order interaction (Opponent × Proportion × Word × Pair) provide some insight into how manipulating the competitive component and fairness of social support affected participants’ responses. Firstly, as reported in Table p = 0.04; NMP, p = 0.0002) and Equal  condition. Note that this difference was found only when dealing with abstract words. No such effect emerged when concrete concepts were presented  nor was found in participants assigned to the Low condition  or Low condition .In detail, RTs were significantly longer if the presented words were abstract , and not at all annoying . In fact, only a minority (4%) considered the possibility of quitting before the end of the session. When asked to rate their performance, most volunteers agreed with the statement “I think my performance was good” . Participants in the Opponent + groups were further asked to describe their performance in relation to the other player, i.e., they were asked whether they agreed with the statement “I imagine the other player did better than me”. It emerged that 80% of participants in the Equal condition selected the noncommittal reply (‘neither agree nor disagree’), whereas this option was chosen by less than half of the participants in the High and Low conditions. In fact, 60% of participants in the two ‘unbalanced’ conditions expected the other participant to have been either more or less successful than themselves.Participants were generally very accurate in their responses (~ 95%). All spent approximately 2 s reading the definition (Def-RT) and 1 s deciding on their response (RT), confirming that they complied with the instruction to call for the word only once they had read the definition. Both variables were affected by the abstractness of the stimuli, the presence of a competitor and/or the proportion of ‘response’ trials assigned to the participant . Time spent on the definition (Def-RT) was longer if the definition was phrased in abstract compared to concrete terms. In the case of concrete concepts, this was true for all conditions, whereas in the case of abstract words this difference was found only for participants in the Low condition. RTs to abstract words were significantly longer than those to concrete words in all cases except for participants assigned to the Low condition, particularly those in the 2-players setting, i.e., participants that were apparently neglected or forgotten by the experimenter. Besides, for abstract words only, RTs of participants in the 2-players setting were significantly longer than those of participants playing alone—but only if assigned to the High or Equal condition, i.e., if they were seemingly supported or treated fairly by the experimenter. Finally, when asked about their subjective reactions, the volunteers assigned to the two unbalanced conditions openly reported to have expectations of their opponent’s performance, suggesting that they clearly responded to the interpersonal nature of the task.Results of the current experiment indicate that abstract stimuli present a selective sensitivity to the manipulations of social context applied to the decision task. Both the level of competitive involvement and degree of social support were varied here, the former by assigning participants to conditions that included vs. not included a direct competitor, the latter by varying the number of response-rounds the experimenter assigned to the participant. Together, these manipulations created situations in which participants were expected to perceive more (or less) support from the experimenter.Responses to the debriefing questions confirmed that participants in the 2-players setting that had been assigned to the ‘unbalanced’ conditions  interpreted the task as social interaction, as expected by the type of manipulation applied. In fact, more than half of them offered an estimate of the other player’s performance vs. their own, which was not the case for participants in the Equal condition, who did not volunteer any opinion on the performance of their opponent. This differential behavior indicates that when a bias was introduced in the competitive context, some form of relational awareness was promoted in the participants, as shown by their appraisal of the other player’s behavior. Thus, implicitly as it may be, the favor/disfavor of the experimenter selectively impacted the performance of these participants but not of volunteers in the Equal condition, who remained noncommittal on the other player’s performance (as could be expected by a fair competition with no overt feedback on what the other player is doing). Given that the question required a comparison with the other player (speculating on whether “the other did better than me”), i.e., an operation relying on a change in perspective that taps into social cognition, the competitive and interpersonal/social nature of the task was evidently at work here.Intriguingly, manipulation of the social context was especially effective when abstract items were involved. As can be seen in Figs. In the case of Def-RTs, longer latencies were recorded when the definition described a concrete item using a theoretical framework or taxonomical relations (abstract definition) compared to when it used real-world examples or perceptual attributes (concrete definitions). This finding emerged in all participants, regardless of the condition they were assigned to and could reflect a general difficulty in retrieving concrete concepts when presented within a more abstract framework. To our knowledge, this is the first time this phenomenon is reported. We hypothesize that the observed lengthening of Def-RTs could depend on the fact that when definitions are phrased using taxonomical relations or theoretical descriptions, they are less likely to elicit the physical and perceptual features that are most relevant to concrete concepts. Thus, retrieval of the corresponding concept may become a more indirect—and lengthy, process. Interestingly, only participants assigned to the Low condition spent a longer time on the definition also when abstract concepts were involved, i.e., when the format in which the definition was phrased was compatible with the type of concept it referred to. A possible reason for this unique behavior could be that these participants were assigned to a globally “unfavorable” condition. Indeed, compared to what would be expected by a fair distribution of “response” trials , these participants received less opportunities to gain points. Consequently, when the concept was phrased in a more complex format, their motivation might have been affected, possibly inducing them to be more careful in their assessment of the definition (to minimize the risk of errors).When RTs are considered, several effects emerged. A general increase in latencies was found for responses to Matching than Not Matching Pairs. This delay could be ascribed to the fact that in Matching Pairs participants engaged in a confirmatory process prior to responding —a process that could be waived in the case of Not Matching Pairs. Importantly, data on RTs further informed on the peculiar interaction between the abstractness of the stimuli and manipulations of the social context applied. Influence of the competitive setting was particularly evident when participants were assigned to a patently favorable condition, namely when they were called to respond in a high proportion of the trials (condition High) or when there was a fair balance between “response” and “wait” trials . In these cases, the supposed presence of an opponent made a significant difference by further lengthening RTs as opposed to when participants were assigned the same amount of “response” and “wait” trials but were told they were playing alone. Remarkably, this difference is only related to the processing of abstract material, supporting the idea that social context influences abstract concept processing. This finding may seem at odds with the idea that the acquisition of abstract concepts relies on the contribution of “helpful others”. However, according to WAT, others can not only be informative and supportive but may also contribute to negotiating the word's meaning, reflecting different positions and points of view Borghi, . NotablyThe simplest explanation could reside in the higher degree of complexity required to cognitively process abstract concepts. Although the concept of abstractness itself still lacks an unambiguous and unitary definition  were comparatively faster than those responding in the 33% of trials (Low groups), i.e., those performing at an overall less demanding pace. These findings, if considered in light of the intrinsic competitive nature of the task, rather suggest that motivational factors probably contributed to the reported interactions, eventually adding to the effects of the complexity of the material. We propose that at least two such factors could be involved.As specified by the instructions given to participants, response turns were assigned by the experimenter—entirely at his/her own discretion. Consequently, it can be hypothesized that a condition that clearly favored participants may have seen them more prone to pondering answers and investing in doing their very best to avoid that the advantage granted appeared as ‘undeserved’. Paying too much attention to performance may thus have delayed responses, due to what has been described as ‘choking under pressure’, namely a specific decrement in performance induced by the stress of the situational pressure  and that could have differently affected the target-word used. As previously mentioned, these components are functionally dependent on the activity of specific and distinct brain networks. Thus, in considering the possibility of a shared cognitive engagement between the interactive context elicited by the task, and the processing of abstract items we cannot exclude that other dimensions, mostly emotional and interoceptive ones, may have also contributed, given their relevance to the experience of a competitive interaction. Consequently, the contextual responsiveness of abstract items could then be thought of as a corollary to their whole complex, multi-composed essence. Albeit reasonable, we believe that the emotional character of words is unlikely to have influenced the present results, for at least two reasons: first, we have deliberately excluded strictly emotional words from the selected ones, and second, recent evidence suggests that abstract concepts are in fact not more emotional than concrete ones . In a similar way, for the purpose of the current study we used a rather broad definition of social context—that extended to both the interpersonal relation with the experimenter and the presence/absence of another player. A more detailed exploration of how the manifold forms of interpersonal relationships interact with the processing of abstract material goes beyond the scope of the present paper but we hope novel studies will be run that focus on selected aspects of social interactions, as they should provide valuable information.To conclude, the data we presented here clearly support the idea that social context is a factor affecting the processing of abstract knowledge. Indeed, as it has been recently pointed out: “during immediate cognitive and affective processing, contextual factors not only have continual influence, but their effects are often substantial” (Barsalou,


Many elderly people wish to die at home but end up dying at the hospital. If the patient wishes to die at home, palliative care provided by General Practitioners (GPs) may increase the chance of dying at home, however, there is a lack of knowledge on how GPs should provide palliative care. We aimed to identify roles, tasks and approaches of GPs enabling palliative care, by exploring the experiences of GPs, other healthcare professionals, patients, and relatives through a systematic review of the qualitative literature.We searched PubMed, EMBASE, PsycINFO, Web of Science, and CINAHL in March 2022. Thematic analysis was used for synthesizing the results., and proactive approach to palliative care and by having sufficient education and training. Furthermore, the palliative care consultation should include symptom management, handling psychosocial and spiritual needs, maintaining a fragile balance, and proper communication with the patient. Lastly, GPs must address several palliative care elements surrounding the consultation including initiating the palliative care, being available, being the team coordinator/collaborator, providing continuous care and having sufficient knowledge about the patient.Four thousand five hundred sixty three unique records were retrieved, and 12 studies were included for review. Of these, ten were interview or focus group studies and two were survey studies with additional open-ended questions. Only qualitative findings from the studies were used in synthesizing the results. Thematic analysis produced four main themes describing the roles, tasks and approaches of GPs enabling palliative care to increase the chance for patients to die at home. GPs can support patients in the final phases of life by applying a holistic, patient-centredThe roles, tasks and approaches of the GPs enabling palliative care include being aware of elements in the palliative care consultation and elements surrounding the consultation and by having sufficient education and training and a broad, proactive, and patient-centred approach.The online version contains supplementary material available at 10.1186/s12875-023-02038-0. Dying is the inevitable outcome of living but talking about death can still be taboo for both patients and their General Practitioner (GP). When elderly people are asked about their preferred place of death, the majority wish to die at home , 2. DespTo help physicians identify patients with palliative care needs, several tools with different complexity have been developed, including SPICT , the SurA systematic review of the qualitative literature was performed. We used Enhancing Transparency in Reporting the synthesis of qualitative research (ENTREQ) standards .th to the 25th of March 2022: PubMed, EMBASE, PsycINFO, Web of Science, and CINAHL for studies published between March 2012 and March 2022. Studies recommended by experts were included and we manually searched the references list of the included studies to make sure no relevant articles were missing from the search.We developed a comprehensive search strategy in collaboration with an information specialist. Following a PICO format, we formed a list of search terms within these categories 1) General practitioner; 2) Palliative care; 3) Patient Preference/psychology and synonyms hereof (see the One author (SB) conducted a preliminary screening, identifying, and removing duplicates as well as discarding articles obviously not meeting the aim of our research question , based on titles and abstracts. Two authors (SB and GO) then screened the remaining articles separately according to the inclusion criteria (see below). If no abstract was available, and the title was of interest, the full text was screened. After having reached an agreement upon which articles to read in full text, the two authors, in collaboration, agreed on which to include in the review.1. Studies published in English between March 2012 and March 2022, based on original qualitative data .2. Studies exploring the views and experiences of GPs, other healthcare professionals, patients, and their relatives on roles, tasks and approaches of GPs enabling palliative care, without interest in one specific diagnosis, training or education, and after the identification of palliative care needs.3. Studies had to have health care systems in which the GP is the first point of contact and thereby act as a gatekeeper to specialist care, including specialized palliative care.Our inclusion criteria were as follows:The first author (SB) employed the consolidated criteria for reporting qualitative research checklist (COREQ) to assess the quality of transparency in the included studies . QuestioThe aim of this review was exploratory, which made it relevant to apply an inductive analysis method. No ‘a priori’ theory or framework was used, and a thematic analysis of the findings of the included studies was performed.Thematic analysis is a recognized and widely used method for identifying, analyzing, and reporting patterns (themes) within qualitative data . Data weFirst, the author (SB) performed a pilot coding of themes of one of the studies. Subsequent studies were coded into pre-existing themes, and new themes were created when deemed necessary.Thereafter the sub-themes were categorized into actual themes relevant to the research question. The coding was done with the free online software program Notion .n = 6), (2) wrong aim (n = 6) or (3) wrong study design (n = 5); 12 studies were included in our final review. The references within those articles were also checked for potentially eligible articles, though no new studies were identified.Study selection is depicted in Fig. n = 3), the UK (n = 2), Canada (n = 2), Australia (n = 2), Belgium (n = 1), Portugal (n = 1), the United States (n = 1). Six of the 12 studies were interview studies, three studies used focus groups, and one was a combination of both focus groups and interviews. The last two studies were survey studies with the addition of open-ended questions. The majority of the studies used thematic analysis and content analysis. One study included critical incident technique before the analysis, one used grounded theory, one used framework analysis and the two survey studies also included closed-ended questions in questionnaires. In those cases data were included descriptively even though the methodology was quantitative.Table The explicitness and comprehensiveness of the ten interview studies were assessed using the COREQ checklist  see Sup. SubstanThe domain in which transparency  was found to be most lacking was the research team and reflexivity; only two studies stated the experience and training of the research team members , 37, andThe included studies described experiences from physicians, other healthcare professionals, patients, and their relatives on palliative care provided by the GPs. Across the included studies we identified 4 main themes describing the roles, tasks, and approaches, that enable GPs in providing palliative care: one about the approaches to palliative care, a second about education and training, a third about the palliative care consultation, and a fourth about elements of palliative care surrounding the consultation. The four themes contained several subthemes visualized in Fig. “We took over a patient from a GP. And he was a patient suffering from end-stage COPD, who additionally had a pulmonary embolism and in consequence a failure of a large part of his lung. The whole hallway, the entrance area, was full of oxygen bottles and the man was lying in a small room. The man had his oxygen running at 14 litres. So we came there and slowly got to know each other. We explained everything during our talk, for a while, and we touched upon his matters. The oxygen was lowered to 4 litres. This was very impressive, that’s when we noticed this had a psychosocial component.” Several of the included studies stressed the importance of a holistic approach to palliative care , 32, 38.“We often intentionally book patients’ appointments for them, I mean, you know a lot of appointments are made when the patient perceives there’s a problem… but we often switch to intentionally booking appointments when we feel there’s discussions that need to take place around their care. In combination with the holistic approach, several studies pointed out the relevance of being proactive , 35, 38.‘You know whatever way they want to go I just let them know that they’re in the driver’s seat and I’m just there to facilitate it for them.’ Furthermore, the importance was stressed to a patient-centred approach , 32, whiThe GPs in the studies had different opinions about education on palliative care. Some GPs judged they had enough experience and/or training , whilst “…Undividable part of his role as [a] doctor” (the ability to manage less complex symptoms)One of the tasks of the GPs in providing palliative care is to care for the patient’s symptoms , 31, 39.“They [the frail couple] are at high risk of falling, highly vulnerable to everything. […] They are supported by all the props our system has. More is not possible. It’s all in a state of fragile balance!”Another task is to care for the patient’s psychosocial and spiritual needs , 30, 32,“Sometimes we don’t even know if the patient is informed or not [about the diagnosis], that’s the worst thing. We received phone calls saying, “Yes, yes, but my dad is not supposed to know about it [meaning end-of-life stage]”, or nope, the wife doesn’t want her husband to know, then I say, “Then we actually can’t care for him”. When we get involved, we do insist that patients are made aware. And we deal with that [palliative care] in rare cases because of the [patients’] huge distress. No one else can provide it [palliative care without patients being informed about diagnosis/prognosis], but we still do it... reluctantly. And if we were to stay at the residents’ bedside, we would speak the truth. Anything else would make no sense. Everybody should question themselves,“ [Do I want] to be fooled by my wife, husband, children [...]?”. The end is near, maybe someone wants to arrange something, perhaps you would like to put all your thoughts in order. I think you might be deprived of your life and the very last part of it, that’s a shame.” Furthermore, a role enabling palliative care is being able to communicate properly with the patient , 32, 39,“I might not say all at once, right, we need to discuss a plan for you, but you just mention it when you might see them every 2 months or something.”After the identification of palliative care needs, the next step is to initiate palliative care. GPs stressed that early in the patient care trajectory they should be the facilitator for discussions about end-of-life care and that patients should be allowed to plan care by giving their prognosis earlier than the very final stage. The knowledge of their prognosis will also lead to better practice care in the later stages of illness . As for “[Urgent care is] used because [patients] might not be able to get an appointment with a provider… [A problem] becomes even more urgent and they just go to urgent care.”In several of the included studies, GPs stressed the importance of being available , 32, 39.“For some people I book regular home visits – if they’re at that point when patients are finding it difficult to come and see me, and often it is more near the end of life, but not necessarily. I had one lady who I was doing home visits for, for the last two years of life. Just because she couldn’t come and see me, so that was the best way to do it.” As time and illnesses progress, patients get more limited. As a result, and as a part of being available the GP’s task consists of offering home visits –32, 35. Furthermore, one GP hired a social worker, to manage the coordination of care, lessening the pressure on the GP and being fully available for patients .All the included studies described the significance of GPs being a collaborator or a coordinator –39. The “(…) the fact that we are being told, does not mean we have to solve it .... We can offer paths, options or give people advice. Several studies pointed out the function of a GP as a coordinator , 37, 39.Another option is to have palliative care nurses support day-to-day care . And wheBecause GPs often are the patients’ first point of contact, GPs see themselves as the ones leading the patient’s care . This coThe function of GPs as a collaborator was repeatedly stressed , 38, 39.“And we actually have very [well] qualified practice assistants who also partly take over home visits. […] And we also have three wound managers […] we are very happy, that it’s not just left to the nursing agencies, but that someone from the practice has a look at least once a week.” Another way of being the team coordinator proposed by multiple GPs is by involving the other practice personnel , 35, 37.“That’s why I naturally make regular visits to these very old [patients], to see, when the time comes, which [of the family members] I may now also involve. Whom can I rely on? Firstly, to understand what the patients themselves want, but also to understand what concerns those standing beside them.” Furthermore in managing and supporting patients with palliative care needs, the involvement of the family is valuable for palliative care , 36, 39,In one study it was proposed to have a family member designated as a primary caregiver who could come to every appointment . Another“Actually, (I see that) also as my obligation as a GP, because they know me and so they will then also ask for me. […] So I can’t fade away when it comes to the end!” The relationship between the GP and the patient enables the GP in providing palliative care. One important factor in the relationship is continuity of care , 35, 37.The continuity of care enables decision-making and planning for End-of-Life . Further“I tell them outright, whatever happens, good or bad, I’m going to be there for you… I am going to do my best to help you. I try to get emotionally involved, because you’re caring for people, and you’ll make better decisions because you’ll know where they’re coming from”Another task that enables palliative care is to know the patient , 37. As To our knowledge, this is the first systematic review of qualitative studies on roles, tasks and approaches enabling GPs to provide palliative care.These can be divided into four themes; approaches to palliative care; education and training; contents of the palliative care consultation; and elements surrounding the consultation. The roles, tasks and approaches of GPs enabling palliative care are a holistic, patient-centred and proactive approach, being sufficiently educated and trained, focusing on the following contents of the palliative care consultation; symptom management; handling psychosocial and spiritual needs; maintaining a fragile balance; proper communication with the patient, and addressing the following palliative care elements surrounding the consultation: initiate palliative care, be available, be the team coordinator/collaborator, provide continuous care and know the patient.Various models to enhance palliative care provided by GPs have been evaluated , 40–42. A major strength of this review is the rigorous methodology that was used during the search. The systematic and thorough approach, developed with the aid of an information specialist, was used to develop the search string and was used in five major databases. To ensure contemporary relevance of the synthesis we limited the search to a 10 year period. All reference lists from the studies included in this review were examined to ensure no relevant articles were missing. Another strength is that after the first screening and removal of duplicates, two authors in collaboration selected the studies included in the review. Furthermore, we used the ENTREQ standards for reporting qualitative reviews, and a quality assessment was made of the qualitative data using COREQ. The inclusion of studies based on participants’ experiences is also a strength because it gives qualitative data that reflect real-life enablers of palliative care. However, some limitations apply: Only limited qualitative research in this area has been published. We excluded studies published in other languages than English and before 2012 and our research question is not the same as in the included studies. Furthermore, the use of quality standards does not necessarily guarantee the quality of intellectual work where interpretation is essential. More specifically, while COREQ does capture several relevant aspects of quality, in our opinion, it also has some limitations as an assessment tool due to its strong focus on the formal aspects of research papers and its relatively less focus on analytical content.It was a strength that the twelve studies were conducted in seven different countries, strengthening the results of this review to be applicable in many countries. Secondly, the participants in the studies were a variation of GPs, nurses, patients, and their relatives leading to a differentiated view of GPs’ work. Thirdly, the studies were a mix of focus groups and independent interviews, covering more topics than one of the study methods could have provided.Although, we also identified some limitations of the included studies: Firstly, the COREQ assessment of the quality of the studies showed a variation in scores between 11 and 29 out of the 32 criteria. Secondly, the included studies did not use participant observations. These could strengthen the validity of findings by supporting the participants’ statements from the interviews but might be costly and impractical.Findings from this review suggest roles, tasks and approaches of GPs that enable palliative care. Further research needs to be done to identify other enablers, that are not identified in this review. A focus on enablers instead of barriers will make the subject more likely to enter our consciousness and make it easier for GPs to practice in everyday work.This study proposes a schematic model of the roles, tasks and approaches of GPs enabling palliative care Fig. , which cAll of the included studies stressed the importance of collaboration between the involved medical professionals, including specialists of relevance. Thereby stressing the importance of developing a system that facilitates communication between medical professionals so collaboration can be effective, and thereby enhancing the palliative care for patients.To increase the chance for patients to die at home, GPs can support patients in the final phases of life by applying a holistic, patient-centred, and proactive approach to palliative care and by having sufficient education and training. Furthermore, the palliative care consultation should include symptom management, handling psychosocial and spiritual needs, maintaining a fragile balance, and having proper communication with the patient. Lastly, GPs must address several palliative care elements surrounding the consultation including initiating the palliative care, being available, being the team coordinator/collaborator, providing continuous care and having sufficient knowledge about the patient.Additional file 1. Search string. Additional file 2. COREQ Checklist.