This qualitative study is intended to explore the factors that contribute to the occupational stress suffered by Chinese doctoral supervisors and the kind of measures needed to effectively address the issue. Through purposive and snowballing sampling, 30 Chinese doctoral supervisors in different disciplines of natural science and social science were selected. A semi-structured interview protocol was used, and the data were analyzed based on grounded theory methodology. Chinese doctoral supervisors experienced varied stressors of nuanced nature, which could be categorized into two core categories, i.e., performance-appraisal-related factors and Ph.D. student-related factors, which were further divided into 18 subcategories and 10 higher-level categories. Chinese doctoral supervisors are under various sources of stress, corroborating with and reinforcing previous research findings in respect to occupational stress worldwide. Through the analysis of the stress triggers, suggestions are presented in regard to what mental health professionals and educational policy makers can do to address the issue of concern for doctoral supervisors. Given the value of work in this society, the amount of time spent at work and the current changes that are affecting the nature of work, it is not surprising that work stress appears to be increasing )http://www.bjnews.com.cn/edu/2019/07/09/600979.html, accessed on 9 July 2019); in October 2020, a female professor of history at Fudan University died at the age of 42 . They are but a few of those scholars who died in their forties or fifties, so rumor has it that fifty is a doomed age for academics. Further, in 2016, a professor of literature and doctoral supervisor at Xiamen University, after being disqualified from being a supervisor due to his failure to comply with the university policy governing the recruitment process for Ph.D. students , published an open letter proclaiming that he had decided to leave academia.Regretfully, no research has ever been carried out to explore the stress issue among Chinese doctoral supervisors. However, quite a few news reports about higher education in recent years have highlighted the importance of the stress issue among doctoral supervisors. For example, on 7 July 2019, a professor and doctoral supervisor at Tsinghua University, died at the age of 56 . Howe. Howe7])Grounded theory (GT), a well-established methodological and qualitative approach for context-specific inductive theory building or an inductive enquiry that explains social processes in complex real-world contexts , is favoA pilot study was conducted to serve such purposes as adding value and credibility to the semi-structured interviews to be used in the major study, avoiding inefficient theoretical sampling or even erroneous purposeful sampling and providing remedial loops, or effecting changes of focus, guidance to improve data collection instruments, and/or informing theoretical sampling , or avoiUpon completion of the initial interview, the data were transcribed and analyzed to deduce themes and concepts. The analysis of research participants’ response to the questions laid a basis for the questions to be used in the follow-up interviews. As themes emerged, the interview questions for the second round of interviews were narrowed down and focused on the existing themes. In this way, new themes emerged while the existing themes were confirmed. So, the follow-up interviews were conducted to confirm or clarify emergent themes, and meanwhile, to explore any new information. The pilot study helped to test the appropriateness of the interview questions, and adjust the research plan, identify the possible problems, obtain experience and build rapport in the follow-up in-depth, semi-structured interviews in the major study.Throughout the process of participant recruitment, purposeful and snowball sampling was used, i.e., early recruits led to the later recruits. The participants consisted of 15 men and 15 women who ranged in age from 33 to 62 at the time of the interview, came from northwestern, southwestern, central, northeastern and southeastern areas of China, and majored in varied disciplines of natural science and social science. Except one who had a Master’s degree, the rest of the participants had doctoral degrees. Participant selection, data collection and data analysis continued until theoretical saturation reached. Data collection ceased after 25 interviews, as it was clear that no new themes emerged; but 5 additional participants were interviewed to reduce the chance of missed themes and ensure that data saturation was achieved.Prior to the commencement of the interview, an initial explanatory statement was sent via WeChat to identified supervisors who were informed about the purpose of the study, the length of the taped interview (approximately 35 to 45 min in duration), the voluntary and confidential nature of the interview , the way of answering the study instruments, their right of withdrawal or termination  and written consent for participation was sought from all participants. Further, official approval was sought from pertinent authority, so as to comply with pertinent codes of ethics e.g., ,24,25).,25.24,25At the outset of the interviews, participants were reassured of anonymity and confidentiality of the interview, helping to build trust , and semEach interview was conducted in Chinese and audio recorded by the in-built audio recording software of WeChat. Each participant was assigned a code number to avoid revealing his or her identity. A professional transcriptionist was hired to transcribe the audio files into Mandarin Chinese, and each interview transcript was under a first-pass verification, i.e., verified by each participant for accuracy and validity, then the second-pass review was conducted by the interviewer using the original audio files and anonymized, formatted transcripts, to complete a final check of content accuracy and then adjust the level of transcription for analysis. After the transcripts were double checked, they were translated into English.In qualitative research, interview translations always aim for semantic equivalence at a minimum and aspire to conceptual equivalence . To valiAfter verifying the trustworthiness or credibility and increasing the accuracy of the study through triangulation, i.e., participant checking, self-reflection and peer review , the traBased on the questions in the interview guide, verbatim transcripts were read and analyzed repeatedly to identify themes related to stress, then filtered and selected through the constant comparative method. The whole process involved three phases of coding  . First, The participants revealed a variety of factors contributing to this widespread stress among Chinese doctoral supervisors. Nevertheless, the GT emerging from the data represented the nuanced nature of participants’ experiences with stress. Categorization of the interview data through open coding yielded 18 subcategories and 10 higher-level categories. The relations of categories were linked through axis coding according to the paradigm model . Data anhexin journals”, meaning “key journals”) during the contract term of three or four years. Second, the requirement to host funded research program at ministerial level or above increased the stress for the participants, although for some participants, it was an alternative to article publication requirement.“…You know, almost all universities in China developed a Guide for Journal Category. Category D1 journals include the rest of journals covered in CSSCI except for Category A, B and C journals. My university adopted the similar journal categorization system that CSSCI journals are categorized into A1, A2, A3…; B1, B2, B3… To get three articles published in these Category C journals, or two articles in Category C journals and two articles in Category D1 journals in three years, is absolutely a fable, at least to me.”(Participant 12)NSSFC  or NSFC  is tantamount to finding a needle in a haystack.”“…Winning any award or hosting a (Participant 3)The participants were found to be engaged in “demanding academic requirements”. First, it was extremely tough, if not totally impossible, to publish three or more articles in such designated journals indexed by SCI, SSCI or CSSCI The interview data also revealed that the supervisors had to undertake “heavy teaching workload”. Different from the credit hour adopted in western countries, the workload (工作量), as devised by the Human Resources of varied Chinese universities, comprises the number of equivalent 40 -min lecture periods and credits for supervising laboratories or supervising graduates per semester. Some universities require that supervisors independently teach at least one undergraduate level course and supervise a certain number of postgraduates per year. The annual workloads of the participants ranged from 300 to 340 credit hours in two semesters, which is equivalent to teaching five to six courses per semester, namely, 10 or 12 credit hours per week for 16–18 weeks. A minimum of their annual workloads, e.g., 120 credit hours of undergraduate-level teaching is required, depending on their respective salary range and position grade they have contracted with their universities.“…student appraisal is always affected by some unexpected or irritating factors…e.g., low scores will result in retaliation from students…”(Participant 2)Further, the supervisors had the end-of-course teaching evaluations by students via a Management Information System at the end of each semester. This system is run by the University, also called teacher performance appraisal system (TPA). It is a 100-point scale questionnaire. Students are instructed to log in to fill out the TPA form online. The evaluation ratings for teachers should reach a minimum score of 90 for teachers to satisfy the requirements set for the position of their respective salary grade.guanxi, but the number of recruitments required would be stressful.hexin journal as required by the University, he/she can’t graduate on time. Further, he or she must compose a thesis (either a monograph or compilation), undergo external review of thesis, and pass the public defense of dissertation for Ph.D.”“If a student can’t publish an article in a (Participant 13)“…Some of my students seldom clean up laboratory glassware or other instruments after they finish experiments, and reluctantly comply with experiment regulations or protocols, although I remind them time and again about the importance of following the rules.”(Participant 11)guanxi, especially when I have some adoring students who decide to pursue a doctoral degree. As such, I often maneuver into a peculiar dilemma as to which student to recruit.”“…Sometimes, it is really hard to strike a balance between those varied (Participant 16)As for “various student-related issues”, the participants reported that student graduation with article publication and thesis completion was the key source of their stress. Moreover, the supervisor–student relationship was an unexceptional trigger for stress. With regards to new Ph.D. student recruitment, not only the unspoken rule or “…one of my daily routines is to ask whether my colleagues have got article rejected, accepted or published. Negative response would console or excite me, while positive response would make me jealous and more distressful.”(Participant 15)“…Supervisors are supposed to have publications in high impact factor journals, and to inspire the students as a role model and command respect.”(Participant 6)All the participants shared “negative emotions” throughout the interview process. The pervading gloominess, sullenness or stress was obvious or pervasive when they mentioned that their articles had been repeatedly rejected by varied journals. Some participants were wondering whether they were psychologically healthy, saying that they could not imagine gloating over other people’s failure. In a sense, article publication involves losing or gaining face.“…I would always be on tenterhooks before program approval is published. When your application is rejected, you would think the sky is about to fall down.”(Participant 5)All participants also remarked that they were always in a paradox, i.e., if their grant proposals were rejected, they would feel heartbroken, but being granted a funding program was nothing more than a short-lived pleasure of success, or just the beginning of another disaster.“The assigned workload makes me worn out, and I easily get irritated even over trifles in daily life.”(Participant 4)“…you know, a low rating for your teaching not only means loss of money, but more importantly, loss of face.”(Participant 18)In all, 8 out of 30 participants remarked that their workload was rather heavy and exhausting. As for teaching evaluations, although 21 participants seemed not bothered by it at all, 9 participants deemed it as a major stressor.During the interviews, all the participants shared the view that thesis and article publication issues were key sources of stress, for failure to meet these requirements not only jeopardizes students’ future , but also exerts significant negative impacts on their supervisors, e.g., illegitimacy to recruit new Ph.D. students and loss of face, among others.guanxi issue in the process of recruiting new Ph.D. students.A total of 13 out of 30 participants mentioned their stressful experience with students. Half of the participants proclaimed to have been stressed by the unspoken rule or “It is quite unreasonable to publish 3 or more articles in key journals, or host a research program at ministerial level or above during 4 years. Moreover, I have to undertake 340 workloads in two semesters. Otherwise I will be degraded or removed from the current post.”(Participant 17)The participants reported that their stress was mostly attributed to “policies and regulations in higher education”, one of which was performance appraisal. As a rating mechanism, performance appraisal is employed by almost all universities and institutions of higher education. In this way, job performance of an employee is evaluated in terms of quality, quantity, cost and time, and human resources development provides continued push for personnel accountability and competency and effective schooling, and determines who needs what training, and who will be promoted, demoted, retained or fired . As dict“Hosting a NSSFC or NSFC or winning those awards not only helps satisfy the requirements for my salary range and position grade, but also provides additional funding to take on new students.”(Participant 21)According to the supervisor’s guide promulgated by most universities, supervisors should have adequate funding to allow the research to progress , and having adequate funding  was the prerequisite for new Ph.D. student recruitment. Consequently, supervisors were desperate for grant programs, availing every effort to draw funds from all sorts of corners to support their students’ research.hexin journal of his or her research field. Further, he or she should accomplish a thesis, which should make a distinct contribution to knowledge and show ability to conduct original investigations and to test ideas whether of his own or of others, undergo external review of the thesis and pass an oral defense.“If my students can’t meet the requirements, they have to extend their timeline of graduation. It will affect the recruitment of new doctoral students. What’s worse, I will be disqualified from being a supervisor.”(Participant 23)As for student-related issues, student graduation comes first. In China, the total duration for completion of degree requirements and submission of thesis for external evaluation is three regular years, or a maximum of six years, as of the date of admission as a Ph.D. student, during which time each candidate shall complete required credits in a subject, and publish, out of his or her research work, at least one research publication (letter of acceptance included) in a university approved “…to criticize students is to ask for trouble…when a student broke down an expensive instrument due to non-compliance with laboratory regulations, I was irritated. But the most stressful thing was that I could not claim compensation, lest it should cause any stress to him and I get punished in turn. Today is yesterday’s pupil.”(Participant 11)In addition, universities are prone to adopt a policy in favor of students whenever there is supervisor–student confrontation or conflict, as evidenced by numerous cases where Ph.D. students suffered psychological stress, or committed suicide due to pressure from study, but their supervisors were criticized for pressing them too much. As remarked by most participants, supervisors were supposed to take responsibility for everything ranging from Ph.D. students’ daily lives to their graduation, otherwise they would be criticized for omission. As a result, supervisors dare not blame or criticize students, although students are lazy and refuse to follow the instructions or abide by certain academic ethics.guanxi plays a very important role in it.“I would like to recruit older candidates from the legal profession for their rich experience in law, but could not always be away from worldly wisdom.”(Participant 19)In terms of the recruitment of new doctoral students, Further, Participants 10, 21 and 27 mentioned the number of Ph.D. students required to recruit was a stressor. The Ministry of Education sets a limit or quota for Ph.D. student recruitment in different subjects or disciplines for each year. As such, in some subjects, a supervisor may recruit one or two doctoral students per year, while in other subjects, two or three supervisors have to share one doctoral student each year.The participants were found to be faced with various stressors, including “personal performance appraisal” and “doctoral student-related issues”. All the participants had difficulties in publishing articles in key journals within the term of performance appraisal, usually 3 or 4 years.“The publication threshold for me is 3 articles in Category C journals. Of the 500 journals covered in the CSSCI database, only 190 journals fall into Category C and above. But of the 190 journals, only 10 journals fall within my research field or discipline…You may say that there are some SSCI indexed journals…you know, it’s even harder, for you have to compete with academics worldwide. What’s worse, only the top 25% of SSCI indexed journals in one particular discipline are deemed as Category C, in accordance with the Journal Category Guideline devised by my university.”(Participant 7)“…it is one thing to be great at your job, but quite another to win any of these awards… you must have good connections, otherwise your application cannot even go beyond the university. You know, candidates for these awards are firstly recommended by the schools to the university, then recommended to the provincial or ministerial department for deliberation.”(Participant 25)“…you have to compose a final performance report which adheres to the Grant Program Guideline, then submit it to the funding authority before the program is due, failing which, you cannot apply for any research program for a couple of years…”(Participant 8)Apart from publishing the designated number of articles, the participants reported that it was tough to meet the requirements to win awards or host research programs at ministerial level or above, from the beginning of application to the deadline.(a)Students’ complaints about supervisor bias or omission,(b)Students’ low caliber or non-commitment to research ,(c)Students’ request to change supervisors due to dislike for each other, and/or(d)other confrontations or noncooperation in relation to their study or research programs.The participants also shared the idea that a tensed supervisor–student relationship was a stressor, including:“Some students complain about my omission in their article publication, claiming that coloration, availability of funds and facilitation in article publication are the key features that must be contained in an active and productive Ph.D. supervisor…it seems as if I have been grossly at fault for their manuscript rejection…”(Participant 9)guanxi involved in the recruitment of new doctoral students.“…if an applicant finds that someone  is well connected to me, the applicant will normally request the contact(s) to refer or introduce him to me, or the contact(s) would ask me to do the applicant a special favor. Where there are two or more applicants, more contacts would come to me.”(Participant 14)One more stressor is related to various (a)Hosting a NSSFC or NSFC(b)Award for Scholarly Achievement (科研成果奖) (at least the Third prize) at national, ministerial or provincial level,Winning an (c)Award for Teaching Achievement (教学成果奖) (at least the Third prize) at Ministerial or Provincial level, orWinning an (d)Talent Excellence Program trainee (优秀人才项目) at ministerial or provincial level.Becoming a The participants reported that in order to meet with the requirements of performance appraisal, they had to “work with long hours”. They devoted nearly all their time and energy to academic research and teaching, wondering all day how to deliver excellent on-the-job performance and fulfill their on-the-job responsibilities, so much so that they spent less time on vacation or other leisure activities. Apart from article publication, they had to strive to succeed in:“…(being granted a funding program)what follows is long-lived torture of tedious research work, day and night, in order to produce either books, monographs, peer-reviewed articles, e-books, digital materials, experiment reports, translations with annotations or a critical apparatus, or critical editions resulting from previous research, before undergoing a review by relevant authority comprising of peer scholars.”(Participant 7)“I have to undertake 340 workloads in two semesters, and teaching students at undergraduate level shall account for 35%  of the total workload. I try to strike a balance between academic research and teaching, always staying up late.”(Participant 26)“…Once, an experiment instrument worth ¥300,000 broke down for the student failed to comply with the obligations specified in the operation protocol. What stresses me out most is I can’t claim compensation, lest it should cause any stress to him and I get punished in turn.”(Participant 11)“…this year, I have to share one doctoral student with a colleague. In the end, I stroke a deal with my colleague, i.e., I gave my half quota to him, so this student is under his supervision this year, and he promised to give me his half quota the following year… this means I can recruit one student every two years.”(Participant 10)While dealing with student-related issues, most participants claimed that they were liable in opting for “self-compromise”, in order to avoid trouble or reduce the conflicts between supervisors and students.“Sometimes I feel frustrated, however, I make full use of my spare time to pursue projects that embody exceptional research, rigorous analysis, and clear writing, carefully and smartly articulate the projects’ value to humanities scholars or general audiences, so that I might edge past the fierce competition and be granted the project.”(Participant 22)“…if I get a low rating for my teaching, I will fail the performance appraisal, resulting in deduction of annual salary, or demotion to a position of a lower salary grade as a punishment…”(Participant 2)“…having no students to supervise not only impairs the conduction of experiment, but also greatly impacts my performance appraisal.”(Participant 19)It is noteworthy that despite their divergent perspectives as to age, gender, length of time and experiences in supervising students, etc., the participants “experienced various stressors”, that is, they shared the same or similar psychological stress as an experience associated with their lives as doctoral supervisors; although some were stressed by a single factor, others were stressed by the combination of a set of factors.The GT of supervisor stress, which was developed from the results of this study, indicates that supervisor stress is a multifaceted process inflicted by the influences of varied factors, individually or collectively, and their current stress at the time of the interview represents a result of the ongoing combination of value system, social norms and/or educational policies.Apprehension at performance appraisal failurehexin journals, receive funding  for research projects and undertake 300–400 workloads simultaneously. After all, performance appraisal failure entailed not only disqualification for recruiting new Ph.D. students, but also reduced income and loss of dignity or face. This finding corroborates the findings of the most recent DFE (Department for Education) teacher workload survey that heavy workload is one of the biggest threats to teacher recruitment and retention and the level of workload is generating stress in schools [Apprehension or angst at performance appraisal failure was viewed by all the participants as the most important trigger for their stress, although the subcategories mattered differently to the participants. Admittedly, it is rather difficult, if not altogether impossible, to publish three or more articles in  schools .The reason for imposing such harsh performance appraisal standards is closely tied to the tertiary education reforms.One of the reforms is the scale expansion of Ph.D. students as a countermeasure to release the burden of unemployment rate among college graduates that has been rising in the past few years. The boosting enrollment means that supervisors have to supervise a growing number of Ph.D. students, which consequently contributes to the double dilemma arising from the apprehension at student graduation. Indeed, Chinese supervisors are carrying a supervision load of 5.77 doctorate candidates, much higher than the recommended threshold of 3 Ph.D. and 5 Master’s students in any given academic year internationally. Theoretically, the more students they supervise, the more stressful they would find it. In contrast, in some countries, the average academic has a maximum potential of training 27 Ph.D. students in a 30-year career . As moreshuang yi liu, 双一流, is short for “The World First-Class University and First-Class Academic Discipline” (Chinese: 世界一流大学和一流学科) Construction). This plan represents a new way of ranking universities in China. Up to date, according to the lists issued by the Chinese Ministry of Education, Double First-Class Universities consist of Class A (including 36 universities), Class B (including 6 universities), and Double Class discipline universities (including 95 universities). It was a tertiary education development initiative designed by the Chinese government in 2015 to develop elite Chinese universities and individual faculty departments into world-class institutions by the end of 2050. Currently, global university rankings attract considerable attention, and such rankings may cause universities to prioritize activities and outcomes that will have a positive effect in their ranking position [The other reform is the Double First-Class Construction  practice is prevalent worldwide, obliging supervisors and Ph.D. students to spend more time scrambling to publish whatever they can get into print . Since tIn addition, thesis writing is a stressor which not only increases stress for Ph.D. students ,51, but https://zhuanlan.zhihu.com/p/46609954, accessed on 12 October 2018, http://news.sohu.com/20160322/n441458886.shtml, accessed on 22 March 2016 and https://lx.huanqiu.com/article/9CaKrnJZX3P, accessed on 22 January 2017, respectively).The relationship between supervisors and Ph.D. students is a complex one. The tensed supervisor–student relationship, whether personal or professional, also makes for a major stressor. The interviews revealed that such factors as students’ lack of interests and skill sets, non-cooperation, hostile conflict, mutual dissatisfaction and defiance of academic ethics, may result in tensions and stress to some supervisors, as evidenced by some news report about plagiarism allegation against two Ph.D. students whose supervisors have been temporarily suspended or permanently removed from the Supervisor Register . These aThe intricacy of the supervisor–student relationship corroborates with other findings that the supervisor–student relationship may be in part comparable to the one between the physician and his/her patient, and at some point of the journey, develop different expectations of one another , or exerFactors that partly contribute to the tensed relationship can be summed up as follows:Nature also reveals the turbulent nature of doctoral research [(1) Students’ failure in understanding what a doctoral degree means. A Ph.D. is the highest academic degree in China, which requires the command of more specialized academic knowledge in a certain field. Regretfully, some Ph.D. students have a lack of commitment to academic research, or not psychologically and professionally ready for the doctoral study. A survey conducted by research . Ironicaresearch . As suchhttps://baijiahao.baidu.com/s?id=1625877107917853133&wfr=spider&for=pc, accessed on 19 February 2019). Coincidentally, a professor at Shanghai Jiaotong University, who usually revised students’ experiment protocols or articles until two o’clock in the morning, was greatly irritated by a student laziness or lack of academic expertise, and posted in a WeChat Group some sharp words such as “rubbish or garbage, shit” to address the students’ experimental findings. Subsequently, the university delivered to him an official notice of suspension, required him to make a public apology to the student and issued a notice of criticism circulated within the department. These cases, among others, reveal in part the stress, anxiety, helplessness and apprehension confronting supervisors who are under significant pressure to complete some major yet urgent projects. So, if students have no clear conception about the doctorate, the stress will be there waiting for supervisors.A recent blog published by a professor at Fudan University may represent the voice of all the stressed supervisors in China. The professor taunted about the decline in the competencies of postgraduates and Ph.D. students in China and called on his Ph.D. students to “…understand the stress and anxiety of ‘an advanced animal’ ” Lack of training on the part of supervisors. Regretfully, in China, there is no mandatory requirement for formal training or monitoring and accountability of doctoral supervisors, except for the obligatory academic requirements, for example, doctoral supervisors should have graduated with doctoral degrees, have published a required number of articles in Proposed suggestionsAnyway, the findings reveal the prevalence of stress among Chinese supervisors. Ironically, few people are aware that scholars are at greater risk of stress-related illness than police, medics and local authority staff . At a ti(1) Clarifying respective rights and responsibilitiesThus, it is high time that relevant policies were updated. Solutions proposed for the issue include:zun shi zhong jiao尊师重教)”.There is no doubt that supervisors should strictly abide by ethics and codes of practice related to their positions, and are highly expected to promote knowledge development and create a research culture during the research process . However(2) Establishing a full-fledged performance appraisal systemNearly all the participants criticized the current policy makers for ignoring the fact that article publication was beyond their control, and suggested that university management adopt more flexible appraisal approaches. Fortunately, the Ministry of Education of China has been committed to the reform of educational assessment, one of the measures being to remove the “five-overemphasis”. On November 8, 2018, the Ministry of Education carried out a campaign against “five-overemphasis” (破“五唯”), that is, the overemphasis on articles, positions, professional titles, certificates and awards . Its purpose is to further push the reform of systems within higher education, improve the mechanism of moral education(“立德树人”), reverse the unreasonable evaluation guidance, operate on the appraisal system based on representative works and value the qualities and the influence of the works. In this way, multi-level performance appraisal is on trial at universities and colleges, including teaching, academic research and service, just as Participant 1 suggested that more indicators should be covered in the performance appraisal system, such as the social service of delivering public lectures or hosting hot-line meetings to address psychological issues related to the novel coronavirus disease. The reform values the evaluation of the teaching process and social service based on the annual assessment. The appraisal system not only covers self-assessment from supervisors, but the appraisal from their peers, Ph.D. students and the administrative staff. All these measures can serve to foster increases in personal knowledge of subject matter and effective methods for delivering the knowledge to students, to increase teacher confidence and, in turn, professional competence and to help teachers reach their potential . After a(3) Adopting a more reasonable or flexible Ph.D. recruitment and education policyApplication andVerificationSystem (申请-审核制) under which Ph.D. candidates shall present their works  and show their personalities , to convince their supervisor committee before they are admitted as Ph.D. students, and this system allows supervisors to dismiss disqualified Ph.D. students after due process, for example.This includes introducing a mechanism for changing supervisors when a confrontation between a Ph.D. student and his or her supervisor arises, and adopting an As to the enrollment policy reform, it is advisable to refer to the results of performance appraisal as an important decisive factor in the annual enrollment decision. Outstanding supervisors and teams are encouraged to share their experience and take the lead in Ph.D. education. In this way, improved student outcomes  and fulfillment of the objectives of Ph.D. education could be ensured.(4) Designing and implementing a supervisor training programIt is essential to establish a three-level  training program, and organize pre-service and in-service training and assessment for supervisors each year. More measures are created to make the training fruitful, e.g., the application of moral education, the development of supervisors’ responsibilities, the acquaintance with educational policies and administrative systems related to Ph.D. students, the observation of academic ethics and norms, the tips of supervisors’ physical and mental self-adjustment, etc. All this is conducted in various forms, such as, experts’ demonstrations, peer communication and seminars. It will effectively provide the basic, but powerful supervisory skills  and responsibilities that all supervisors must have in order to understand and connect with the students and drive results, integrating a theory of “becoming a supervisor” into supervisor professional development.(5) Providing supervisors with a continuum of school mental health services It is vital to offer students access to a continuum of free, confidential school mental health services to effectively address issues directed to supervisors’ work life and safeguard supervisor well-being . It shouThere are three main limitations of this research. Firstly, selection of participants was limited to certain regions, and the sample size was rather small, not indicative of the large population of supervisors across China. Secondly, further analysis should be conducted to cover different levels of stress suffered by participants due to their personal experiences. Thirdly, use of WeChat for data gathering methods tremendously limited the amount of non-verbal data which could have been gathered otherwise, thus limited the probes and follow-up questions concerning the positive or negative influence on the well-being of supervisors following the reforms in higher education.This study brings to light just how stressful the job of doctoral supervision can be, cohering with yet contributing to the emerging and growing body of literature on the psychological health crisis prevalent in higher education. More importantly, this study applied grounded theory to reveal varied factors of academic and interpersonal nature for occupational stress that the participants experienced as doctoral supervisors, and to present a substantive theory that explains the relationship between a variety of related conditions.Hopefully, this research can provide some insight for certain reforms in respect to doctoral education, arouse concerns from universities and institutions about the psychological health of this special group of people, facilitate the promulgation of related guidelines to alleviate the distressing symptoms among supervisors and promote sustainable development in higher education.This qualitative study conducted semi-structured interviews to explore the perspectives of the supervisors through inviting them to share their own stories, as it is their perceptions and experiences which are of interest here. Thus, more strategies can be put forward to cope with their stress based on their respective experiences.


Dear Editors,We read with interest the recent published review by Dressler and Johnson  and woul“…primary release procedure for DYSPORT uses a cell-based potency assay to determine the potency relative to a reference standard”  and Canada, and that these important changes were well publicized in 2019 and 2020, respectively Ipsen . The US d” Ipsen . In addi“idiosyncratic potency labelling”, the reader may mistakenly infer that other available botulinum toxin type A products  are comparable—when there is no consensus on this. In fact, regulatory agencies in the US, Europe, and most other countries worldwide require a statement that botulinum toxin units are not interchangeable from one product to another. This reflects the fact that these are biological products and, as Dressler and Johnson highlight in their review, have clear differences in the manufacturing processes, formulations, and assay methods used to determine units of biological activity. Furthermore, each product may behave differently depending on where it is targeted  must always be considered individually. In the absence of well-designed comparative studies, the best way to do this is to consider the evidence of safety and efficacy for each product based on their indication. Our stance will almost certainly change in the future when recombinant technologies become clinically available (Fonfria et al. RespectfullyAlberto Esquenazi, Mark Elliott, Andreas Lysandropoulos


Few studies have explored the factors influencing user uptake of interventions designed to enhance therapeutic drug monitoring (TDM). This study aimed to identify barriers and facilitators to acceptance of a pilot intervention, the TDM Advisory Service (the Service), that provided prescribing advice for the antibiotic, vancomycin at an Australian public hospital.n = 10), and a sample who had not (n = 13), participated in semi-structured interviews. Interviews were transcribed verbatim and analysed independently by two researchers for emerging themes. The Theoretical Domains Framework (TDF) was used to synthesise barriers and facilitators to Service acceptance.A sample of prescribers and pharmacists who had interacted with the Service  and ‘Environmental Context and Resources’ (accessibility of dose advice). For participants who had not interacted with the Service, key barriers aligned with two TDF domains: ‘Knowledge’ (uncertainty of Service processes) and ‘Environmental Context and Resources’ (accessibility of dose advice). Key facilitators for both participant groups aligned with ‘Beliefs about Consequences’ (improved prescribing and patient outcomes) and ‘Environmental Context and Resources’ (accessibility of dose advice). A novel domain, ‘Trust’, was identified.Independent of participant interaction with the Service, knowledge of Service processes, perceived beneficial outcomes, improved accessibility, and trust in Service capabilities were key determinants of acceptance. This evidence can be used to inform the adoption of strategies to adapt and enhance integration of the Service into clinical workflow.The online version contains supplementary material available at 10.1186/s12913-022-07927-1. Staphylococcus aureus (MRSA) infections ” . Barriers and facilitators reported by prescribers and pharmacists were similar, so are reported together.Interviews were conducted with prescribers . Lack of awareness of the existence of the Service, as well as limited scientific knowledge to interpret terminology used in dose reports, were also noted. “I feel like I’ve prescribed vancomycin this year and this didn’t get used” .Poor understanding of how the Service operated, including information collected and ability to cater for complex patients, was a key barrier to acceptance reported by participants who had not interacted with the Service: “… it’s just how accessible the information is, and how much effort I would have to go to to source the information” (P18).Accessibility of dose advice was a key concern across both groups. In particular, the lack of 24/7 decision support, dose report turnaround time and the effort required to source advice, were key barriers to acceptance of the Service. One registrar commented: “… with anything in healthcare, [it] comes down to how those results are communicated to a team” .Participants who had not interacted with the Service identified poor communication between the Service and clinical teams as a potential hinderance to acceptance: “Ultimately, they [seniors] have the final say” .For participants who had interacted with the Service, the prescribing hierarchy was reported to prevent acceptance. Advice provided by senior clinicians and clinical experts, including ID consultants, took precedence because For both participant groups two TDF domains, ‘Beliefs about Consequences’ and ‘Environmental Context and Resources’, captured key facilitators to acceptance of the Service Table . Facilit“… the idea is that you’re achieving better therapeutic drug monitoring and individual dosing for patients so that you can achieve therapeutic levels more efficiently and for [a] greater period of time, as well as trying to mitigate those risks of developing toxicity of vancomycin” . Additionally, the Service was identified by both groups as resulting in increased ease and efficiency of vancomycin prescribing, including reduced workload, attributed to not needing to collect specifically timed blood samples or interpret laboratory information. One registrar noted: “… if you don’t have to take trough levels, that’s pretty handy” (P20). Improved confidence and decision-making were also aligned with the dose advice.Across both groups, participants reported that acceptance of the Service was facilitated by a belief that the Service’s advice would result in better prescribing outcomes: “‘What should my next dose be?’, I would make that information as easily accessible as possible so that people don’t have to rummage through” (P04).Both groups described efficient communication between the Service and medical teams, as well as easy access to online dose reports, as facilitators to acceptance of the Service. One JMO commented: “I trust the expertise of the department” . Participants who had interacted with the Service associated the Service with “another level of security … for the patients and for yourself” .Interview analysis revealed barriers and facilitators that aligned with a novel TDF domain, ‘Trust’  from the bedside: “… the person who’s writing this [the dose report] probably hasn’t seen the patient in person as well, so it’d be a bit hard to trust them just based on this alone” . Lack of trust in the Service was particularly evident when prescribing for complex patients. A pharmacist noted: “… it’s hard for me then to recommend it again until we work out the system for critically ill” (P21).A barrier to acceptance of the Service for both participant groups was a lack of trust in its ability to cater for every patient as it was Limited work has been undertaken to understand user integration of TDM interventions into routine workflow , 15, 16.“so much easier” . The shift in barriers and facilitators to acceptance of the Service reinforces the value of ongoing evaluation, particularly as an intervention moves from hypothetical to actual.The TDF domains identified here are similar to those identified prior to piloting of the Service , but theIntegration of the pilot Service into current vancomycin prescribing processes was welcomed by most interview participants. However, the prescribing hierarchy, as was reported by both prescribers and pharmacists, appeared to be a dominant barrier to acceptance by participants who had interacted with the Service. Although doctors are central to medication decision-making, interprofessional relationships have a strong influence on this process –35. If sPositive perceptions of, and trust in, clinical interventions facilitate their uptake by healthcare professionals , 37. Duaend-users and context of use of an intervention are critical to ensuring an intervention is accepted and used, more so than the intervention itself. Following on from this, previously reported strategies addressing contextual barriers could be employed to improve acceptance of different prescribing interventions. For example, ensuring appropriate information technology infrastructure is available at different sites is essential to minimise barriers associated with accessibility  and facilitate incorporation of digital interventions into the workflow of users [Although our study was one of the first to examine acceptance of a TDM Service in-depth, the key barriers and facilitators identified are not unique to TDM interventions. Rather, they align with those reported in work identifying factors that influence prescribing –41. Thisof users , 43. SimOnly two groups of healthcare professionals, prescribers and pharmacists, were interviewed. However, participants were drawn from 25 clinical units, and different levels of seniority, thereby representing a strength of the study. The TDF was not used to devise interview questions, thus interviews may not have revealed outcomes relating to all domains. However, this design ensured questions captured outcomes beyond the TDF, such as trust. Using the TDF provides a theoretical basis for the selection of strategies to support uptake of the pilot Service , 19, 44.This study showed that barriers to acceptance of a TDM advisory service included uncertainty of Service processes, the prescribing hierarchy, and potential poor accessibility of dose advice. Key facilitators included perceived improvements in prescribing and patient outcomes and easy access to the dose advice. Trust was identified as a key factor, suggesting that strategies to build trust in the Service will facilitate user acceptance. The evidence gathered will be used to inform the design and implementation of strategies to adapt and enhance integration of the Service into clinical workflow.Additional file 1: Supplementary File 1. Interview guide. Supplementary Fig. 1. Process map depicting vancomycin TDM processes before implementation of the pilot Service. Tools used during interviews. Supplementary Fig. 2. Process map depicting vancomycin TDM processes after implementation of the pilot Service. Supplementary Fig. 3. A dose report provided for healthcare professionals by the pilot Service. Supplementary Table 1. Barriers and facilitators aligned with the novel domain, Trust.


Exploratory factor analysis and Cronbach’s alpha statistics were applied. Having experienced one or more of 10 specific behaviors was defined as sexual harassment exposure and was reported by 17.1% of staff/PhD students and 21.1% of students. Exploratory factor analysis yielded two factors with Eigenvalues above 1, labeled ‘unwanted sexual attention of soliciting type’ and ‘unwanted sexual attention of non-soliciting type’. Rape/attempted rape fell outside of the two factors. The Cronbach’s alpha values of the original 10-item scale and of the two newly formed scales were 0.80, 0.80, and 0.66, respectively. The mentioned statistics were markedly similar among men, women, and non-binary individuals and between staff/PhD students and students. We conclude that the 10-item instrument could be used for assessing sexual harassment in university settings or any type of workplace.The objective was to investigate the validity and reliability of a new instrument assessing sexual harassment at a public university in Sweden. In-depth interviews and focus group discussions resulted in a 10-item instrument, the ‘Lund University Sexual Harassment Inventory’ (LUSHI). A survey was sent to all staff, including PhD students, and students, with a response rate of 33% ( Sexual harassment (SH) is a well-established work-related risk for health, especially with regard to poor mental health ,2,3. StuThe main difficulty regarding the assessment of SH seems to be the question of whether the instrument should be based on the legal definition of SH or on the psychological/emotional experience . The legMoreover, there seems to be a considerable contextual influence on what is regarded as SH. As an illustration of this, an European Union-wide survey  revealed a seemingly paradoxical pattern, namely that the prevalence of reported SH was considerably higher in European Union countries that score high on the gender equality index, compared to countries characterized by a low score . It was Power emerging from gender relations could also be an explanation for the finding that sexual advances in the workplace may be perceived as threatening and thus as harassment by most women, while not by most men . FeminisThe influence of contextual factors on the definition of sexual harassment thus implies a continuous arbitration regarding where the limit should be drawn. This makes it important not only to register the experience of certain behaviors/situations in questionnaires and interviews, but to clearly include information about whether they are regarded as unwanted or not, as well as the gender of the victim and preferably also the perpetrator.In conclusion, it seems very different to assess SH in a population or at a workplace in the same way as other important health risks, e.g., air pollution, noise or repetitive movements, where the biological response is given for a defined dose of a well-defined exposure and where comparisons of exposure over time or between populations are unproblematic.However, despite the difficulties discussed above, there seems to be consensus in the scientific community that exposure to SH constitutes a significant risk for poor health that needs to be dealt with by increasing knowledge about its prevalence and the mechanisms underlying the negative effects on health. Therefore, the best available instruments should be used and continuously evaluated and developed in order that their virtues and fallacies may be discussed in relation to the interpretation of any empirical results.One of the oldest and most widely used instruments for assessing SH at the workplace is the Sexual Experiences Questionnaire (SEQ), introduced by Fitzgerald et al. in 1988 . This qugender harassment, unwanted sexual attention, and sexual coercion, achieved the best fit with regard to theory and statistic evaluation, while at the same time, constituted a conceptual link between the psychological and legal constructs of SH. Gender harassment, often expressed as comments, jokes, gestures, etc., has nothing to do with sexual desire or with a wish to ‘elicit sexual cooperation’ [unwanted sexual attention, gender harassment would reflect the (American) legal concept of ‘hostile work environment’. Sexual coercion  would correspond to the legal term ’quid pro quo’ [In 1995, Fitzgerald et al. suggested that a ‘tripartite’ version of the SEQ, consisting of the three concepts eration’ , but rateration’ ,15,16. Teration’ . Togethepro quo’ . The SEQ has over time been used in a number of workplace settings, often with minor or major adaptations , for inssexual coercion showed questionable evidence of reliability, and that all subscales were highly correlated with each other, which could imply that they are not sufficiently distinguishable from each other [that they) … do not describe sexual behavior’, as, for instance, in ‘said things to put women down, for example that women don’t make good supervisors’ [In 2004, Gutek et al. presented a thorough criticism of the SEQ, claiming that the many numerous versions precluded any entitlement of being a standardized instrument, that the subscale ch other . More imch other  was not rvisors’ . Finallyrvisors’ .Regarding the latter objection, it is well documented that any inquiry detailing descriptions of potentially offensive behaviors will yield a higher prevalence than self-labeling of SH with a single item. This might be due to an unwillingness to admit victimization  or to thDespite this criticism, the SEQ or, rather, the theoretical framework built by Fitzgerald et al., is repeatedly cited as fundamental . Therefogender harassment is completely lacking. As noted by Timmerman and Bajema [However, in both of these questionnaires, the concept of d Bajema , this isd Bajema . Therefod Bajema ,25.A reasonable conclusion of the description of the state of the art seems to be that a true ‘gold standard’ for assessing SH does not currently exist and might not even be possible to develop in the future, due to the contextual dependency of how SH is perceived. Furthermore, SH is a controversial and significantly ideologically laden subject, both in a general context and from a scientific point of view. However, a commonly occurring nihilism, characterized by emphasis on the fact that very few studies have used an instrument yielding comparative results, may seriously hamper the growth of knowledge in the area of workplace SH. A constructive way out of this for new studies on SH would be to perform a critical validation of the instrument used, that addresses as many as possible of the issues raised above. ’Tellus’, a project aimed at reinforcing preventive work against sexual harassment at Lund University, Sweden, was initiated in 2018. Individual interviews and focus group discussions were held with members of the target population , the resRegarding the selection of the items of the instrument, on the one hand, we chose to align with previous research outside of the United States and, as described above, with the definition of SH in Swedish law, which, in turn, corresponds to public opinion, by restricting the behaviors indicated to those with a clear sexual connotation. This was clearly specified in the instructions to the respondents to the survey. On the other hand, we used the expression ‘unwanted comments’ as one of the items. This would allow respondents to include various offensive remarks, which for them had a sexual connotation. For the choice of items describing other specific behaviors, we were inspired by the questionnaire used by Phillips et al. . The aimThe ‘Tellus’ project at Lund University, Sweden, was initiated in 2018. Two survey questionnaires were shaped, one for university staff  and another one for students. After permission from the Vice chancellor’s office, e-mail addresses for all university staff and students were obtained from the university administration. The original items in English were translated by the research team in a process involving both native Swedish and native English speakers. Before sending out the questionnaire, face validity and feasibility of the SH items were discussed against the background of interviews and focus group discussions, which had been made by members of the core research team as another part of the Tellus project, as well as against comments from a small pilot sample of employees and students. This resulted in some very marginal linguistic changes.The survey forms were sent out in November 2019. The response rate was 33% for university staff and PhD students and 32% for students. After exclusion of those with missing data on both sex and gender (see below), age , and those who did not answer any of the 10 questions on experiences of sexual harassment , the final study population consisted of 2736 university staff and PhD students and 9667 students. Two questions concerning the gender of the respondent were asked in the survey: ‘What gender were you assigned at birth?’  and ‘what is your current gender identity?’ . We used the answers to the second question to categorize participants as woman, man, or non-binary gender; however, in cases with a missing answer on this question , the answer to the first one was applied. Those who had refrained from answering both questions were excluded from the analyses .Age was categorized into groups, separately for staff/PhD students and students. Country of birth was recorded as ‘Sweden’, ‘Nordic countries (outside Sweden)’, ‘Europe (outside Nordic countries)’, or ‘outside Europe’. Professional group was specified according to nine types, which were then aggregated into five categories, ‘professors‘, ‘senior lecturers’, ‘lecturers and researchers’, ‘PhD students’, and ‘administrative and technical support staff and others’. Students self-reported as ‘international student’, yes or no. The following text introduced the survey section about experiences of sexual harassment (SH). ‘We will now ask some questions about your experiences of sexual harassment and sexual violence. Sexual harassment is defined as conduct of a sexual nature that violates someone’s dignity. This can be, for example, through comments or words, groping or indiscreet looks. It can also include unwelcome compliments, invitations, or suggestive acts. Sexual violence is defined in this study as attempts to conduct, or the conduct of sexual acts in which the person did not participate voluntarily. Have you experienced any of the following situations during your employment/your time as a student at Lund University?’ This text was followed by descriptions of 10 different behaviors, with the answer alternatives in each case: ‘Yes, once’, ‘Yes, more than once’, and ‘No’. As mentioned in the Introduction, the choice of items was based on the results of the performed interviews and focus group discussions. Moreover, it was inspired by the list of items produced by Phillips et al.; however, the term ‘unwelcome’ was preferred before ‘inappropriate’ . The folp < 0.05. All analyses were performed using the IBM SPSS package, version 25. Spearman correlation was used to obtain a correlation matrix involving all 10 items. Exploratory factor analysis, using both oblique and orthogonal (Varimax) rotation, was performed in order to examine the relationships and to potentially discriminate between different aspects of sexual harassment. Factors with Eigenvalues of >1 were included. Thereafter, the reliability of the 10-item scale and of two sub-scales, derived from two of the factors, was assessed with corrected item—total correlations and Cronbach’s alpha. The correlation between the two new subscales was determined. Statistical significance was accepted at the level of The sociodemographic characteristics of the participants are presented in Among female students, the same behaviors were reported, but in a different order. Thus, unwelcome suggestive looks or gestures was the behavior most frequently affirmed. The most frequently reported behavior among male students was instead unwelcome bodily contact, such as grabbing or fondling, while both unwelcome suggestive looks or gestures and unwelcome ‘inadvertent’ brushing or touching were affirmed by 4.7%. Persons defining themselves as non-binary reported the same three behaviors as staff/PhD students, and in the same order, although with higher prevalence.One item loaded with approximately the same level of pattern coefficient value (0.46–0.53) on both factors. This item, ‘unwelcome soliciting or pressuring for ‘dates’, was deemed on face value to relate to factor 2, which we thus labeled as ‘unwanted sexual attention of soliciting type’, and factor 1, consequently, was labeled as ‘unwanted sexual attention of non-soliciting type’.A third factor emerged within the group of staff/PhD students only. Due to this fact and to the relative infrequency of the two corresponding items, stalking and attempted and completed rape , this factor was not further considered.The reliability of the original 10-item scale and of the two newly formed scales, non- soliciting SH and soliciting SH, is presented in The correlation coefficients between the two new subscales were 0.37 for the entire study group, out of which, for women 0.37, for men 0.36, and for non-binary persons 0.40; for staff/PhD students: Women 0.35 and men 0.26; and for students: Women 0.35 and men 0.38.The population distribution of having experienced the two types of SH was also analyzed (data not shown). Experiencing ‘non-soliciting SH’ was nearly two to three times more common than ‘soliciting SH’, among staff/PhD students and students, as well as across all three gender groups. The results of this study showed that the 10-item scale used for measuring sexual harassment among university staff and PhD students and students, i.e., the Lund University Sexual Harassment Instrument (LUSHI), had good reliability both among staff and students, regardless of gender. However, when performing a formal factor analysis, two factors with Eigenvalues above one emerged, both among staff and students. The first factor comprised four of the scale items and the second factor five items. Considering the current discussion concerning the SH phenomenon, they were labeled ‘unwanted sexual attention of non-soliciting type’ and ‘unwanted sexual attention of soliciting type’. It was noted that there was a considerable overlap regarding exposure to the two factors. One item, assessing whether the respondent had experienced rape or attempted rape, was significantly correlated with all the other items of the scale, but fell outside of the factors produced in the factor analysis. While rape may be considered the ultimate form of ‘sexual harassment’, this more unusual and extreme event might more appropriately be classified as ‘sexual violence’. These two phenomena are explicitly identified as discrete, for instance in the review by Fedina et al. on campus sexual assault . gender harassment, unwanted sexual attention, and sexual coercion) [gender harassment. This aspect of SH was assessed in conjunction with another instrument in our university-wide survey, which tapped the prevalence of all types of discrimination, as defined by current Swedish law . Our results could be compared with previous similar analyses of the SEQ or SEQ-like instruments reported earlier in the scientific literature. The early versions of SEQ consisted of five dimensions, which after analysis were reduced to three factors (oercion) . Howeverunwanted sexual attention’. The SEQ-factor ‘social coercion’, mainly defined by the legal notion ‘quid pro quo’ , was not represented by explicit items in our instrument, since this type of situation seemed rare and was not reported at all in the numerous interviews and focus group discussions that informed the discussions regarding our choice of survey instrument. However, the subscale ‘unwanted sexual attention of soliciting type’ may also tap dimensions of sexual pressure, i.e., the victim may perceive implicitly that accepting an individually directed sexual invitation or contact attempt could potentially give something in return , or similarly, i.e., that declining the invitation could mean being blocked from these resources.All items fell by and large within the SEQ-factor defined as ‘Our 10-item scale covers two central aspects of sexual harassment and one important indicator of sexual violence. The first aspect, ‘non-soliciting SH’, could be regarded as an indicator of a more general climate of sexual harassment at a certain workplace, and different from ‘general’ gender harassment by its clearly sexual content. The other aspect, ‘soliciting SH’, indicates a more explicit effort to create a sexual relation between two individuals. This invitation may be experienced as particularly unwelcome if the initiative emerges from an individual who has a superior position in one of the prevailing power structures ,  could be used as a tool for assessing sexual harassment in university settings or presumably any type of workplace, due to its demonstrated high reliability and acceptable construct validity. Furthermore, a formal factor analysis showed that the items could generate two subscales, ‘unwanted sexual attention of non-soliciting type’ and ‘unwanted sexual attention of soliciting type’. Future studies might show differences in the quantitative as well as qualitative impact of those constructs, e.g., on mental health, or that the impact differs according to the gender of the victim and/or perpetrator.


Lymphoedema is a common medical condition, with early identification leading to more timely management and better outcomes. However, people with lymphoedema in Australia express frustration about the lack of knowledge of their condition among doctors and other healthcare professionals, resulting in diagnostic and treatment delays. The overall aim of this cross-sectional study was to understand the perceptions of newly graduated doctors (interns) toward their understanding of the lymphatic system and lymphoedema, and the extent to which both were covered within their Australian medical degree. It was found that interns perceive their understanding of the lymphatic system and lymphoedema to be suboptimal, and comprehensiveness of medical curricula specific to the lymphatic system and lymphoedema to be lacking. Findings from this research will be used to strengthen teaching of the lymphatic system and lymphoedema within Australian medical schools, thereby improving early recognition, management, and outcomes of lymphatic system disorders, such as lymphoedema.n = 230) perceived their understanding of the lymphatic system and lymphoedema to be low, and comprehensiveness of medical curricula specific to the lymphatic system and lymphoedema to be lacking. Subscale scores did not differ by participant characteristics. Improvement of medical graduates understanding of lymphoedema may facilitate greater awareness of lymphoedema, thus optimizing the timeliness of diagnosis and access to treatment. The aim of this study was to survey the perceptions of recent  Australian medical graduates regarding (i) their understanding of the lymphatic system and lymphoedema, and (ii) the extent to which the lymphatic system and lymphoedema were covered as part of their medical degree. Medical graduates were invited to participate in a 17-item online survey that asked respondents to rate their level of agreement  to statements that explored their understanding and comprehensiveness of their medical degree. Responses to each item were described using n (%). Subscale scores for understanding and medical degree were computed by summing scores of individual items, described using means (SD) and compared by participant characteristics. Medical graduates ( Lymphoedema  is a progressive, chronic condition that occurs when fluid accumulates in tissue spaces due to an imbalance between interstitial fluid production and the body’s ability to transport it, resulting in significant physical and psychological morbidity . It may While the prevalence of secondary lymphoedema following treatment for breast cancer is estimated to be approximately 20% , there hLymphoedema is a life-long condition with no known cure. It is associated with a high burden of disease, owing to its physical, functional, psychological, and psychosocial impacts, and adversely affects quality of life . PhysicaWhile there is no cure for lymphoedema , correctKnowledge of lymphoedema among healthcare professionals, including doctors, is generally considered to be low , and accIn recent years, the International Lymphoedema Framework have published the Lymphoedema Education Benchmark Statements, compiled through a process of expert panel consensus as a teaching resource . They weThe overall aim of this study was to explore the perceptions of new medical graduates toward their understanding of the lymphatic system and lymphoedema, and the extent to which the lymphatic system and lymphoedema were encompassed within their Australian medical degree. An online survey was conducted with a quantitative method design conforming with the CHERRIES checklist for reporting results of internet electronic surveys  26]. Su. Su26]. Participants were eligible to complete the survey if they had (i) completed an Australian medical degree within the past 12 months and (ii) were employed as a doctor within their first postgraduate year. Those who answered “no” to either question were not able to proceed with the survey.The survey consisted of 17 questions that asked participants to rate their level of agreement, using a 5-point Likert scale from “strongly agree” to “strongly disagree”, to statements regarding their perceived understanding of the (i) anatomy and (ii) physiology of the lymphatic system; and (iii) pathophysiology, (iv) clinical features, (v) assessment, (vi) diagnosis, and (vii) treatment of lymphoedema. The survey then asked respondents to rate their level of agreement regarding the extent to which the (i) anatomy and (ii) physiology of the lymphatic system; and (iii) pathophysiology, (iv) clinical features, (v) assessment, (vi) diagnosis, and (vii) treatment of lymphoedema were comprehensively covered within the curricula of their Australian medical degree. The final questions asked respondents to rate their level of agreement regarding whether they perceived the amount of time devoted to (i) the lymphatic system and (ii) lymphoedema to be enough for their clinical practice, with the last question providing opportunity for open-text responses .n (%) for each of the categories were calculated and reported. Second, two subscale scores were created by summing responses to all items that explored medical graduates perceived understanding  and perceptions regarding how well the medica curricula covered the lymphatic system . To gauge the reliability of our survey, internal consistency of the subscale scores “understanding”, “medical curricula”, and “appropriateness for clinical practice” were calculated. To gauge the reliability of our survey, internal consistency of the subscale scores “understanding”, “medical curricula”, and “appropriateness for clinical practice” were calculated. Internal consistency of alpha (α) ≥ 0.9 was considered “Excellent”, α ≥ 0.8 as “Good”, α ≥ 0.7 “Acceptable”, α ≥ 0.6 “Questionable”, α ≥ 0.5 “Poor”, and α < 0.5 as “Unacceptable” [All data were exported from LimeSurvey into the IBM SPSS Statistics for Windows Version 28.0). A bot screening tool was developed and applied to remove responses that were likely derived from an internet robot , where i.0. A boteptable” . Higher n = 230) completed all or part of the survey and were included in subsequent analyses (n = 230) are described in A total of 800 respondents accessed the survey. Of these, 67 did not meet eligibility criteria, while 503 respondents were identified as being potential bots . Eligible respondents , while the majority reported that they strongly disagreed or disagreed with having a thorough understanding of the methods available to assess the presence and severity of lymphoedema (67.4%) and treatment options available to manage lymphoedema (61.4%) . Nearly p > 0.1). Quantitative findings were corroborated by open-text responses, such as “I don’t know much about lymphedema”, and “good recognition however very limited treatment knowledge” . Out of a possible score of 35 (with higher scores indicating agreement with a thorough understanding of the lymphatic system and lymphoedema), the mean and SD for the total subscale score for the sample was 18.8 (4.4) . Agreemeowledge” .The majority of respondents strongly disagreed or disagreed with five of seven statements relating to medical curricula comprehensively covering the lymphatic system and lymphoedema . For thep > 0.1). Open-text responses supported quantitative findings, such as “Did not hear of lymphoedema until completing medical graduate studies, only aware of symptoms and management due to my own studies during internship”, “Quite limited coverage of lymphoedema in medical school. Most of my knowledge comes from background in physiotherapy” and “This condition is not adequately covered in medical school considering how common it is to see in general practice”, but also highlighted “I think there could be slightly more teaching, but like many areas, this is quite specific post graduate knowledge. We can’t learn it all at medical school” . Out of a possible score of 35 , the mean (SD) of medical curricula was 17.4 (5.4), and these scores were similar across respondent characteristics . Just over one in three respondents disagreed or strongly disagreed that the amount of time devoted to the lymphatic system and lymphoedema during their medical degree was appropriate for their clinical practice. Open-text responses included “Would not be able to manage lymphoedema on my own or diagnose on first presentation” and “I think I underdiagnose lymphoedema due to reduced confidence with the condition”, while others highlighted “Lymphoedema was not extensively covered but is also not something I have come across as a student or so far as a doctor” .This study explored the perceptions of new medical graduates toward their understanding of the lymphatic system and lymphoedema, and the extent to which the lymphatic system and lymphoedema were encompassed within their Australian medical degree. Less than one in four participants considered their understanding of the lymphatic system to be thorough (at most 24.2%), and less than one in three participants considered the lymphatic system to be comprehensively covered (at most 32.0%) within their medical training. Similarly, for lymphoedema, only the minority of participants reported thorough understanding (at most 27.0%), with the exception of understanding clinical features  of lymphoedema (47.4%), and at most, 21.5% of participants considered lymphoedema to have been comprehensively covered within their medical training. Only one in three participants (at most 29.9%) considered the amount of time devoted to the lymphatic system and lymphoedema to be appropriate for their clinical practice. Perceptions of understanding and medical curricula were similar irrespective of sex, age, enrollment type, state of medical degree/employment, clinical setting, and location.The obstacles that people with symptoms of lymphoedema encountered when presenting to physicians in the hope of accessing appropriate treatment were recognized in a review nearly two decades ago . Apathy While an education gap has been proposed in the literature, so too has the absence of lymphology being formally recognized as a medical subspecialty, with subsequent insufficient numbers of tertiary level doctors specializing in lymphatic medicine. A 2018 study highlighted that, outside of the Netherlands and the United Kingdom, medical expertise in lymphology is not formally recognized . NotablyDoctors are arguably the most trusted healthcare professionals when any new medical symptoms, including chronic swelling, arise. While medical doctors may not be responsible for all aspects of lymphoedema treatment, their skills in medical assessment, investigation, and diagnosis are imperative, especially where multiple comorbidities (as is often the case) may complicate the clinical picture. Furthermore, once a diagnosis has been made, doctors are well-positioned to facilitate appropriate referral to other members of the healthcare team, who are well-equipped to assist patients in managing the symptoms of their lymphatic system disorder. However, for people with lymphoedema, significant diagnostic and treatment delays have been described in the literature, with the patient perspective being that low medical awareness and availability of specialists exacerbate delays ,31. ConsThe lymphatic system has been notably neglected throughout history, and its relationship to human health and disease is poorly understood . Some suWhile previous studies have suggested that knowledge of the lymphatic system and lymphoedema among healthcare professionals is not favorable , and curOur data represent a sample of convenience and may not be representative of the views of all recent medical graduates in Australia. The study response rate distribution across states was consistent with the expected distribution , but recThis study has highlighted that Australian medical graduates perceive their understanding of the lymphatic system and lymphoedema to be suboptimal and the comprehensiveness of medical curricula specific to the lymphatic system and lymphoedema to be lacking. Improvement of medical graduates understanding of lymphoedema may facilitate greater awareness of this chronic condition, thus optimizing the timeliness of diagnosis, access to treatment, symptom burden for patients, and costs to global healthcare services.


Hence, Black women ADIOs' perception of organizational inclusivity is informed by their own intersectional lived experiences of exclusion in sports and society writ large.Select collegiate athletic departments have adopted Athletic Diversity and Inclusion Officer (ADIO) positions. ADIOs are formally tasked with the job responsibilities of creating diverse, equitable, and inclusive athletic departments, and many individuals holding the positions are Black men and women. This hermeneutic phenomenological study focused on the leadership of Black women in ADIO positions and examined how their racial and gender identity informed their perceptions of organizational inclusivity. Findings reveal that the intersecting identities of Black women are drawn upon and centered to make sense of what organizational inclusivity is. More specifically, organizational inclusivity is creating contexts that do not mirror Black women's experiences as  Recent media depictions of Black women participating in sports  and reprformally tasked with the job responsibilities of leading an athletic department's diversity, equity, and inclusion (DEI) aims  aims . The adoEI) aims , 16, 18.acy [see ], as athacy  status .icipants .As of August 2020, NCAA institutions are required to designate the role of Athletic Diversity and Inclusion Designee, commonly referred to as ADID, to an administrator affiliated with NCAA athletic departments . ADIDs hvia email and met the following criteria: (a) identified as a Black woman, (b) held the ADIO position for at least 3 months, (c) their position title included some semblance of language around diversity, inclusion, and equity, and (d) they currently work for a Division I institution. Given the ADIO position is in an emergent state  . IPA is icipants , 44. Thesense of . Idiograsense of . This inAfter each individual interview, I immediately engaged in memoing, specifically on the following: (a) my initial thoughts, (b) rememberable comments, (c) statements that challenge preconceived notions I held, (d) blatant commentary about being a Black woman ADIO, and e) my reflections on how being in this space with participants made me feel. Engaging in this process led to me organically participating in interpretation and idiography. While engaging in this immediate post-interview memoing, I would ask myself “why questions,” like (a) Why was Monique able to laugh while sharing hostile stories of raced-gendered exclusion, (b) Why does Nia continue to stay in her organization if she feels silenced, and (c) Why is Serenity comparing her leadership to Stacy Abrams? As I posed these questions to myself, I was grappling with the meaning of these lived experiences while also being attuned to “the particular,” like laughter, the language use of “silenced,” and the peculiarity of an ADIO comparing themselves to a contemporary Black woman political figure . Consequently, my immediate (and continued) memoing centered on meaning-making, interpretation, hermeneutics, and idiography, which are critical aspects of interpretative phenomenology and IPA.meaning. Consequently, a shared code did not equate to a shared interpretation, which led to me engaging in the iterative process of creating new codes/engaging in more analysis, which eventually led to the theme development centered on meaning. After completing this process for each participant, I examined how participant themes diverged and converged and examined if shared themes held a similar interpretation, which led to the creation of three superordinate themes.I then transitioned to coding each participant's lived experience individually before examining how participants held congruent and divergent experiences . Consequlooks and feels like. Black women ADIOs use these experiences of raced-gendered marginalization to inform their perceptions of organizational inclusivity, illuminating how they center their “own oppression”  andession” [ p. 747] outsider within mostly White athletic departments, their lived experiences in marginalizing systems, and their distinctive lens as a Black woman (Black feminist thought) inform their perceptions of organizational inclusivity. Consequently, the aforementioned realities are marginalizing experiences due to Black women navigating systems of patriarchy and racism , you know, there's times they (non-Black women), haven't been the only one in the room that looks like them. And what has happened to me in the past, allows me to, no it forces me to think about everyone else in a way that I wish people would have thought about me.outsider within lived experience “forces” her to think of others. Her use of “forces” emphasizes how she cannot refrain from incorporating her experiences as a Black woman into her perceptions of organizational inclusivity. Additionally, she perceives Black women as having a distinctive insight, because “they,” meaning individuals who are not Black women, rarely experience such an isolating experience. Although being the only Black woman in collegiate sports spaces creates an outsider within reality  had the inequity, the gaps, the discrimination, the oppression, like we felt all those things. So that- that experience as a Black woman can almost translate into the- the experiences of all these other underrepresented groups.outsider within .She continues to use her adverse lived experiences  on the margins of power and the concomitant feelings of her own exclusion  to influence how she “responds” as an ADIO. As an ADIO, her “respond[ing]” to exclusivity or marginalizing conditions or incidents is reflective of her perception of organizational inclusivity, as her need (“trigger”) to respond signals that addressing organizational inclusivity is an intentional effort. Additionally, Jalyiah equating her “respond[ing]” to exclusivity as a “trigger” demonstrates how her perception of organizational inclusivity is based upon her own lived experiences. She reacts like a “trigger”  because she is familiar with how individuals in positions of power attempt to keep her on the margins or outside. This expertise becomes imperative for thinking about how others “fit in” or are valued in collegiate athletics.Black women ADIOs using their lived experience as an outsider in the “industry”  as a barometer for addressing the marginalization of others is evident in how Monique poses questions to herself:Yeah, I think, being a part of two identities (race and gender) that have been historically underrepresented, marginalized, and oppressed in our society and in this industry as well, definitely is part of, like how I come into this space. I think it, it influences me and I'm always reflective of, um, “How would you feel if this happened to you?” Or, “How did you feel when it did happen to you?”outsider within  and using her experience as “the most disrespected person in America” to do so, are entangled in one another. Moreover, Jalyiah perceives her professional perspective on “bettering the experience of those under [her leadership]” as connected to Black women “having intersectional identities [entangled in many systems].” Like others in this study, Jalyiah's lived experience of marginalization holds the l praxis  in the AThe participants provided specific examples of how their own adverse raced-gendered experiences  informed their perceptions of organizational inclusivity. Kayla shared how burdensome it is to comply or be pressured into complying with White patriarchal standards in the workplace as a Black woman . She disyou, even if you wanna be seen, I think that allowed me to be more cognizant of other people's identities.There are these two identities (race and gender) that I cannot change and people already may have an opinion about me because of these identities and realizing like that's a lot to carry, especially if you're like, I'm just trying to be good at whatever it is. And now I feel like I have to think about, “Okay, well I'm a woman in this space, so how am I dressing properly? I'm Black in this space? So is my hair appropriate? Like, can I say something like all of these things add up?” So, I feel like as I started to realize that the world isn't gonna always see For Kayla, the sexism  and racism  is the simultaneity of marginalization that intersectionality brings attention to , 26. WheSo I think those intersectionalities make it a big point because you're like, “Okay, if you can accept one part of me, how about the other part of me?” Um, so I think that those layers allow for you not to only think about gender and race, but then to think about, “Okay, what about sexuality? What about disability?" And really tie those into like, this is not just one part of someone like, yes, it is a piece of who they are, but like, you can't just ignore that part because it's, it's a larger part of who they are as a whole.critical praxis  mean that Black women must be reflective of self and their marginalization, which makes their familiarity with marginalization become a tool for conceptualizing organizational inclusivity.Nia equates her responsibilities as an ADIO to “feel” like her lived experiences as a Black woman. But, upon making this comparison, she only shares the adverse realities of Black womanhood , like “mak[ing] herself smaller”  and “do[ing] the heavy lifting” . ADIOs lusivity . Nia, drPrevious scholarship studied how Black women administrators navigate racist and sexist organizational cultures because their identities are non-prototypical identities for collegiate sports leadership positions , 21, 27.Um, so it's personal, it's personal because, um, I've been on the receiving end of being stereotyped, being marginalized, being silenced. Um, on the, you know, receiving end of poor culture-... and negative culture. And that's why I do it, um, 'cause I don't want the people who come behind me in any of these positions, or any of these spaces to have to endure, or experience some of the things that I have.Monique states “it's personal” two times, which seems to emphasize just how personally connected she feels to ensuring others can evade the marginalization she has experienced. Because she knows what a “poor” and “negative culture” looks and feels like, she centers these lived experiences to ensure they do not happen to others. Additionally, what she has “endure[d]” is the entangled nature of working in sexist and racist sports organizations . She shaAs participants discussed their ADIO leadership position, they alluded to Black women being uniquely equipped for the position, given that Black women have a “different lens,” are “inherently [different],” and “have a unique perspective.” I interpreted these proclamations as participants perceiving their intersectional identity as unlocking a particular consciousness, a Black feminist consciousness [or a Black Feminist Thought (BFT)] , 29 thatjust know what they are doing because the job responsibility of creating inclusive organizations is a task that enables her to bring herself (lived experiences) into her job responsibilities of cultivating a shared perception of organizational inclusivity. Jalyiah states:Jalyiah speaks about this consciousness as if it is innate to Black women, as she asserts “…we (Black women) know what we're doing when we are advocating for that norm (read: exclusive practices/cultures) to be changed.” Nia brought attention to how the ADIO position is “hand in glove” with her lived experiences as a Black woman. Similarly, Jalyiah supports this notion by proclaiming that Black women in diversity leadership positions And therefore, we (Black women) know what we're doing when we are advocating for that norm (read: exclusive practice) to be changed. Um, we have a different lens of not fitting in, not having a voice, not being respected, having to fight up against again, all the systems that we're mentioning. We have just a very, very like unique intersectional lens with how we like wake up every morning and live our lives as women of color, Back women. Um, but then that directly translates into my ability to have a unique perspective and voice in our roles.espoused to do, which is to cultivate a shared organizational understanding of inclusivity . Kayla shares:The consciousness that is developed from experiencing, navigating, and “fight[ing]” marginalizing systems is relevant to Jalyiah's ability to have a “unique perspective” in an ADIO position. Like other participants, she discusses how her lived experiences as a Black woman cannot be divorced from the realities of what an ADIO is lusivity . Howeverlusivity , 25, 35.I think that you have the – and this could be biased. But like, I think we (Black women) have, um, [a] unique way to connect with different people, um, because you, because of the intersectionality, right? Like, I feel like we can connect with the female student athletes, I also think we can connect with the [racially minorit[ized] population male or female.Monique discusses how her experiences of being stereotyped as a Black woman give her the consciousness necessary (read: BFT) to be alert to how organizational spaces disregard those who have marginalizing experiences. Monique shares:We (Black women), we... Many of us are stereotyped in the same way because we're talking about systems that operate in making assumptions about people. Systems that have made up their mind about Black women, regardless of where we come from. So, uh, many of those stereotypes follow us. So, when you think about the uniqueness of being in that room [read: in meetings with a majority White senior-level leadership], is that there are some shared and common experiences that, whether we've had them kind of personally, we know are happening in other spaces, and we're conscious of that.Monique uses the consciousness that is derived from her own marginalizing experiences to acknowledge that her lived experiences are not happening in a vacuum. Her own oppression gives her the awareness and wherewithal to be conscious of how some organizational dynamics, create disadvantaged experiences for other marginalized communities as well. Consequently, her perception of organizational inclusivity considers how marginalizing experiences can occur due to the intersection of power, identity, and space. Nonetheless, this perspective is only developed from the consciousness that is unlocked from navigating “systems that have made up their mind about Black women.” Monique continues to build on this notion of her BFT, informing her perceptions of organizational inclusivity. She discusses:And I think we (Black women) bring the perspective, um, because we inherently, like from a very basic level are different... than the people in the room. We have had to live in a world that we don't have the same privilege that a White male would have, and that has given us different experiences. And so, we're in a society that, um, views us differently.just knowing what organizational inclusivity is because Black women are “inherently, like from a very basic level are different” and have vast experiences of exclusivity in organizations. Consequently, navigating collegiate athletics and their own respective athletic departments puts the BFT of Black women ADIOs into critical praxis  lived experiences entangled in systems of oppression, specifically sexism and racism, and (c) experiences that cultivate BFT in Black women, as this consciousness is bolstered through adverse realities of exclusion. The adverse experiences of Black women in sports being used as expertise to inform their perceptions of organizational inclusivity means that (a) these leaders consider the whole person and the varying systems that implicate their organizational experiences , (b) their leadership is attentive to who resides outside the margins of power (read: outsider within), (c) Black women ADIOs are conscious of how power and identity intersect to privy certain groups, and (d) they are attentive to how oppression can be shared but disparate with other marginalized groups.The Athletic Diversity and Inclusion Officer (ADIO) position is unlike any other position in collegiate athletic administration. It is the only position in which one's marginalization is drawn upon to meet the demands of the job responsibilities. ADIOs must hold a clear perception of organizational inclusivity , and Blacritical praxis  and addressing  issues of organizational inclusivity (Given that Black women in sports are conscious of their marginalization, moving forward, scholars must be attuned to how they make sense of this oppression and if they possibly lusivity .do this work but also examinations of how they take care of themselves while engaging in this work.Lastly, although not explicitly shared, one can infer from the excerpts how navigating such hostility must have an adverse effect on participants' mental health and ability to remain committed to the work of creating diverse, equitable, and inclusive athletic departments. As the ADIO position continues to become more widely adopted, we need not only investigations of how Black women ajhanai.keaton@louisville.edu.The datasets presented in this article are not readily available because Data will not be uploaded, shared, or accessible to the public. Requests to access the datasets should be directed to The studies involving human participants were reviewed and approved by University of Connecticut Institutional Review Board. The patients/participants provided their written informed consent to participate in this study.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.