Long-term follow-up studies in patients with borderline personality disorder (BPD) consistently show persistent impairment in psychosocial adjustment, although symptoms tend to decrease over time. Consequently, it might be better to deemphasize symptom-oriented interventions and instead promote interventions that incorporate patient perspectives on recovery. In this study we aimed to examine the feasibility and acceptability of a novel intervention  in the clinical treatment of long-lasting BPD difficulties.This was a qualitative study. We developed an initial 8-week group intervention for long-lasting BPD. Upon completion of the 8-week program, the participants were asked to participate in a group discussion to provide feedback. Based on that feedback, the intervention protocol was modified and then offered to a second group of patients, who also provided feedback. The protocol was revised again and administered to a third group. A total of 32 patients participated in the group interventions; of these, 20 provided feedback in the qualitative study. The main outcome measure was acceptability.The following overarching themes emerged from the group interviews: helpful, unhelpful and neutral practices; internal/external barriers; facilitators; and effects. Participants reported difficulties in imagining an optimal future and self-compassion. By contrast, positive skills were associated with an increase in positive emotions. The main internal barrier was facing difficult emotions. The main external barriers were language-related issues. The group format was perceived as a facilitator to success. Dropout rates, which were assessed as an additional measure of acceptability, decreased substantially in each successive group, from 60 to 40% and finally 20%.The intervention was feasible to implement in the clinical setting and participants rated the final set of skills highly. Most of the skills were considered useful. Participant feedback was invaluable to improve the intervention, as evidenced by the large increase in the retention rate from 40 to 80%. Randomized clinical trials are needed to test the efficacy of this intervention in promoting well-being in participants with long-lasting BPD. Borderline personality disorder (BPD) is a severe mental disorder characterized by pervasive emotion dysregulation, impulsivity, identity disturbances and conflicting interpersonal relationships , 8. In tDespite the severity of BPD, remission rates within 10 years of diagnosis are as high as 85% , 77. HowIn recent years, the concept of good mental health has been expanded to comprise more than simply a reduction in symptoms. Good mental health involves several domains, including meaningful living, the establishment of significant relationships and self-management strategies , 43, 46.Psychotherapy is recommended as a first-line treatment for BPD , 72. SevResearch in DBT has focused mainly on stage one  and stage two  , 52, 62.Studies on DBT skills training (DBT-ST) in BPD have evaluated the effectiveness of training four skill modules: mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance . Those sPositive psychology (PP) has emerged as an interesting, evidence-based approach to improving well-being , 21, 47.Although numerous studies have demonstrated the value of DBT for the treatment of stage one and two BPD, there is a notable knowledge gap regarding the value of DBT for stages three and four. Although some preliminary evidence suggests that positive psychology, loving-kindness and self-compassion exercises might be useful, more data are needed to support their use. In addition, published studies on patient perspectives on recovery in BPD are scant, and more data are needed to make treatment and outcome targets more relevant to patients.In this context, there is a need to perform feasibility studies to determine whether an intervention is appropriate for further testing . These tAccordingly, we performed the present qualitative study to examine the feasibility and acceptability of an expanded skills DBT-based intervention targeting long-lasting BPD. Acceptability was assessed through group discussions designed to obtain extensive feedback from the participants.A total of 32 outpatients with long-lasting BPD participated in the novel treatment program (see below). All of these patients were recruited from the BPD unit at a public hospital in Spain. For the purpose of this study, “long-lasting” BPD was defined as the presence of some clinical improvement (no life-threatening behaviors or trauma-related symptoms for at least 12 months) accompanied by persistent low mood, poor psychosocial adjustment, and/or feelings of emptiness.Inclusion criteria were: adults of either sex between 18 and 65 years of age; primary diagnosis of BPD according to DSM-IV-TR criteria and the structured Diagnostic Interview for Borderlines Revised (DIB-R) ; previous participation in two DBT-ST interventions and signed informed consent. Exclusion criteria were: presence of life-threatening behaviors in the last 12 months; PTSD or related symptoms; diagnosis of drug-induced psychosis, organic brain syndrome, bipolar or psychotic disorder; intellectual disability; participation in any other psychotherapy treatment during the study. A subgroup of 20 participants participated in the qualitative study, which was conducted to assess the participants’ perception of the intervention.First, we reviewed the available literature to identify interventions designed to treat long-lasting BPD symptoms. This review showed that PP exercises and compassion strategies seem to be useful for enhancing well-being , 47, 57We developed an initial 8-week intervention designed to treat long-lasting BPD. Ten patients were assigned to a group intervention. Upon completion of the 8-week program, the participants were invited to participate in group discussions to explore their experience with the training and the particular practices offered in those sessions. Two group discussion sessions were conducted by two independent researchers, who were not involved in the treatment of patients. The information obtained during these interviews regarding the value of each specific practice was then used to improve and refine the content of the intervention. The revised treatment protocol was then offered to a second group of patients, who also participated in a group discussion after completion of the 8-week intervention. This process was repeated to develop the third and final intervention, which included only the skills/practices considered most useful by most patients. Practices that had an aversive effect  were discarded; only those practices considered useful by participants were retained.The initial intervention was based on a combination of PP and mindfulness-based frameworks . The trThe first eight-week intervention was entirely based on the WTCP program . This prTo address this high dropout rate and dissatisfaction with certain elements of the intervention, the intervention was modified based on feedback from the participants. The “My best possible self” skill was reduced to 1 year (instead of 10) and we also modified the sequence of skill presentation. In addition, during the post-intervention interviews, participants reported experiencing high levels of distress during the intervention. Consequently, we moved the presentation of self-compassion skills to session 1, and also extended training in self-compassion to four sessions. The “regulating negative emotions” model session  was repln = 10) that met the inclusion criteria were recruited from the BPD Unit to participate in this revised intervention. Upon completion of this second 8-week intervention, feedback from the participants confirmed difficulties with the “Best Possible Self” practice. Consequently, we decided to eliminate this skill in the next version of the protocol. Participants also reported difficulties with the concept of “self-compassion”, which some perceived as sorrow or self-pity. Importantly, six of the ten participants completed full intervention, a dropout rate of 40% (versus 60% in the first group). Both patients and therapists agreed that eight sessions were insufficient to introduce and train all of the content.A second group of patients , whIn addition, we detected a need for strategies to defuse cognitive barriers for self-care training. Consequently, we developed and included a new module, which we called “Cognitive Self-Care”, to address different polarities of thought. Defusion strategies played a key role in these practices. Additionally, we incorporated a practice called “Wise-Matrix”, which combines “the Matrix” from Acceptance and Commitment Therapy (ACT)  and the In this study, we used a mixed-methods approach, which consisted of a quantitative description of the participants’ characteristics and attendance rates, together with a qualitative description of the participants’ experience with the intervention obtained through group discussions led by experienced clinicians.We evaluated the opinions and experiences of the participants as a result of the process. We obtained qualitative data by means of a clinician-led discussion within the established groups. These discussions were based on a series of semi-structured questions designed to investigate the participants’ experiences around six different themes established by the research team (these themes were selected prior to conducting the group discussions) Table . First, A total of 32 outpatients participated in the group interventions. Most patients (95%) were female. The mean age (standard deviation [SD]) age was 40.3 (6.1) years . Twenty of these patients were interviewed in the post-intervention feedback groups. The educational level was as follows: university studies (56.3%), secondary studies (37.5%), and primary education (6.3%). At the evaluation, 37.5% of the sample was unemployed, 31.3% were receiving an invalidity allowance, and 25% were employed. Most patients (75%) were single. Most patients lived alone (43.8%) or with their birth family (31.3%).Six overarching themes were explored in each group discussion, as follows: 1) helpful practices, 2) unhelpful practices, 3) neutral practices, 4) barriers, 5) facilitators, and 6) effects. Later, several sub-themes were identified based on an analysis of the transcribed text of the discussions ”.A central theme was the distinction between helpful, neutral, and unhelpful practices, which was based on the participants’ experience with these different skills during training. Among the helpful practices, practicing gratitude and savoring, and mindfulness were associated with an increase in positive emotions in 15 of the 20 participants (75%), as evidenced by the following comments:“I already knew I had these characteristics, but perhaps I did not see them as strengths. There are things that people say about me that I do not believe. The questionnaire has helped me to see them as good things about myself”.Some participants  reported that completing the Strengths Questionnaire was helpful to become more aware of their strengths. The questionnaire helped raise awareness of some personal characteristics that they had not noticed before or shifted how they perceived some of these characteristics.“According to the questionnaire, some of my strengths are equanimity, honesty, and appreciation of beauty and excellence. At first, I could not believe it because I have always been in touch with the negative side. Now, I do not see myself as bad as I used to”.For some, being more aware of their strengths was also related to decreasing self-criticism:“I am so harsh on myself. Compassion practices help me notice that and decrease the number of self-judgments, which has an impact on the way I see others. I do not judge them as much either”.“For me, the best thing has been the work with self-criticism, it has helped me a lot to use the third person, to ask myself if I would speak to another person like that”.“Combining self-compassion talk with touch helps me. It didn’t help me as much to tell myself things as it would to someone else, but to put a hand on my chest and feel myself, helps. If I just tell myself I don’t believe it, then the reassuring touch helps me believe it”.In addition to identifying these personal strengths, a substantial proportion of participants  noted that practicing self-compassion and loving-kindness had a positive impact:Just realizing what is the internal world and what is the external world is what helped me the most. Understanding it, integrating it and practicing it is the most important thing. I wouldn’t have been able to stand being in this group if it hadn’t been for the matrix, because my heart is going super-fast and I can still stay here”.““The matrix has placed me in the world, it has made me more aware of what I had in my head and believed to be real. Now I can distinguish the difference between my inner world and the outside world”.“The matrix is very useful, but I have to keep working on it. When something affects me, I wonder if it is something from the outside world or from the inside world. Now I see that difference, but I still find it hard not to believe what my mind is telling me. I also am more aware of whether or not I am moving away from what matters to me. For example, with interpersonal relationships, if I am very vulnerable, I prefer to take a step back and face another day, instead of saying or doing something that is going to be bad for the relationship”.Finally, most participants  rated the “Wise-Matrix” as a useful but complex tool:“Trying to practice self-compassion was awful for me because I became aware of how much I criticize myself, not three times a day, but 20 hours a day. This made me feel like some monster, and it was unpleasant for me; it made me angry. It is tough for me to practice self-compassion".By contrast, some of the practices were considered unhelpful. For example, being more aware of particular internal processes was associated with an increase in negative affect.“I do not see the point in writing the letter. I find it difficult to survive each day, so I cannot make a plan for the next six months”.In addition, the practice of writing a letter to the future self was perceived as bitter-sweet. While some participants  considered it to be a sort of “roadmap” for the future, for most  the experience of projecting themselves into the future was unpleasant and triggered anxiety.“Some days, I am just not open to this. On those days, having to find things to be grateful for is negative. If I have a bad day, I prefer to deal with it rather than feeling forced to find good things in my life”.“When I feel “normal”, practicing is not a problem. However, when I am having a bad day, it is impossible for me to apply self-compassion. I wish I could, but I simply cannot”.In relation to internal barriers, many participants  identified “moodiness” as the primary obstacle to practicing the skills presented:“Sometimes I thought that the group leader was oversimplifying this and was being condescending. We have particular problems as a group. We deal with pervasive emotion dysregulation, and the leader must acknowledge that”.In terms of external barriers, some participants  identified the characteristics of the group leader as not being helpful. A few participants  also criticized how the content was presented, suggesting that it would be better to use a more structured presentation during the session, with a booklet to review the content at home. Most participants underscored difficulties in the use of concepts such as “happiness” and “self-compassion” during the training.“You can tell that the therapist practices these skills … and I wanted to be a little bit like him, if only just a little!”With regard to facilitators, most participants  pointed to the value of the group format, as seeing others experiencing difficult times helped to validate their own feelings. Some participants also noted that the therapist’s ability to “embody” these practices and to direct the group to prevent deflection from the session’s subject.“Five years ago, I would not have had the necessary skills to understand these. I could neither understand nor regulate my emotions. I was in a very dark place”.“Some years ago, I felt that I was living in a storm most of the time. If somebody had said to me `look at the sun`, I would not have been able to do so. I would have thought: what are you talking about? Some years ago, the content of these practices would have been impossible for me to understand”.The role of practice was also considered pivotal to integrating the concepts learned during the sessions. A high proportion  of participants highlighted the importance of having previously attended DBT-ST before being introduced to these new skills:“Now that we have finished the training, I notice that I am more kind to myself … I have to work on this a lot, but I am starting to see the effects”.Lastly, in relation to the effects of the intervention, several participants perceived a decrease in self-judgment upon completion of training:“I have learned that good things happen to me despite feeling pain, so I can feel bad about something and still appreciate good things in my life …”An increased capacity to notice small things that happened during the day was also relevant for many:“Being more self-compassionate and more in touch with positive emotions is something that has not only helped me, but it has kind of expanded to other people in my life”.“My daughter and I do not get along. She is going through adolescence, and now I am more aware of the details. I sometimes notice that she does things that make me happy”.The effects of the practices were also evident in terms of interpersonal relations, with participants finding themselves to be “less reactive,” “less judgmental,” and “more compassionate” towards others:Based on the participants’ feedback, the researchers rated each skill and strategy used in the group interventions as useful , neutral, or not useful (or adverse effects reported). Fig. This qualitative study was performed to examine the feasibility and acceptability of an add-on skills training intervention involving the combination of DBT-ST, positive psychology, and contextual-based skills. This combined intervention was implemented in a clinical setting to treat long-lasting BPD in a group of patients who had previously undergone DBT-ST. The intervention was feasible to implement in this real-world setting and participants rated the final set of skills highly. Most of the practices were considered useful.DBT-ST primarily addresses the first stage of DBT treatment, mostly focusing on reducing life-threatening behaviors and provide the emotional regulation and tolerance required in order to then shift the emphasis to trauma-related symptoms in stage 2. In this regard, strategies that facilitate the transition to stages 3 and 4 of DBT in patients with long-lasting BPD are needed, with a focus on enhancing connectedness and reducing the sense of emptiness. Positive interventions could help to promote both of these aims. A strategy designed to increase positive emotions would seem appropriate once behavioral decontrol has been overcome when further clinical improvement may come at the cost of social isolation, low mood, and generalized avoidance ;). GivenFor most participants, practicing positive skills such as gratitude, savoring, and working with personal strengths was associated with an increase in positive emotions, in line with the findings described by ). This iDespite the potential benefits of positive psychology for both nonclinical and some clinical populations , 16, theSelf-compassion exercises also triggered difficult experiences, which some patients found hard to regulate when they became aware of their self-criticism. Interestingly, this finding contradicts preliminary evidence from other studies that suggest that compassion exerts helpful effects in patients with personality disorders , 51. HowAlthough the sequence of skill presentation in DBT has not been extensively studied, future studies are needed to investigate this aspect in more detail. Elices and colleagues  found thSelf-criticism and self-invalidation  refer toIn our study, some participants described “moodiness” as an internal barrier to practice. As some participants noted, they did not always feel “open” to the practice, which suggests that a certain degree of emotion regulation may be necessary before practicing certain skills. In this context, it is worth noting that all of the participants had previously received DBT-ST before enrolling in the current study. As a result, their prior training provided them with the personal resources necessary to face distressing emotions provoked by new skills. Several internal barriers to practice were detected, making these potential targets for future studies. Indeed, defusion strategies were needed to address these barriers, mainly the “wise matrix” tool which we developed for this intervention.External barriers were mostly related to the attitude of group leaders and language-related issues. For example, the use of concepts such as “happiness” and “self-compassion” had a negative impact. Talking about “increasing happiness” evoked unrealistic expectations, which was experienced by some participants as something that “cannot be achieved”. As a result, this caused frustration and was perceived as invalidating for most of the participants. The main “facilitating” factor was the group therapy format, as it can reduce feelings of being “weird” or “alone”.This study has several limitations. First, the sample was predominantly female and Caucasian, and all participants had prior experience with DBT-ST. In addition, only the participants who had completed the full intervention took part in the post-treatment group discussions. Unfortunately, as occurs in many qualitative research studies, we were unable to explore the experiences of the participants who dropped out. In addition, due to the preliminary study design (aimed at assessing feasibility and acceptability), we did not use validated measures to assess the impact of the intervention on different domains. Similarly, we did not track home practice, and therefore, we cannot make any definitive claims about the association between adherence to practice and the effects thereof. We used a series of broad questions to elicit a wide range of responses. As a result, the participants’ statements about the intervention were spontaneously reported. We purposely did not ask about specific skills, as we assumed that skills not mentioned were neither helpful nor unhelpful. In retrospect, it might have been better to specifically ask about each skill and it would probably be beneficial in future studies to do so. Despite these limitations, the study also has several important strengths. First, the findings broaden our understanding of the feasibility and acceptability of a positive-contextual psychology skills training intervention in patients with long-lasting BPD. This study also represents an important first-step towards facilitating the transition to stages 3 and 4 of DBT, and towards developing a targeted program whose efficacy could be evaluated in future research studies. In addition, by examining the specific skills rather than the final “package”, we increased our understanding of the processes of change in psychotherapy, which is congruent with new approaches in the field such as the process-based framework .In this qualitative study, we examined the feasibility and acceptability of a novel 8-week intervention designed to treat long-lasting BPD. The intervention was feasible to implement in the clinical setting and the final set of skills was highly rated by participants, who considered most of these strategies/skills to be useful. By using the participants’ feedback to modify the intervention, we were able to substantially improve retention rates , which doubled from 40% in the first group to 80% in the final group. More research is needed to test the efficacy of this intervention to promote life fulfillment in participants with long-lasting BPD.


Animals may be included in clinical care because they are suggested to reduce patients’ anxiety and stress and increase their interaction with practitioners. In this study, we surveyed and interviewed clients and students from a university teaching clinic about the inclusion of a therapy dog in the delivery of exercise physiology services. The dog and her handler worked together as a team in the clinic for one day a week for most of a year. No other animals worked in the clinic. Services in the clinic were led by students, who were supervised by the exercise physiologist who was also the canine handler. All clients came to the clinic to engage in exercise as medicine, that is, exercise as part of disease management or for recovery from injury or illness. One person who took part in the study had not actually met the dog, so we excluded those results. Everyone else who was surveyed or interviewed considered the dog, a female black Labrador, to be a well-behaved dog, and no-one considered her to be problematic to their engagement in exercise. Including a dog in clinical exercise practice may enhance some parts of the service delivery. Therapy animals in clinical settings are purported to reduce patients’ anxiety, decrease agitated behaviour, serve as social mediators, enhance the social atmosphere, and increase patients’ openness towards practitioners. A therapy dog worked alongside her exercise physiologist handler for approximately 1 day/week in a university clinic. The canine and handler functioned as a team, while the handler simultaneously undertook supervision of students. The clinic was open 24 h/week, and no other therapeutic animal was present for any part of the week. We explored, via surveys and interviews, human responses to the dog. The survey comprised 15 statement items regarding the canine’s role, behaviour, and acceptability in the clinic, ranked from strongly disagree (−2) to strongly agree (2), followed by an open item inviting participants to follow up interviews. Eleven (11) clinical clients and seven (7) students completed the survey. One client had not encountered the canine; these data were excluded. Four (4) participants from the client sample provided subsequent telephone interviews. All participants identified the canine as well-behaved; no participants considered that she detracted from their exercise sessions. Most participants were equivocal to statements regarding social lubrication and openness to practitioners; only three clients and two students identified that they felt more willing to share health information; three students identified that they felt they could confide more in the canine than in the practitioner. Interviewees’ reports were similarly favourable, reinforcing the information obtained from the surveys. Interview transcripts were subject to thematic analysis, which focussed around four key themes: (1) the canine’s good behaviour, (2) clients giving permission, and the canine as both (3) a pleasant distraction from the effort of exercise, and (4) nice to have. A therapy dog may enhance some aspects of exercise physiology service delivery. Animal-assisted therapy (AAT) is clinical care delivered with the assistance of one or more animals . The mutAs well as in emergency medicine, general medicine, and surgical recovery, AAT is used in physical rehabilitation and talking therapies, across a wide spectrum of clinical conditions, and in a variety of clinical settings including residential aged care and hospitals .Therapy animals in clinical settings are purported to reduce patients’ anxiety, decrease agitated behaviour, serve as social mediators, enhance the social atmosphere and increase conversation, allowing patients to be more open with their healthcare providers . Dogs, tThere have been several systematic reviews of clinical trials of AAT demonstrating benefits and enhancements beyond usual care. Charry-Sanchez and colleagues conducted a systematic review of 23 trials of AAT  in adults with depression, dementia, multiple sclerosis, PTSD, stroke, spinal cord injury, and schizophrenia. Frequently identified outcomes with canine-assisted therapy included reduced loneliness, agitation, and apathy, as well as increased social engagement and enhanced mood . Jones and colleagues undertook a systematic review of canine-assisted psychotherapy in adolescents. The included studies provide some emerging evidence of improved efficacy of mental health treatments in self-selected adolescent populations through reducing primary symptoms , and secondary factors such as improved engagement, disclosure, and retention in therapy .Coakley and Mahoney undertook a cohort study of 59 haemodynamically stable, hospitalised, adult patients who received a single pet therapy visit (approximately 10 minutes duration) in addition to usual hospital care. Systolic and diastolic blood pressure, and pulse rate were marginally, non-significantly, increased after pet therapy visits, and statistically significant reductions were observed in respiratory rate and patients’ self-reports of pain, along with improvements in energy and mood states. Statistically significant improvements were reported on the tension/anxiety, anger/hostility, fatigue/inertia, and depression/dejection subscales of the Profile of Mood States (POMS), and clinically important changes were noted in tension/anxiety, fatigue/inertia, and total mood disturbance . p < 0.001), and reduced pain perception (p = 0.01), when compared with usual recovery procedures among controls  and her sister had a dog, Toby, and before she died she was allowed to take it into the care home.… And the dog sat on the bed and she had a pat of her beautiful dog…. And a neighbour here has a mother in care. And he’s got mother’s dog. All mother wants to do is see her dog. She’s not allowed. She can look at it through the window. That’s not going to help her at all. She needs to be able to touch that creature she adores.(Interviewee B)Participants reported that the canine served as a pleasurable distraction from chronic and complex disease, and the effort of clinical exercise. Participants primarily described that Bella’s presence helped them relax and relieved some of their anxiety. It’s good because you’re sitting near, you’ve got the dog there and give her a rub up… and it just takes your mind off everything and just you’re just looking at the dog and thinking about the dog and the good thing she is.(Interviewee C)She makes you happy… Relaxes you. All those things. You give her a pat. She loves it and you love it too.(Interviewee B)I think it actually took my mind off the pain of exercise… A distraction because I’d be thinking about the dog and or looking at the dog and just a sweet, calm dog. So I think anything that that gives you any motivation or any help while you’re exercising, is a good thing. Very good thing.(Interviewee A)It reminds me of when I had a dog and it just makes me remember all the fun and all the friendly you know feelings that I had when we had our own dog.(Interviewee D)Sort of calms you down when you’re feeling nervous, anxious. You see the dog wagging its tail at you and you just get you know get a real calm feeling.(Interviewee D)Participants consistently described the canine as a pleasant addition to the services of the university clinic, but not part of the core business. And if Bella isn’t there, does it affect you in any way?(Interviewee)No, not at all. It’s just nice. It’s nice to have her there.(Interviewee A)Um, well, you know, she’s not there. So a sort of, there’s a little gap there of nothing.(Interviewee C)Oh I miss her but it doesn’t affect me, it doesn’t affect me, no. I can still exercise and do what I have to do but I do look for her and think “where is she?”(Interviewee D)This study was exploratory, probing the acceptability of including a therapy dog in a new clinical setting, namely a student-led exercise physiology service within a university. Survey results from students and clinical clients showed generally favourable views towards the inclusion of a therapy dog in this service. When interviewed, clinical clients offered further insights that aligned with the responses to the survey. Bella was universally reported as a well-behaved dog (100% of survey respondents strongly agreed with this item), and described as likable with a soothing, calming presence in the clinic (“behaviour” theme). Behaviour and temperament of an animal are integral to the success or failure of AAT; a misbehaving dog may be a problem rather than an asset in a clinical setting.Our particular clinic has predominantly an older adult clientele engaged in exercise to help manage chronic non-communicable diseases. Bella shared some things in common with our clients. Bella was 10 years old, a senior dog, when she first attended the university clinic. She also had some osteoarthritis in the large joints of her hind limbs that limited her capacity for rapid movement. Although Bella may have served as a social lubricant among our client group, we acknowledge that a quiet, slow moving, older dog would not necessarily be a good fit for all types of exercise services. Our clients played ball games with Bella, and these games provided opportunities for clients to challenge themselves physically, and move in unaccustomed ways . The same ball games played with the same dog may have been unsuitable interventions if working with younger, more mobile clients who might throw a ball too far or fast for the dog to fetch—therapy dogs should be well-matched to tasks to minimise stress, miscommunication, anxiety, or disinterest in their role . We woulTherapeutic exercise requires client engagement, repetition, and, to make physiological gains, progressive increases in training demands. An ongoing challenge in clinical exercise practice is maintaining the client’s adherence to, and enthusiasm for, exercise. “Get a dog” is oft-suggested common wisdom to motivate older adults to undertake regular exercise. Curl and colleagues determined, from a large population-based study, that dog ownership per se is not related to increased physical health or positive health behaviours such as regular exercise . Rather,Many of our clients live alone, or with one other person. They may experience shrinking social and physical worlds, as their physical limitations reduce their mobility in the community, and their own longevity bites with the double-edged sword of outliving one’s friends. Some clients told us that they were no longer able to have a dog of their own, and appreciated being able to share “ownership” of Bella through the clinic. Because it is not simply owning a dog, but whether you walk the dog that contributes to your health , we wantParticipants told us that they noticed Bella’s absences from the clinic, but for the most part, asserted that her absence had no effect on their exercise behaviour (“nice to have” theme). Interviewees described Bella as a pleasant alternate focus from the difficulties of exercise or chronic disease, reducing the anxiety they can feel with clinic visits (“distraction” theme). Students unanimously reported that they liked the idea of including a dog in clinical exercise physiology services. Clients also strongly favoured this item in the survey, and reinforced this message with their comments in interviews. Participants and students told us that they looked forward to their exercise sessions because they knew that Bella would be there, and that they would recommend a clinic with a therapy dog to others. Notably, our survey respondents were largely pro-dog: the modal response among students and clients to survey item 12  was 2 (strongly agree).Our results appear consistent with a study by Reddekopp and colleagues on patients’ views on being visited by a therapy dog in the emergency department (ED) of a hospital . Most paBecause of the anonymous nature of our survey, we could not relate any participants’ responses with clinical attendance data, however, we noticed that some clients’ behaviours suggested a bond had been formed with Bella—they greeted Bella first upon arriving at the clinic, brought her gifts, and asked us about her when she was absent. Clients dropping out of exercise  is a particular challenge in exercise physiology practice. In future studies, we would like to explore whether AAT influences adherence to clinical exercise, perhaps by increasing accessibility for people unfamiliar with exercise, or by reducing dropout rates from ongoing training. Anthropomorphism—the attribution of human traits, emotions, and intentions to non-humans—has long been unpopular among animal behaviouralists , but maySocial catalysis may be both a benefit and a risk of the human–animal bond. Fine  maintainDisclosure in clinical practice needs to be met by clinician capability; that is, it is important that clinicians have capacity to meet clients’ needs, either in direct care provision, or via referral to other providers. Clinicians’ judicious use of the human–animal bond is key to AAT. Bella’s handler is an experienced clinician (25+ years) with the professional skills and network to respond to a wide range of client needs. We offer a caveat that AAT may not be suitable for novice clinicians—the early years of transition to clinical practice are typified by erratic confidence and somewhat rigid adherence to learned procedures, accompanied by some introspection . The chaAnother avenue for further study could include investigation as to whether inclusion of a dog in clinical exercise physiology service prompts changes in any physiological measures of stress . We emphasise that reduction in stress measures is not always desirable in the clinical exercise context. Although clinicians do not intend to distress clients, exercise itself can be used as a physiological stressor, and temporary elevation in heart rate or other measures may be desired outcomes. It is important to determine whether AAT could possibly hamper exercise service delivery by dampening desired physiological responses. The university clinic is both a teaching space and a healthcare delivery service. Student clinicians were supported and guided in their clinicial practice (including AAT) by the handler’s clinicial experience. Although we did not gather any qualitative reports from students as part of this study, we observed the enthusiasm with which students embraced Bella’s involvement in the clinic, the delight they showed at her arrival each week, and the diligence with which they upheld the “rules of engagement” with Bella . Further, we noticed that during exam periods, when the university campus was filled with anxious students, Bella appeared to be particularly busy, attending to many students, sitting beside them for pats and cuddles. Therapeutic animals are increasingly used in teaching spaces, with some evidence of benefits, but most studies underpinning this work have been undertaken among children, and are of variable quality. These results are not automatically transferrable to the university sector . StudiesWe acknowledge that the samples in this project are small, may be biased in favour of people who like dogs, and that the results may apply only to one canine in one clinic. We conducted survey data collection in hard copy only, which we anticipate reduced our total recruitment. We had intended to distribute surveys online to extend recruitment, however, when the clinic was closed to face-to-face consultations due to the COVID-19 pandemic, we considered that it would be somewhat “tone deaf” to engage clients and students in surveys about a clinic they were unable to attend. Further exploratory research could be undertaken to determine the ideal canine attributes for exercise physiology settings , and the effect of canines on clients’ exercise adherence, stress or anxiety during clinical exercise, and on student practitioners during clinical service provision. We recommend that any clinician interested in AAT should invest in some training for themselves and their dog prior to engaging their dog in the workplace, and comply fully with all workplace health and safety requirements. Animal-assisted interventions are possible within clinical exercise physiology. A therapy dog may enhance some aspects of exercise physiology service delivery, including serving as a social catalyst for client disclosure. A dog may be intentionally and actively engaged in the delivery of clinical exercise interventions.


Among the many lines of research that have been exploring how embodiment contributes to cognition, one focuses on how the neural substrates of language may be shared, or at least closely coupled, with those of action. This paper revisits a particular proposal that has received considerable attention—namely, that the forms of hierarchical sequencing that characterize both linguistic syntax and goal-directed action are underpinned partly by common mechanisms in left Brodmann area (BA) 44, a cortical region that is not only classically regarded as part of Broca’s area, but is also a core component of the human Mirror Neuron System. First, a recent multi-participant, multi-round debate about this proposal is summarized together with some other relevant findings. This review reveals that while the proposal is supported by a variety of theoretical arguments and empirical results, it still faces several challenges. Next, a narrower application of the proposal is discussed, specifically involving the basic word order of subject (S), object (O), and verb (V) in simple transitive clauses. Most languages are either SOV or SVO, and, building on prior work, it is argued that these strong syntactic tendencies derive from how left BA44 represents the sequential-hierarchical structure of goal-directed actions. Finally, with the aim of clarifying what it might mean for syntax and action to have “common” neural mechanisms in left BA44, two different versions of the main proposal are distinguished. Hypothesis 1 states that the very same neural mechanisms in left BA44 subserve some aspects of hierarchical sequencing for syntax and action, whereas Hypothesis 2 states that anatomically distinct but functionally parallel neural mechanisms in left BA44 subserve some aspects of hierarchical sequencing for syntax and action. Although these two hypotheses make different predictions, at this point neither one has significantly more explanatory power than the other, and further research is needed to elaborate and test them. A substantial amount of research on embodied cognition has focused on action, especially in the context of the Mirror Neuron System (MNS), which consists of bilateral parietofrontal circuits connecting regions of the intraparietal sulcus, supramarginal gyrus, precentral gyrus (including both premotor and primary motor cortices), and posterior inferior frontal gyrus [especially Brodmann area (BA) 44]. The MNS has received tremendous attention for several reasons. Not only does it appear to facilitate the perception and understanding of observed actions by mapping them onto the onlooker’s own motor repertoire  has the same nested structure as a standard jazz piece (theme {solos} modified theme) and complex everyday action sequences (open door {switch on light} close door). In each case, a superordinate sequence surrounds a nested action or sequence (in the inner parentheses).” Bringing these separate strands of work together, F&PF suggest that, at least in some non-trivial respects, linguistic syntax and goal-directed action may have parallel sequential-hierarchical structures that are represented by common neural mechanisms in left BA44. To illustrate some of the structural similarities between these two domains, The agent who called the actress was happy, the agent is the one who was happy, despite the fact that the sentence contains the sequence the actress was happy.1F&PF’s papers spurred a great deal of further discussion of the relation between syntax, action, and left BA44, starting with In a subsequent paper (1)Acceptable WH-question formation:a.Bill believes that Susan ate a cricket.b.What does Bill believe that Susan ate?(2)Unacceptable WH-question formation:a.Bill believes the rumor that Susan ate a cricket.b.*What does Bill believe the rumor that Susan ate?1 “Setting aside various technicalities, what matters here is that according to the version of generative syntactic theory that In a follow-up paper The men who he saw were tall as an example and makes two points about it: first, the embedded clause who he saw can only occur in a certain position; and second, in the main clause The men…..were tall a syntactic dependency involving plural number agreement obtains between the noun and the verb. Shifting to action, he takes an example from The men….were tall. Based on such considerations, he concludes that “the idea of a ‘syntax of actions’ remains a metaphor if compared with the syntax of any human language” , a very different biphasic response—specifically, an early left anterior negativity (ELAN) followed by a P600—is typically triggered by a violation of syntactic structure  studies. In neurolinguistics it is well-established that while an N400 is typically triggered by a violation of semantic content  than to both intransitive verbs like swim (which has an agent S) and transitive verbs like build (which has an agent S and a patient O).Due to the “subject salience” principle, which reflects the temporal and causal precedence of the agent over the patient in the prototypical transitive action scenario, clauses in which S precedes O should be more computationally tractable for left BA44 than clauses in which O precedes S. In my previous papers I cited several PET and fMRI studies that confirm this prediction, since they found greater left BA44 responses to O-initial than S-initial constructions. More recently, similar results emerged from a meta-analysis of 22 experiments that involved diverse languages , but also when both the V and the O differed . 3Turning to a different development, recent fMRI work suggests that during the comprehension of transitive clauses, left BA44 is modulated not only by the order of S and O, but also by whether the designated event involves a physical action or some other state of affairs. The available data, however, are mixed, and their interpretation is not clear. On the one hand, in two separate studies A closely related issue that also deserves more attention involves the proper predictions regarding left BA44. Given that this region has been implicated in representing the sequential-hierarchical structure of goal-directed actions, the most natural prediction seems to be that it should respond more strongly to sentences that describe such actions than to sentences that describe other states of affairs, as Another development relates to the question of how left BA44 processes transitive clauses in those rare languages for which the basic word order involves placing O before S. Almost nothing is known about how the mind/brain handles such languages, but a few hints come from recent work on Kaqchikel, an endangered Mayan language spoken in Guatemala . First, As mentioned in the Introduction, humans have a propensity to impose nested tree structures—which is to say, hierarchical patterns—on strings of data in multiple domains of experience, including not only language and action, but also music, mathematics, and other kinds of auditory and visuospatial stimuli. These phylogenetic discoveries provide a useful perspective for thinking about how left BA44 evolved to promote the distinctively human predilection for hierarchical sequencing, particularly in the two domains that are the focus of this paper—namely, linguistic syntax and goal-directed action—but in other domains too. With specific regard to syntax and action, we have concentrated on the proposal that some of their sequential-hierarchical structures are subserved by common neural mechanisms in left BA44. However, as mentioned in the Introduction, and as the previous two sections reveal, the literature on this topic is not always clear about what “common” really means in this context. With the aim of helping to move this field forward, two separate hypotheses are outlined below.Building on Lashley’s (1951) seminal ideas, This formulation of Hypothesis 1 may be a more precise way of capturing , p.357 vAn alternative approach is elaborated by This view is supported by A considerable amount of theoretical and empirical work has recently focused on the complex relation between linguistic syntax, goal-directed action, and left BA44. As this review has shown, a number of intriguing ideas about these functional-anatomical links have been developed, and new insights have come from many studies employing diverse brain mapping methods. However, this topic remains contentious, and further research is needed to not only address the many unresolved issues described here, but also elucidate how both the similarities and the differences between syntax and action extend beyond left BA44 to many other cortical and subcortical structures.The author confirms being the sole contributor of this work and has approved it for publication.


To describe the professional practice experiences of fifth year nursing students during the COVID-19 pandemic.Qualitative research design with content analysis. Participant sampling was purposive. 13 fifth-year nursing students participated. All of them completed their professional clinical practice in public hospitals and private clinics who cared for COVID-19 patients in Chile. The data were obtained through guided online written self-reflections.  Three main themes were inductively identified: (1) Facing with a very difficult and stressful situation, due to the permanent use of personal protection elements, multiple emotions, and physical fatigue, as well as facing ethical-clinical dilemmas in daily tasks; (2) Recognising different coping styles in difficult moments, highlighting contact with significant people and combination form of support and harmful ways of coping with stress; and (3) Experiences disciplinary learning and personal growth, such as: nursing care management, interpersonal skills in times of crisis and having contributed to the country in this adverse context.  The clinical experience of the students in times of COVID-19, was an opportunity to learn how to perform nursing care in times of crisis, humanize care and support health teams in some of the country's hospitals. A new global virus called SARS-CoV-2 emerged in the Chinese city of Wuhan in December 2019, it was called COVID-19 by the World Health Organisation.5Both pandemics presented a threat for the development of emotional disorders such as stress and anxiety in the healthcare corps from the risk of infecting their families, stigma and post-traumatic stress.During curricular practice, nursing students develop personal confidence and strengthen professional competencies.Design. A qualitative study design with content analysisn=25) doing professional clinical practice in 2 public hospitals and 2 private clinics in Chile, who cared for COVID-19 patients, between the months of March and August 2020 were invited. The study included 13 students, 11 women and 2 men, who voluntarily accepted to participate. Their ages ranged between 22 and 28 years, with average age being 23.4 years. 72% lived with their families, 83% were religious and 2% agnostic, and all were single. The students were invited via email by the secretary of the school of nursing, who is a person external to this study, for diminishing possible conflicts of interest. Subsequently, a videoconference was done to divulge the aim and purpose of this study by the researchers.Setting and participants. The study was done in a university in Chile, with nursing students, who obtain their degree after 5 years of training. In their last year they complete 540 hours of clinical practice, for 16 weeks. Participant sampling was purposive. All nursing students  How has been your experience completing your professional practice during COVID-19 pandemic?, (2) What has meant for you to do your professional practice providing care to COVID patients?, (3) What has been your experience of preserving human dignity during your clinical practice? How have you dealt with it in your personal and professional life?, (4) What and/or who has helped you in difficult moments you have experienced during practice? How has the help been?, (5) How has your learning experience been from the perspective of nursing management, focused specially on patient in Pandemic framework?, (6) How have you worked communication with patients and their families in COVID-19 times?, and (7) What has your experience of writing and self-reflection been like? Written self-reflections provided an opportunity to know students’ thoughts, feelings, emotions, and experiences during their professional practice. It also allowed them to freely express themselves without judgment, as a benefit for the participants. The researchers of the study are female nursing school professors and only they had access to the data collection. All the researchers have clinical and theoretical teaching experience with nursing students. The first two researchers have worked with qualitative methodology before. All of them have a master's degree. Each student was asked to use a pseudonym to protect their anonymity. Reflections were protected with a password and were later erased. The process ended when the meaning saturation criterion was fulfilledData analysis. Qualitative content analysis was done according to the guidelines of Graneheim & Lundman.Credibility was manifested by presenting the results to participants, who recognised themselves in the experience (member checking). The trustworthiness criterion was achieved by detailing the methodology and analysis of the study (audit trail). To guarantee confirmability, the entire study process was recorded, giving evidence of participants’ and researchers’ testimony by writing their personal reflections in a field notebook during the study. Finally, to facilitate transferability the participants’ characteristics and the study scenario were described in detail. Rigor. Methodological rigour was assured via the criteria of Lincoln and Guba.Ethical Considerations. This study was approved by the scientific ethics committee of a chilean University. Number of certificates: CEC202043. All study participants previously signed an informed consent release, ensuring their voluntariness, information confidentiality and data anonymisation. Three main themes emerged from the analysis of the written self-reflections describing what this experience meant: (1) facing a highly difficult and stressful situation, (2) having significant support to face difficult moments, (3) learning experience and professional and personal growth. .Coronavirus cases in Chile and their spread weren’t traceable anymore. That’s where the anxiety started and the fear of entering a clinical setting (E1). Taking the bus and the underground wearing mask and gloves was the weirdest thing I’d done: When I got to the Clinic I changed my uniform and clothes three times a day…when I got home, I did it again... (E2).As the academic year begun in March 2020, the final year nursing students started their professional practice at the same time the COVID 19 pandemic was confirmed worldwide and nationwide. This situation generated changes or worsens the conditions for clinical practice: various hygiene measures with several clothing changes when entering the clinical setting and returning home, changes in the working hours and fear of infecting their families: My clinical practice become a daily challenge of body, mind and soul…Every day it’s heavier and harder to think…how heavy your legs are, how your hands burn from so much washing, your face hurts from using the mask and the suffocation you get from using it, plus all the aprons and the facial shield (E5).COVID-19 caused the mandatory use of personal protection elements (PPE), posing a challenge for nursing students in their professional practice; extensive workdays led to physical and psychological irritation. However, these measures granted greater security: Physically it’s got really exhausting, since we’ve had to do 24 hour shifts from the first day… talking about the situation with my family generates more chaos, stress, angst and worry (E5); There’s physical and emotional exhaustion within the team… The different protocols and changes we’d face every day made me feel constant angst (E6); It’s meant facing my own fears. It was a hard process I never thought I’d go through... (E3).For nursing students, professional practice turned out to be a great challenge involving physical exhaustion and various feelings and emotions: sleeplessness, uncertainty, stress, anxiety, fear, angst, and sadness over their families’ distance: …I think this pandemic dehumanised care, since it’s so protocolised and you always try to go into the patient’s room the least number of times…forcing you to provide colder and more distant care than we’re used to (E8); …I’ve thought about omitting some care, so I can progress with my work and finish on time… (E12). The dignity of the person was perceived from different perspectives, recognizing its intrinsic value in a particularly vulnerable period. Dignity is when you make them feel like a person again and you don't treat them like a disease...it is through human interaction that you reach and reinforce that dignity (E6). However, there were times when this was compromised: Patients are treated as mere diseases (E7); Some nurses or technicians are in such a hurry that patient care is not kind or personal (E10).Students’ experience involved facing difficult situations related to ethical aspects of patient care, including dehumanisation around dignity in care, facing dying alone, and unequal resource distribution. There were times when they omitted activities that were not a priority, to optimize care times, which was perceived as a form of dehumanization of care, taking distance from the patient, and not delivering comprehensive nursing care: We’ve tried to let the family see them for at least 10 minutes, from a distance with PPE. But I think it’s not enough. How are you going to say goodbye to someone who was important to your life in 10 minutes? That’s the other side of COVID… Then they’re wrapped in the shroud and then in a sort of plastic bag, they’re sealed and then put in the freezer (E9); I feel a deep sorrow in those people who cannot experience a dignified death, being surrounded by a hostile, oppressive, distant and mechanized environment. This is how I would describe the environment that exists in critical patient wards (E4). Finally, another highly relevant ethical dilemma described by some participants was the way of assigning and using resources among the elderly, generating questions about inequity affecting the principle of justice, where the age of the patient was perceived as an indicator for making decisions: I’ve felt that doctors try to hurry up some older patients’ deaths… they lower their oxygen to free up the negative pressure room for other patients that’re younger and more critical (E10); Patient’s dignity is violated when we don’t have the means necessary to care for everyone equally… we can’t appropriately care for our population, since we have to choose who we treat and who we won’t (E4).For some students was the first encounter with death. It was difficult considering patient’s loneliness and isolation from the loved ones, and not receiving end-of-life care based on human dignity. Some students were irritated and angry because the right of the patient and their family to die with company was violated: …Right now I’m getting a lot of support and care from all of my family, friends, teachers, boyfriend, etc. which makes me feel like I’m not alone in this process (E13); I was lucky enough to have an excellent nurse to guide and mentor me who’s supported me unconditionally, as well as a really great teacher, understanding and kind (E7).Students in professional practice had different significant people to better face all the difficult moments previously described. They highlighted support from family, friends, hospital teams, partners going through similar experiences, guiding teachers and instructors: Students described in detail the different forms of support to decrease distress, anxiety and improve sleep, such as: phone calls, letters, patients' words of thanks, the teacher answering her phone after hours, faith, yoga, and natural medicine: My family has been an absolute pillar, in long phone calls, since distance separates us (E3); Patients are very thankful for how we’ve listened to them. That makes me want to carry on, keep going and receiving that affection that is so reassuring, so that, at least for a few hours, all your fears get left aside (E2); The one who’s helped me most in every tough moment, is Jesus… he helps me to find deep meaning at every shift. I personally always have a precious cross in my pocket and every time I’m going through a rough patch, I squeeze it really hard, so I don’t feel alone (E10). They also manifested detrimental ways of coping, behaviour that was subsequently modified: I hit the bottle a lot of times too, one glass as a nightcap to calm the nerves, the anxiety and the angst that would come over me suddenly, or some strong pill to get to sleep. Now I’ve dropped the earlier doses and concentrated on yoga, having more contact with my friends and natural medicine (E5).…I’m not talking about putting up a screen, I’m talking about something deeper, interpersonal relations and communication where we can know each other… finding out new needs, giving integral care when I can know the patient, talk about their family, laugh, know their worries, help them. I feel like it was a job well done (E6). Entering the room all covered being unable to show a smile, an expression, is tough. Hearing some people saying there’s nothing else to be done, makes me angry and sad…we can always do something else (E11); …A patient was really depressed and started to desaturate…she didn’t know how to use the videocalls…I showed her, and she could talk to her kids and grandkids… it changed her mood 100% and her saturation rose (E10).Over time, students caring for patients with COVID19 recognized that care was not only clinical but realized how important it is to provide holistic and humanized care. They identified the emotional and spiritual dimensions through the pain, loneliness, and fear of the patients: It’s hard to organise times and manage patients’ care in an integral fashion… but if the nurse won’t do it nobody will. The spiritual and psychological side strongly influence their recovery (E10); For me, doing this clinical experience has meant re-encountering Nursing (E13).For the discipline, learning is described on the base of clinical management, action and decisiveness, leadership, teamwork, learning from the professional and acting ethically with care prioritisation, fortifying, or accelerating the encounter with the essence of care: It’s an experience that taught me a lot, helped me grow and increase my ability to adapt, my empathy and my teamwork (E6); It’s true that we’re learning to manage the stress and frustration of situations like what we’re going through, which we probably wouldn’t learn in practice under normal conditions (E13). Furthermore, students indicated that self-reflection let them put their thoughts in order and express in writing their experiences: It’s helped me (the self-reflection) to get my head together about what I think and feel, to hear my feelings, to reflect on how I want to be a nurse tomorrow regarding patient treatment…writing reminded me of various scenes that made me explode, which I find good because that way I could express it and release it (E10).Students on practice referred not only having learned from the perspective of the discipline, but also from a personal growth experience, reflected in adaptation, empathy, flexibility, stress management and frustration: At the end of the day I’ve got the chance to make history…I was together with my future colleagues helping my country (E11): We all know that what we’re doing is just a drop in the ocean. But if it wasn’t there, the ocean would lack something (E6).Finally, in the middle of this adverse context there are thanks, achievements, and satisfaction from students for the opportunity to do their clinical experience reflected in elements such as being part of the team, being on the front line, feeling lucky, being happy giving care, contributing and learning in an unrepeatable context: The objective of this study was to describe the experience of students doing their professional practice in units with patients with COVID-19. Students acknowledged that curricular practice in a pandemic context entailed difficulties and might not have been the most favourable stage for their professional training, coinciding with Peres.21Additionally, students’ self-reflections show that they require more tools for deliberating and decision-making regarding complex ethical and clinical situations25Within the results of this study, faith is described as a form of help in coping with complex moments. This has not been reported in other studies. On the other hand, coinciding with some accounts from the students in this study, a 2021 report on health professionals in Chile revealed an increase in the consumption of alcohol and sedatives during the pandemic.From the perspective of professional learning, a major challenge in this pandemic is humanising care when facing with the depersonalisation of treatment. This requires nurses who are “partners in human transactions” and can be humanitarian and ethical agents.This study has several limitations. This research was done with nursing students, in the intra-hospital setting in Santiago, so generalization could be limited. Students’ experiences in primary care are unknown, as are the experiences of other healthcare students. Most of the participants were women. The researchers were also teachers supervising some of the students on practice, which may have conditioned the students’ self-reflections to be less critical in their discourse. However, their data confidentiality and anonymity were assured.In conclusion, this study allows us to understand more deeply the students' experience in performing their professional practice during the COVID-19 pandemic. Despite the difficulties, the students recognized the importance of the support received and the provision of humanized care, such as: body language, conscious eye, and physical contact, even without dialogue, establishing itself as an element of relief and a relationship of trust between the patient and the nursing student. The accounts of the students in our study express methods of care oriented to prioritize close treatment, valuing the role of nursing as an integral discipline.A Brazilian study whose objective was to reflect on the work experienced by nurses in dealing with the COVID-19 pandemic in a public hospital indicated that despite the various barriers: emotional commitment, fear of contagion, lack of human resources and personal protection elements, the nurses were able to practice with satisfaction and leadership, contributing to the improvement of public health.Relevance to clinical practice. This study provides relevant information on what could help improve the teaching/learning process for students and thus have a positive impact on the quality of care for patients and their families. Nursing schools should develop a strategic plan to support students' needs and strengthen coping tools in future health crisis situations. The results of this study reinforce the need to address mental health with active self-care strategies for students and health professionals especially in times of crisis.


Workplace and environmental exposures pose health risks for racial/ethnic minorities in rural agricultural communities, placing them at a disadvantage in accessing needed health care. Over three fourths (76%) of the 2.4 million farmworkers in the United States are immigrants, mostly from Mexico. However, little is known of the community health concerns and barriers to care of Latinx farmworkers in inland southern California. This qualitative study used a community-based participatory research approach, conducting nine in-home meetings to obtain meaningful community input on health concerns and barriers to access healthcare services among rural residents of the Eastern Coachella Valley, who are also located near the desert-bound Salton Sea of inland southern California. All interviews were audio-recorded and analyzed via listening to the audio recordings and summarizing data in templates and matrices. Participants discussed health concerns related to agricultural labor, including heat-related illness, musculoskeletal ailments and injuries, skin disorders, respiratory illness, and trauma. Participants raised concerns about environmental exposures related to agriculture and the nearby Salton Sea, a highly saline lakebed, and proposed solutions to improve the health of their communities. The findings from this study suggest farmworkers are aware of the health risks posed by living and working in rural farmlands but lack resources and information to act upon and advocate for improved public health. US agricultural production has doubled since the beginning of agribusiness in the 1950s, with a decline in family-run farms and US-hired farm workers and an increase in the employment of contract-based foreign laborers. Over three fourths (76%) of the 2.4 million farmworkers in the US are immigrants, most of whom are from Mexico and authorized to work in the US (NAWS 2015–2016)  the lungs, allergies, because there, well at work, lots and lots of soil blows, and that’s what gives lots of allergies or headaches.”“Bronchitis, because that’s what you get now with those winds that come with all the dust and you start with chest pain and it’s bronchitis.”“The [people] who are near the lake, the smells and that water…. There’s a lot of colds, allergies, sinusitis, asthma…. Supposedly, it gives asthma to children, it’s infected many with asthma…. In their noses, it [the Sea] smells awful.”Some participants, aware of the poor air quality, inquired about the validity of the link between the Salton Sea and disease, suggesting they lacked information on the health-related risks associated with the Salton Sea.“I have a question, regarding the diseases of the [Salton Sea], how true is it that the [Salton Sea] produces … like right now that you can feel that the air is the kind that can damage the lungs of the children, how true is that?”In all in-home meetings participants discussed the effects of extreme heat conditions, long work hours, bending and lifting, excessive consumption of caffeine, little water consumption, and pesticide exposure on chronic health conditions and psychological and emotional distress. They were aware that their status as immigrants (documented or undocumented) exposed them to these negative labor conditions:a gabacho [White person] all pricked? Or scratching and scratching? They aren’t like us [immigrants], working ourselves to death out in the field. On our knees.”“When have you seen [Americans] working their tail off, in this blazing heat, getting sunburnt, with thorns? I work in the date [farm], I am all pricked, all blistered. When do you see They also noted some health conditions were directly connected to workplace negligence and their inability to ask for better work conditions. Participants raised concerns about employers failing to provide cool water and workplace training on heat-related illness. Participants said the water provided was often hot due to the high temperatures outdoors. Having to work under extreme heat without appropriate hydration, they explained, put farmworkers at risk for heat exhaustion and other heat-related illness—topics about which they lacked information. Participants also stated farmworkers are afraid to speak up to superiors about workplace conditions.“Because of the [high] temperatures, you can get heat exhaustion, but you don’t inform [a supervisor]. You can deal with it because they’re going to fire you or because you need work. But you must speak up… And they don’t give you information. They only give you a workplace training one time, but you need to be informed.”Chronic health conditions. Participants extensively discussed the impact agricultural labor has on their physical health, ranging from headaches to hearing loss from noisy machinery to musculoskeletal conditions , back and sciatic nerve pain from heavy lifting, deviated discs, muscle sprains, and fractures. They also discussed skin conditions related to workplace exposures . Although the consensus was that working long hours in the heat and under the sun’s rays was a major contributor to chronic health conditions, participants agreed that exposure to dust, soil, pesticides and chemicals used on the fields either caused or exacerbated these skin conditions and contributed to the respiratory and vision problems they and their families experienced .Participants were also aware of the threat posed by pesticides and chemicals—so much so, they believed pregnant women should not work in the field. Autism, ADHD, learning disabilities, developmental or genetic disorders, Down Syndrome, and birth defects were discussed as conditions linked to chemical exposure.“I think that many children are born that way with mental delays, possibly because the dad used drugs, or the mom, or because of the chemicals, or because of what they spray here over the plants and field. Because I’ve seen a lot of kids here who have mental delays.”“The ones who are pregnant, the chemicals they spray on the vegetables and all, that’s why they come out sick, the kids, the babies. They are [born] sick, too, because of that. The pesticides.”The attendees also mentioned kidney disease, prostate cancer, and other deaths in their communities they attributed to pesticide and chemical exposure.“There are many people that suffer from the chemicals. We have a family member who died from that. He breathed in too many chemicals and died. Intoxication of chemicals. And that’s [also] a cause of prostate cancer.”Stress and trauma of labor conditions. In addition to chronic physical health conditions, farmworkers also experienced stress and trauma connected to their work conditions. Participants connected physical exhaustion from work with mental exhaustion. Working mothers stated insomnia and/or lack of sleep due to waking up at dawn to go to work and having long hours of physical labor, in addition to household chores and duties, which caused stress and worsened physical ailments. One participant shared how they lived with trauma and jitteriness after having accidentally run over a coworker with machinery.“To be honest, I do suffer a bit from nervousness… I think that maybe I did end up traumatized. Like scared. [My employer] told me to go see a psychologist so that I could receive therapy, but I felt fine. But, like, sometimes I don’t know, I just jump. I’ll be sleeping, and suddenly I jump.”Participants acknowledged the importance of treating mental health in a timely manner to prevent suicide. They believed depression and high stress levels could lead to physical illness, heart attacks and strokes, but that such mental illnesses went undiagnosed or untreated. Some expressed frustration: they wanted to share their mental health struggles but feared the result of seeking care, either due to being immigrants and/or being identified as a threat to oneself or others:“I, [have depression], because I lost a daughter… It’s just that here, when a person is depressed, it’s a threat because they’re supposedly suicidal, they are going to kill themselves or harm someone, but it’s not like that; if it’s treated in time, it’s not like that… Many people, because they’re in this country, I’m referring to Latinos, we don’t go to a doctor. We [can’t] say, ‘Oh, yes, I feel depressed, I cry a lot, I feel a void, I feel very lonely…’ because then they tell you, ‘Have you tried to commit suicide? Who have you hurt?’ And it’s not like that. I don’t want to kill myself; I am just sad.”Seeking psychological help is not common practice in immigrant Latinx communities, especially among men, but the additional burden of losing time at work to travel to distant sources to obtain mental health care made it inconvenient. Others, who were not uninsured, could not afford to seek psychological care. However, access and cost were not the only limiting factors. At all in-home meetings, participants wanted health information, including on mental health, and they shared the importance of training doctors on the signs of mental illness. Participants suggested mental health surveys were needed to better identify psychological conditions.Coping with labor conditions. Others talked about the physical pain of their labor conditions and common practices used to deal with such pain. Use of pain medications, including codeine and prescription painkillers, is a widespread practice in these communities. Because the majority of immigrants in the ECV are uninsured, self-medicating  and sharing medications is commonplace, as is obtaining medications from Mexicali, Mexico where doctor’s visits and medications are more affordable and sometimes of better quality.“There are many people medicated or self-medicated… It’s like a bit of an irony that mom and dad are against [teens using drugs], but they are also really drugged at the workplace.”Some participants were unaware of self-medication with pain killers in the workplace, until they experienced it first-hand. For instance, one participant shared:“One day I had a headache and, I asked the supervisor, ‘Do you have any pills for headaches?’ and she told me ‘No, but I have, here have some of this.’ And she gave me one [opioid], and boy did they have me high. She bought them in Mexicali. I felt like a drug addict, like I was flying. They’re the ones they call opioids, but she said they were the prescribed kind and that’s why she’d get them from Mexicali. They don’t sell them here unless you have a prescription. That’s why she gets them there.”Other participants said they gave their painkillers and prescription medications to co-workers. They stated many in their community do not have access to treatment options and medications due to cost, no local pharmacy, and the lack of health insurance coverage.Participants also discussed drinking multiple caffeinated beverages  and mixing painkillers with energy drinks as a common practice used to stay alert and meet work demands. Although some participants were aware of the consequences of energy drinks , they stated that the need to make a living and keep their jobs was more important than the possible negative health effects. One participant commented: “You can’t work if you don’t drink Monster.”This fear of losing their jobs creates a situation where many farmworkers stay quiet when it comes to unsafe workplace conditions and injuries. Participants spoke of times when they noticed health risk factors in the workplace , but did not voice their concern out of fear of being fired and thereby losing the ability to provide for their families. Similarly, many do not report workplace injuries out of fear, representative of their lack of information regarding their rights as farmworkers.In response to the harmful environmental exposures and noxious air, participants stated a need for community involvement, improved sewage systems, and increased pest control, as well as clear information on the environmental health hazards of the ECV and Salton Sea.As an example, participants said they had been informed via the public radio about a recent outbreak of mosquito-borne disease in a neighboring community and suggested aerial insecticide spraying might help, but also accepted that, given they live in close proximity to the fields and work in them, exposure to mosquitoes was inevitable.“There are many mosquitos here, and more so here because you know there are a lot of puddles… A lot of water is thrown below the plants, they need water to grow, and that is where mosquitos breed, and a lot of mosquitos.”Participants understood that their respiratory illnesses were a chronic and growing problem related to their work and environment, and also that they could better manage their health with the right tools. One participant suggested local classes, similar to diabetic health coach-led classes, on respiratory illness would be helpful.“…And also to take a class on what is bronchitis. I think there are classes on breathing [problems], because there are breathing classes for people who have that problem.”In addition to respiratory illness, local health-coach led classes free to the public could inform ECV residents of other health-related topics . Ideally, a variety of classes would be open to the community to improve health quality. Arts and crafts classes for adults and youth could help relieve stress and promote mental wellbeing. In addition to constructing outdoor recreational options , air-conditioned gyms could provide farmworkers and their families the option to pursue recreational activities in a comfortable and safe environment. This, coupled with an instructor to show people living with chronic health conditions or work-related injuries how to appropriately exercise and eat well, could prove even more effective than medications, participants said. They also stated their belief that local health workshops and group discussions could foster a sense among community residents and farmworkers that one’s health should be a priority.At every in-home meeting, participants brought up their need for more health-related information. Although a few participants were uncertain about commenting on community health conditions because they knew little about medical topics, many made accurate associations between cholesterol and heart disease, HPV and cervical cancer, and sun exposure and skin cancer, etc. Participants acknowledged the relationship between their lack of information and a lack of confidence to act upon their health: they either did not seek treatment for a health concern or failed to do so before it turned into a chronic illness or fatal disease.“You can also get cancer from being in the sun. In the skin, you get [cancer], but [cancer] can later be in the blood. When a person has leukemia and you work in the field, they don’t know they have leukemia. You get [cancer]—but most people don’t know when they have leukemia. They just say, ‘Oh I think I have that,’ but they don’t go get checked… Also, many people don’t know what cancer is, because there are many forms of cancer you can have. I’ve seen it on TV.”Participants asked which illnesses they needed to be aware of and their causes, symptoms, treatment, and prevention. Were they to have the right information, they would use it to not only better their own health, but also that of their families.“Anemia … one doesn’t know what anemia is, sometimes one doesn’t know. They don’t inform us. [People] just say, ‘Oh, my kid got anemia,’ but [they] are not informed… But when one doesn’t know, one doesn’t take heed. That’s why more information is so important.”With the information in hand, they stated the stigma associated with having an illness or visiting a doctor could be minimized; the shame of being identified as ill, overcome; and the fear of losing their jobs, dissipated.“… Many people who are injured at work do not speak up, so long as they don’t get fired. Because you don’t have information, you have to obtain information regarding injuries: that you have rights to speak up over why you feel sick and that they should pay for the days that you didn’t work. But no, we go to work saying, ‘No, they will fire me’. But no, you have to have the right information.”Across all discussions, participants discussed the need for structural neighborhood and workplace changes as essential for the improvement of their communities’ health. Participants wanted improved road and sidewalk security ; expanded bus stops and routes for those without a vehicle to drive to medical appointments; recreational parks where children and adults could relieve stress and stay healthy; neighborhood daycare centers to care for children while they attended their medical appointments, and a greater availability of supermarkets . Some participants suggested acquiring signatures to advocate for the much-needed changes. One participant expressed the need for an advocate, especially when it came to addressing workplace conditions.With restrictions to employment including language barriers, immigration status, and limited formal education, many Latinx immigrants seek labor in agriculture. These farmworkers reside in some of the most remote locations in the US. where farmlands abound and labor under unforgiving conditions to meet production demands and feed their families. Their labor makes substantial contributions to both international food security and the U.S. economy. However, their labor comes at a cost. Participants in our study identified health concerns and illnesses linked to agricultural labor as well as the local environment.Our findings on work-related illnesses, physical injury, musculoskeletal and skin disease, respiratory problems, and mental illness, echo the work of others ,47,48,49Such working conditions require farmworkers, supervisors, and employers to practice and promote workplace safety not only for on-the-job risk reduction but also to reduce the effects of chemical exposure for family and community. For the participants in our study, reducing exposure to chemicals was difficult either because they had little to no training or had no way to remove themselves from chemical exposure. For instance, with limited transportation and employment options, most of our participants resided near or within farmlands and were continuously exposed to pesticides. While agricultural workers are required to take pesticide training as they are mandated by the US Environmental Protection Agency through the Worker Protection Standard, national data suggest only slightly more than half (57%) of farmworkers report having received pesticide training (NAWS 2015–2016).In addition to concerns around pesticide exposure, participants discussed an increase in respiratory illnesses among adults and children. Proximity to the Salton Sea, a desiccating body of water that has been used to drain agricultural runoff from the nearby farmlands creating a toxic body of water, was commonly indicated as a contributing factor. Many participants expressed concern about the Sea’s smells, its toxic dust, and the harm it causes to human health, especially chronic child health conditions . Apprehensions about the Salton Sea and its effect on community health match the research community’s understanding of the release of the Sea’s toxicities in the form of water and dust, the latter of which is carried into homes and community spaces through windstorms . This toStudy findings offer important insight into perceptions of common health concerns among Latinx farm working communities in the ECV, as well as barriers to accessing healthcare services and public health information. Yet, several limitations should be considered when interpreting the findings. First, study participant characteristics are similar to those of the general population characteristics of communities that border the northern part of the Salton Sea but also differ in important ways . AccordiFurthermore, it was difficult to recruit men for our study and children between the ages of 0 to 18 were not included in the in-home meetings. Thus, the results more so reflect the experiences and perspectives of adult women  in farm working communities. Last, the original study, which was exploratory and intended to elicit community health concerns did not set out to focus on workplace health or environmental health hazards. However, during the analysis workplace health, specifically in the context of agricultural labor, and the health effects of the Salton Sea both emerged as important themes and were further developed.promotoras in reducing barriers to healthcare access [promotoras—the latter of whom play a critical role in healthcare delivery as local physicians and medical facilities are scarce [Despite these limitations, this work laid the foundation for subsequent research and healthcare service delivery by creating a baseline understanding of community health needs. The main findings, published in Migration and Health, informed a policy brief published in English and Spanish that served as the basis for several lines of research including child health specifically childhood asthma and childhood obesity, as well as adult obesity and diabetes prevention, and mental health . We havee access . Furthere scarce .US agricultural production demands place a heavy burden on Latinx immigrant farmworkers shaping their health and often decisions about their living conditions. Farmworkers often live in isolated regions with limited local resources, including healthcare facilities to address the detrimental effects of their living and work environments on personal and family health. Often without health insurance, access to medical facilities, sick pay, transportation, and/or fluency in the English language, rural Latinx farmworkers are at a greater disadvantage than others when it comes to health care access. The US depends on Latinx immigrant human labor to meet the demands of agricultural production. The health of these workers and their families should be a national priority. While farm labor is inherently a risky job, risk-reduction efforts via timely, legally mandated workplace health hazard training, as well as public health information about the effects of local environments on health outcomes, are crucial to reducing chronic health conditions among families and children in Latinx farm working communities. Furthermore, national associations that survey farm working populations such as the National Agricultural Worker Survey should consider assessing not only workplace hazards but also environmental hazards on the health of farm working communities.