For data collection, we used the Questionnaire of socio-demographic, life style and work and health aspects as well as the Work Ability Index, Workplace violence questionnaire, questions about intention to leave and the Turnover Intention Scale. The predictors of intentions to leave were evaluated through Poisson regression models.workplace violence increased and better satisfaction with current job decreased the probability of greater intention to leave the unit, institution and profession. Better work ability decreased the probability of greater intention to leave the unit and profession. The more qualified workers and those who had been working in the institution longer was more likely to greater intention to leave the profession.promoting job satisfaction, work ability and a violence-free environment is possible to decrease the workers’ intention to leave the job or profession, but nursing managers need to understand the three phenomena of intention to quit individually for retention strategies. These factors constitute the real nursing shortage, and there are authors who highlight the possibility of a pseudo-shortage, in which the number of nursing workers is sufficient, but they are not willing to work under the conditions offered by some health organizations.The shortage of nursing workers is a global phenomenon and source of concern for several countries currently. The aging of the general population and of the nursing workforce coupled with the increase in demand for health care, decrease in interest for the nursing career and the desire of young nurses to leave their profession are some of the contributing factors resulting in the current shortage of nursing professionals-8. Thizations,9., this is because nursing is responsible for most of the care provided on health services. Studies indicate that the inadequate number of nurses can contribute to negative outcomes, such as patient mortality, infection and adverse events. In addition, the reduction of nursing staff makes the remaining workers responsible for caring for a higher number of patients, increasing the workload and stress of the remaining workers and contributing to job dissatisfaction and burnout.However, the nursing workers shortage is a challenge for health systems with regard to the ability to care for people, standards of care quality provided and overall health reach,-12, tservices. Studieevents,-14. Inout,,-16.. As the factors are different among countries, it is relevant to analyze them within national contexts to support specific action plans.For these reasons, the nursing workers retention is a particularly important issue for the health system, and initially requires an understanding of the factors that are associated with workers’ intention to leave their job and profession in each country. As theon plans.. Besides, estimates indicate that for each 100 young people there will be 153 elderly people in 2040 in Brazil, which requires health system preparation. Nevertheless, the number of studies on the maintenance of a sufficient and specialized nursing workforce for health care, in order to avoid the lack of nursing workers in this country, is still restricted. These factors led us to carry out this study to identify the factors related to the nursing workers’ intention to leave the work unit, health institution and profession. The present study is one among the few studies that evaluated these three intentions to leave among Brazilian nursing workers.In Latin America, which includes Brazil, studies on nursing workers recruitment and retention are included in nursing research priorities. Besideparation. Nevert. In addition, there is usually prolonged waiting time due to increased workload and high demands(-). Emergency nursing workers are likely to situations that can lead to physical and mental exhaustion (e.g. workplace violence), besides contributing to the experienced nursing workers’ intention to leave their job or health institution(-). The Research Ethics Board of our university approved this study (CAAE number: 41225814.4.0000.5404).This is a cross-sectional study with quantitative approach carried out with 267 nursing workers who worked in seven emergency units in three public health institutions in Brazil, with two institutions in the countryside of São Paulo state, and one in the countryside of Santa Catarina state. The work in emergency units includes caring for patients in complex conditions often unexpected and contact with anxious family members. In add demands-20. Etitution-22. TThe participants were nurses, nursing technicians and assistants who are professional categories that integrate the nursing team in Brazil, and had been working in the units for at least three months, considering the importance of a work period for professional experience in the emergency unit and contact with their characteristics. We used a probabilistic sampling scheme that included stratification per work unit and professional categories, besides random sample of workers. According to the attributions of each professional within the nursing team, we defined two categories for the sampling scheme: (i) registered nurses and (ii) nursing technicians and assistants.For sample calculation, we inserted an equal p proportion 0.50, significance level 5% and error 5%, which generated a minimum sample size of 201 nursing workers. We exceeded this minimum sample and collected data from 267 workers, ensuring a response rate of 63.7%. In order to ensure equivalence and strictly maintain the sampling scheme criteria, the number of participants that exceeded the minimum sample size was defined considering an additional proportion equivalent to the three health institutions. Finally, we distributed this number according to the amount of workers in each work unit and professional category. The workers which were not working  did not participate in this study.The data collection was carried out from 2015 to 2017. The workers were individually approached in their work units by the first author. Information about the research was provide and we invited them to participate voluntarily and anonymously. A consent form registered the workers’ agreement to participate of the study. The forms were returned to the researcher on the same invitation date, while the researcher remained in the unit to support or answer doubts, or at another agreed time between the parties. In this situation, the researcher returned to the unit in order to collect the forms.. This questionnaire was developed in Brazil and it has been used in different researches in occupational health area for two decades, including studies involving nursing workers. The QSETS allowed variables collection such as: (i) socio-demographic variables - sex, age, marital status, having children and education level; (ii) lifestyle and life aspects variables - physical activity practice, satisfaction with current life, stress, tiredness and/or dismay after work, good sleep after work and number of leisure activities; (iii) health conditions - compared health and health problem in the last 15 days; and (iv) job-related features - professional category, time working in the work unit and health institution, age of first job and satisfaction with current job.For general data collection on the sample profile, we used the Questionnaire of socio-demographic, life style and work and health aspects (QSETS). This q workers. The QSrent job.We used the Turnover Intention Scale (EIR) to evaluate the worker’ intention to leave the health institution. This is a scale developed and validated in Brazil, which allows the worker to express to what extent he or she plans, thinks and desires to leave the institution. The response options ranged from one (never) to five points  and an average score was generated. The score classification ranged from high or medium intention (3 to 5 points) to low intention (1 to 2.9 points). For both intentions, we classified the scores into two categories: unintentional or low intention - score up to five points; and greater intention - score higher than five points.Two questions evaluated the nursing workers’ intention to leave the work unit and profession. The questions were: (i) Do you intend to quit working at the current emergency unit? (ii) Do you have intend to leave your profession? The workers responded in a response option scale with two extremes, zero (no intention) and ten (strong intention). For bo. This index is originally Finnish and it was validated for use in Brazil. The score ranges from seven to 49 points and indicates a better work ability as it increases.For work ability evaluation, we applied the Work Ability Index (WAI). This in Brazil. The scncreases.. Five specialists in measures validation, workplace violence and nursing practice evaluated the questionnaire. We considered victims of workplace violence who suffered at least one of three types of violence. In the same way, this criterion defined witnesses of workplace violence. In addition, these three types of violence supported the classification into analysis categories: not suffered, suffered one type, suffered two or all three types of violence, and had not witnessed, witnessed one type, witnessed two or all three types of workplace violence.A questionnaire organized from previous measures and literature accessed the experience of workplace violence in the last 12 months, specifically three types of workplace violence: verbal abuse, sexual harassment and physical violence. Five sionnaire. We con®, version 20.0) and Statistical Analysis System . First, we analyzed the intention to leave the work unit, health institution and profession using descriptive statistics. Secondly, the chi-square test or Fisher’s exact test allowed us to analyze the existence of statistically significant associations between the intentions to leave and other categorical variables. The Mann-Whitney test and Kruskal-Wallis test evaluated differences between groups of intentions to leave regarding to numerical variables. The data did not adhere to the normal distribution from the Kolmogorov-Smirnov test and Shapiro-Wilk test, which supported the use of non-parametric tests. Finally, the analysis variables that resulted in p-value less than 0.20 were inserted as independent variables in the Poisson regression model corresponding to each intention to leave(-). The independent variables insertion occurred in groups of similar variables . The models structure respected steps and we inserted one variables group in each step. The variables with statistical significance in the current analysis step remained in the model for analysis in the next step. The variables sex, age and workplace adjusted the three models. We have always considered as significance level a p-value lower than 0.05.For data analysis, we used the Statistical Analysis for the Social Sciences , ranging from 21 to 68 years. The average time working at the emergency unit was 5.5 years (SD 5.7) and 7.9 years (SD 7.4) at the health institution.With respect to the nursing workers’ intention to leave the work unit the average was 2.9 (SD 3.4), ranging from zero to ten. 24.1% of workers expressed greater intention to leave the work unit. In Besides the satisfaction with current job, we found workplace violence and work ability as predictors of nursing workers’ intention to leave the unit. The self-reported victims of workplace violence were more likely to want to leave the unit than non-victims. For each point increased in the work ability score (better work ability), the probability of greater intention to leave decreased 7% .On the other hand, we found that 80.2% of nursing workers had low intention to leave the institution and 19.8% medium or high intention. The satisfaction with current job and workplace violence were also predictors of nursing workers’ intention to leave the institution, in both steps. The workers who were satisfied or very satisfied with their current job, neither satisfied/nor dissatisfied, were less likely to medium or high intention to leave than the group dissatisfied or little satisfied. In the self-reported victims of workplace violence, we identified greater probability of medium or high intention to leave the institution than non-victims. The probability of medium or high intention to leave the institution was 215% higher among victims of one type of workplace violence and 241% higher among workers who suffered two types or more, having as the reference group the non-victims . In thisThe intention to leave the profession was on average 2.2 (SD 3.4), ranging from zero to ten, and 17.3% of workers had greater intention to leave the profession. The satisfaction with current job, educational level, work ability and time working at the institution were independent variables related to intention to leave the profession in the two steps of the model. Data revealed that workers neither satisfied nor dissatisfied with current job were less likely to report greater intention to leave the profession than the dissatisfied or little satisfied group. The probability of greater intention to leave was even lower among satisfied or very satisfied workers with their current job, considering the same reference group. The probability of greater intention to leave the profession was higher among undergraduate and graduate workers in relation to the group up to technical level, and for each additional point in the work ability score, the probability of greater intention to leave decreased 5%. Moreover, for each additional point in the duration of work at the institution, the probability of greater intention to leave increased 8% .Another predictor of nursing workers’ intention to leave the profession was the number of types of workplace violence suffered during the last year. The probability of greater intention to leave was 105% higher in the victims of two types or more of violence than among non-victims .. In this way, we considered this recommendation and the need to expand studies on the nursing workers’ intention to leave the job and profession in Brazil to develop this research, as well as the importance of contextual recognition for future design of actions focused on workers’ retention and quality care promotion(-).In the literature, it is evident the importance of knowing the nursing workers’ intention to leave the unit, institution or profession and the factors that lead workers to want to leave the work and nursing,-31. Iresearch, as welromotion-34.. This fact suggests that promoting job satisfaction may be a possibility to decrease intention to leave and improve retention rates. On the other hand, as this concept often involves more than one factor, to promote workers’ intention to remain working in the unit, institution or profession it will be necessary in some cases to know basis factors that lead to different levels of job satisfaction and which consequently contribute to the intention to leave.The results of the present study indicated that satisfaction with current job is a factor related with intention to leave the unit, institution and profession in Brazil. Other studies show similar results, highlighting the influence of job satisfaction on the worker’s intention to leave the job, position and field-,-,-37. T-,-,-37. Oto leave.. The more qualified workers can represent a significant loss for the institutions, health system and nursing care. In addition, researchers revealed the relationship between nurse’s education and the probability of patients dying, indicating that an increase equal to 10% of nurses with bachelor in nursing decrease the patient deaths by 9%. In this way, it is evident that education is one factor that can contribute to obtain better results in patient care(-).We found that nursing workers with higher qualification levels were more likely to express greater intention to leave the profession, agreeing with an integrative literature review on nurses’ intention to leave the profession. The mohs by 9%. In thient care-14.. The current study presented the workplace violence as a predictor of the three forms of intention to leave analyzed. We found that the probability of medium or high intention to leave the institution increased as the number of types of violence suffered was greater, but this result was not common for the intention to leave the unit, for example. We used a variable that represents the types of violence suffered and not the impact and number of times suffered, which may be behind this result. At any rate, studies developed in several countries, such as England, China and Ghana, also identified correlations between workplace violence and workers’ intention to leave the institution and profession. The results obtained coupled with previous researches suggest that promoting work conditions, good interpersonal relationships, safety and support of supervisors are strategies that can contribute to improve the retention of nursing workers.Furthermore, authors consider the elements of the work environment as special in the studies about the workers’ intention to leave,38. Ts result. At anysion,-,40. T workers,41.. This recommendation has support in the literature that confirms the influence of low work ability on the increase of intention to leave the unit, job and profession(-). In this context, strategies aimed at building good interpersonal relationships are important because they can neutralize the impact of low work ability on the intention to leave. The maintenance of work ability could also contribute to the retention of more experienced nursing workers who have a significant role for teaching, care and nursing management as a result of structured knowledge during their career. However, the most experienced workers at the institution were more likely to have greater intention to leave the profession in our study. It is evident that managers need to provide attention to all these details and find alternatives for action while the workers have the intention, but have not yet definitely opted for leaving the institution and later, the nursing profession.In the same way, the present study suggests that managers need to assess and promote the work ability in order to keep workers at the unit and profession. This rofession-42. Ito leave. The mar career,41. Hsion,,-44.. Secondly, we seek to ensure the use of questionnaires with known psychometric properties, but this was not possible in all cases. On the other hand, experts evaluated the questionnaire on workplace violence during the face validity process and the socio-demographic data questionnaire integrates several studies within occupational health area over the years. In Brazil, the low availability of validated measures to assess workplace violence is a challenge for researchers of this theme. Thirdly, we defined the sample size in order to estimate the proportion of workplace violence, considering the central axis of our study and the existence of more than one outcome. Another study limitation is the evaluation of the previous events of workplace violence, which demanded the recall of participants. In these cases there is the possibility of memory bias, but the authors recognize that events are better remembered when marked by negative experiences or related to risk factors (e.g. workplace violence), and when participants are asked to provide details about it.This study has limitations. First, the cross-sectional study characteristics do not allow for the establishment of causal relationships, although they indicate the influence of certain variables on the outcomes of interest. Secondis theme. Thirdlabout it.This research has implications for health organizations and new studies. We recognize the relevance of studies on the nursing workers’ intention to leave the unit, institution and profession in Brazil, besides the identification of the strength of each factor in the intention to leave within specific groups such as professional categories and people in different phases of their career and life. The retention factors among younger workers and people working for more time may be different, and both groups are important for the performance of the health institution and system to work collectively.In this context, it is interesting to highlight that not all workers who suffered workplace violence expressed intention to leave. Our theory proposes that the worker’s intention to leave and their effective departure, when not motivated by good new opportunities, is be related to the existence of a balance or imbalance in other domains . The studies on life and professionals trajectories can be important in this sense and they need to articulate the career and life phases, as well as the individual and collective support network.The permanence of workers when they are determined to leave the unit, institution or profession is another element that requires attention in terms of worker’s health, professional-patient/professional interaction and nursing care. The fact of working in an unwanted environment can be a highly negative experience for the worker’s health particularly when the regulation of emotions is fragile. In this way, to study the nursing workers’ intention to leave the unit, institution and profession is important in order to monitor the dynamics of intentions and subsequently act in advance to avoid crises in the Brazilian nursing workforce and in other countries.From this study, we conclude that workplace violence and satisfaction with current job are important factors for nursing workers’ retention because they predicted the three forms of intention to leave. Better work ability also decreased the probability of greater intention to leave the unit as well as the profession. In this way, we identified that some factors are common among the intention to leave the unit, institution and profession, but there are elements that relate only to one of these three forms. The results suggest that promoting job satisfaction, work ability and a safe environment in relation to workplace violence, it is possible to decrease the workers’ intention to leave the job or profession, but nursing managers need to understand the three phenomena individually to propose nursing workforce retention strategies according to the institution’s objectives or health system.


The focus of medical schools in developing countries is on fulfilling a quantity of faculty members. A faculty development model will help formulate programmes that accommodate faculty members’ needs as well as institutional demands. This study aims to formulate a faculty development model relevant for medical schools in developing countries, specifically Indonesia.This is a qualitative study with a phenomenological approach. It starts with a literature review using large databases, followed by interviews with 10 representative experts from medical schools in Indonesia.Based on the 10 studies retrieved, several components of faculty development were identified as the basis for the model. Ten experts gave input for the model. Components of the model can be grouped into: (i) content, which is materials that need to be delivered; (ii) process components, which depict aspects related to the preparation, execution and evaluation of sustainable faculty development; and (iii) components in the educational system that affect faculty development implementation.A comprehensive review and development process has likely made this faculty development model suitable for medical schools in Indonesia. Breaking the model into components may help medical schools to prioritise certain aspects related to faculty development programmes. A faculty is the most important resource in a higher education institution because improvement of educational quality is mostly influenced by the quality of the faculty. In other words, one factor that could improve the quality of a higher education institution is the systematic implementation of a faculty development programme . FacultyThe faculty development model is a management system for a comprehensive development programme that includes self-development (attitude), instructional development (process) and organisational development (structure) . The facThe design of a faculty development model depends on the context in which the model will be used. One of the problems in faculty development in developing countries, especially in Southeast Asia, is the different learning culture of medical schools compared to those in Western countries . These dA ‘developing country’ is a term generally used to define a country with a low level of welfare. Indonesia is a developing country in Southeast Asia. The low per capita income of Indonesian citizens affects the higher education faculty hiring process. Sometimes the effort to recruit faculty members is only aimed at filling the number of vacancies without considering the competency of those members . This ceIndonesia has 83 medical schools with various accreditation levels . The natThis study used a qualitative method with a phenomenological approach. This approach is appropriate to explore the essence of stakeholders’ experiences in faculty development, so that a better understanding of these phenomena in our context can be obtained . Data coThe review was conducted systematically to identify faculty development models that currently exist in the literature, especially in medical schools. The steps for the literature review were as follows: (i) formulate the search strategy, (ii) identify relevant studies, (iii) analyse the data and (iv) report the results.The search process was conducted using two large databases, PubMed and ERIC and applying three sets of combined keywords: (i) faculty development/faculty training/staff development, (ii) medical education/medical school/higher education and (iii) model/framework/programmes. The search focused on English-language journals published in the last 10 years.Inclusion criteria in this study were research articles using primary data with various empirical elements; research articles focused on faculty development in medical schools, higher education or other health profession educational setting; and accessible full-text versions. The exclusion criteria were research articles written in languages other than English and no access to the full-text version of the article.The primary researcher (RA) read all titles of the articles collected and eliminated articles with similar titles and unrelated subjects. Then, RA filtered the articles based on information in the abstract. The full text of the remaining articles was reviewed by RA and a co-researcher (DS) to obtain the final articles that fulfilled the inclusion criteria. Data analysis started with reduction, including summarising, selecting and focusing on important matters and removing unnecessary information, then applying codes to certain aspects. Data were extracted from selected articles using Steinert’s framework . The resThe in-depth interviews involved experts in faculty development from several medical schools in Indonesia. The criteria for selecting medical schools were regional representation, type of institution (public or private) and the school’s level of accreditation. Experts interviewed were medical education experts with either a formal master’s degrees in medical education or a doctoral degree in medical education in progress, along with work experience as a faculty member for at least five years.Interview questions were developed based on the literature on faculty development and the initial concept of the faculty development model based on the literature review results. Each interview was recorded and lasted around 60 min. Afterwards, an interview report was prepared for the interview subject’s approval of the contents. The results were transcribed verbatim and analysed using thematic analysis , 15.This study obtained ethical clearance from the university’s Medical and Health Research Ethics Committee. Participation in this research was voluntary, and participants provided their written consent prior to the interview.The search process resulted in 9,180 titles from two databases. Following the application of inclusion and exclusion criteria , 10 artiMost articles described the definition and objectives of a faculty development programme. Four articles specifically discussed a faculty development programme with specific contexts, such as programmes in higher education, programmes for clinical faculty members and programmes for faculty members of medical schools in general , 17, 18.Eight studies implied an extended definition of faculty development that was not only developing teaching skills but also personal and professional skills as a teacher, clinician, researcher and administrator relevant to the vision and mission of the institution. Most studies stated that to prepare comprehensive and effective faculty development, a needs analysis is required, for example, in relation to teaching clinical skills, the latest teaching and assessing methods , technolApproaches and types of faculty development activities can be divided into three categories: (i) independent learning, which was conducted in nearly 50% of the whole faculty development activities, especially in improving pedagogic skills , 23, 25;Topics related to pedagogic competencies, such as teaching skills, were still the main choice in faculty development, especially those related to current student generation, class preparation, large class teaching, counseling and communications , 21, 22.Two studies specifically explored the approaches used in evaluating faculty development activities. One was through participants’ satisfaction surveys, and the other was based on performance changes as described by evaluation reports and interviews of fellow faculty and students , 25.Based on the findings from the literature review, we developed a faculty development model consisting of components such as instructional, organisational, leadership and professional development influenced by medical schools’ trends, policies, characteristics and student generation. This model was then subjected to expert review.A panel of 10 faculty development experts from medical schools in Indonesia, with characteristics as presented in The interviews resulted in four main themes with several subthemes . The theThe results of the interviews showed that institutions have a significant role in implementing faculty development programmes. Some respondents stated that the implementation of faculty development is varied, influenced by the level of institutional awareness regarding the need for such development.Its [faculty development] implementation is now varied and individual, [and] depends on each institution and the level of awareness of the institution on the importance of faculty development. (T1)Respondents agreed that needs analysis is the main step in preparing faculty development programmes in Indonesia. Needs analysis is conducted to identify the needs of the faculty based on an evaluation of teaching practices and feedback from students or fellow teachers.Based on the needs of the faculty, we design our planning programmes… we also routinely evaluate the implementation of modules…, collect feedback from the students to identify their learning needs, as well as get feedback from the lecturers to find out their needs; [and] what materials need to be given to them. (T7)Respondents added that, so far, most of the implementation of faculty development programmes is still based on situational needs. One of the hurdles is the funding factor, which often makes faculty development programmes less than optimal.Proposals for such activities [faculty development] are still facing funding-related problems, such as …limited budgets and [there] are other activities that are more prioritised. (T5)Although a faculty development programme may be supported by an institution, it will not produce expected results if the participants are not motivated to be involved. The respondents described the low motivation of the faculty as one of the problems of faculty development implementation in Indonesia.So, it seems like… the policy already exists, the leaders or heads of the departments have supported the programme, but the awareness of the faculty is low so it feels like they do not really need it. (T2)Regarding the implementation of a faculty development model, respondents agreed that a large generation gap between students and teachers poses its own challenges in model implementation, especially in implementing technology-related concepts in the teaching process. Resistance to new concepts, although considered a normal response when something new is introduced, should also be identified and properly overcome. Another challenge in implementing the model is the difficulty of clinical faculty members to manage time between clinical practices, teaching and personal development.Respondents also stated that local culture will affect how teachers interact with each other, and this will shape the institutional culture.Here, the bonds between teachers are strongly felt, maybe because we are all Minangnese. This way, we will especially pay attention to junior lecturers or new juniors, to a degree, when they bring new information. Junior lecturers will not hesitate to share their knowledge. Maybe it is one of the advantages of the culture here. In Java, especially in big cities, it is dominated by individualism, so it may affect the culture, in my opinion. (T6)During the interview process, the respondents were shown the proposed faculty development model in order to obtain their responses regarding it. According to the experts, the faculty development model is expected to describe the skills needed by teachers to develop their skills, not only in teaching but also skills in their areas of expertise. A faculty development programme is also expected to contribute to the attainment of the vision and mission of the institution.The respondents proposed an ideal faculty development model that consists of three main components—content, process and system—that influence the implementation of a faculty development programme. Each component is further broken down, and Combining the findings from the literature review and in-depth interviews, a final model of faculty development was formulated . The conThe model was first developed based on the findings from the literature review and further refined through interviews with faculty development experts. Results from in-depth interviews strengthened the proposed model because the interviews involved representative experts from various medical schools in Indonesia. The process of formulating a model consisting of these two stages has a distinct advantage compared to other faculty development models that used only one stage of development , 28, 29.This study produced three main components in a faculty development model: content, process and system. These three components have made this model more comprehensive and ideal to be practiced in medical schools in developing countries, particularly Indonesia. The distinctive characteristics of this faculty development model are within the process and system components. Content-wise, almost no new faculty development materials arose from the expert review, except for spiritual development. The process and system components in this model have considered and accommodated the challenges and difficulties in developing countries. For example, the staging of a faculty development programme may help an institution set priority programmes based on limited funding and available teaching experts. The acknowledgement of the expert availability component in the faculty development model enables expert and resource sharing among medical schools in the region.The content component covers all materials required in faculty development programmes in which instructional development skills are still the most significant domain , 18, 21.Respondents in this study agree that the inclusion of spirituality in the faculty development model will benefit both students and faculty members by having regular spirituality-related discussions among faculty members or routine sermons/preaching to encourage spiritual development. In a religion-based institution, spiritual development is important in a faculty development programme . MoreoveThe process component includes all aspects that influence implementation of the faculty development programme, from needs analysis to evaluation at the end of the programme, in all stages of the programme. The staging of a faculty development programme should consider aspects such as teaching experiences, teaching context and career path. Student generation and trends in medical education are also important topics to be discussed in the faculty development programme, especially to help teachers determine appropriate teaching approaches and content delivered to students , 24.The system component, which highly correlates with the educational system of each institution, also plays an important role. Leadership is one aspect of the system, and it concerns how far leaders prioritise the faculty development programme and their understanding and commitment to faculty development . InstituThe development and increased use of technology in medical education is inevitable , includiAnother finding in this study is the conflicting schedule and commitment of faculty members, which may hinder them from engaging in faculty development programmes. Therefore, early socialisation and implementation of this model is expected to benefit both medical schools and teachers. The balance between consistency and flexibility is important to make faculty development programmes accessible for all teachers, to encourage participation of all stakeholders and to maintain the quality and quantity of the planned programme .Existing faculty development models originated from Western contexts, so there is a need to have a model that will suit the characteristics of medical schools in different contexts. As previously discussed, the improvement of educational quality is mostly affected by the quality of the institution’s faculty members . The expAccording to Kim et al. , in mostThe researchers acknowledge the limitation of the literature review, which may have missed models developed in languages other than English. However, a triangulation through in-depth interviews with representative experts has enabled the incorporation of different points of view.This faculty development model is produced through the comprehensive process of a literature review and expert interviews, which have made this model ideal and suitable for medical schools in Indonesia and other developing countries that share similar situations. This model, which consists of content, process and system components, is expected to assist medical schools in preparing a more comprehensive and sustainable faculty development programme that will lead to improved educational practices.


To partner with and understand the health of Somali Bantu refugee women, small group sessions were designed and conducted using a community-based collaborative action research (CBCAR) approach. Health topics identified by this community were presented in 42 sessions with eleven women. Follow-up individual interviews with the women were used to ask questions about health experiences and plan for future health education. The objective of this qualitative study was to provide refugee women with knowledge to help them adjust to new health challenges in the United States, and to share personal narratives in a safe environment.The process of sharing health information with the women resulted in a collaborative exchange of culture and community. Individual interviews allowed women to voice their opinions outside of the influence of their community elders. CBCAR is an effective tool to involve refugee communities, and other populations small in number, in addressing their unique health challenges. Results from this study demonstrated that small group sessions and a CBCAR approach can be effective in sharing knowledge within small communities of refugee women. Findings from the study will assist in the future planning of health education programs for refugee women and their families in this community. Educational interventions for refugee families are essential for health literacy –3, especEngaging community members as collaborators has been effective in planning interventions with refugee communities , 8–10. CHealth educational content was formulated through consultation and partnership with the Somali Bantu community and the refugee resettlement agency working with this community in the Kansas City metropolitan area. Forty-two small-group sessions, of approximately 90 min each, were held four times weekly for 12 months. Sessions were guided by session leaders who were trained in health education, and familiar with the cultural norms and unique needs of Somali Bantu refugee women. The study participants included eleven Somali Bantu refugee women who attended an existing refugee resettlement agency program  was used to determine correlations between two variables to determine if retention was predictive of topic frequency. The written interview transcripts and notes were reviewed by the first and second author and interpreter, and corrected to assure accuracy. The transcripts and notes were read again independently, and codes were assigned using CBCAR to guide the deductive development of codes for qualitative analysis of thematic content. To assure accurate coding of the data, the authors and the interpreter also discussed and confirmed agreement for the identified recurring patterns and emerging themes. The corrected, typed transcripts and notes were entered into NVIVO 10.0  to classify, sort and analyze the data.The refugee women spent an average of 8.5 years in refugee camps. The average age of the women was 29.3 years. The women had an average of four children each. Of the 48 total children, six were born prior to living in the refugee camps, 39 were born in the refugee camps, and three were born in the United States. The marital status of the women included married (72.7%), divorced (18.2%) and widowed (9.1%).“We were hungry a lot of the time.”“Some days we waited a long time for food.”“We had plenty of food when we lived on our farms.”The most frequently presented topic was nutrition based on requested interest of the women Table . The womNutrition was also discussed in terms of food preparation, healthy and non-healthy foods, and why certain foods are good for prenatal health. During this study, six women were pregnant, and all women indicated that they had breast-fed their children. Therefore, four sessions were dedicated to nutrition during pregnancy and breast-feeding.Diabetes and obesity were discussed during one and two sessions, respectively. The women indicated that they thought diabetes only occurred during pregnancy. When the women were shown soda beverages, alcoholic beverages, and potato chips together in a picture and asked which items were unhealthy, they indicated only the alcohol. The women indicated that they thought healthy babies were “not skinny”. During some sessions, the women prepared ethnic dishes to share, which were observed to be high in oil, salt, and carbohydrate content. In addition, the women reported their physical activity and daily exercise were decreased.“American doctors always want to cut and look inside.”“My husband does not like the doctor to look inside.”Reproductive health, including reproduction, contraception, and childbirth, was discussed during two sessions. When asked about prenatal visits, inducing labor, and caesarean surgery, the women expressed fear and reluctance. Some comments included:“We had no doctor.”“I was hit and beaten.”“They came and attacked me.”Post-traumatic stress disorder (PTSD) because of living in refugee camps and trauma was concerning to the community. The three session leaders had worked with refugee populations previously, two session leaders were culturally representative, and discussed PTSD in terms of “feeling sad.” The women indicated that they did not suffer from any symptoms described. This was contrasted with their previous descriptions of hardships in refugee camps, including difficulties with health care and suffering from violent physical attacks:During the interviews, a questionnaire was used to collected qualitative data about health behaviors and knowledge, and the women were asked about what they remembered from the sessions. Of the topics presented, nutrition was the topic most retained, and was remembered by 63.6% of the women Table . Ten of Retention of the topics was compared to the number of times the topic was presented. The topic that had the highest rate of retention, nutrition, was the topic presented the greatest number of times. Analysis using the Pearson co-efficient showed a strong positive correlation between the number of times a topic was presented and the number of women that retained the topic . A positive, but not significant, correlation was found between the number of women attending sessions and the number of women that retained the topic .Satisfaction with access to health care was discussed. The women communicated ease related to going to the doctor or hospital, and reported being satisfied with how health professionals behaved towards them. The possession of a medical card was specifically mentioned by four women. They indicated that transportation to the doctor was easier in the United States than in Africa. The availability of interpreters was also expressed to be adequate, with seven women indicating that an interpreter was always provided.The coded data were analyzed according to CBCAR dimensions of partnership, dialog, pattern recognition, dialog on meaning of pattern, insight into action, and reflecting on evolving pattern.This qualitative study used CBCAR to guide and provide a pathway to explore, share and understand personal health narratives . The sixPartnership: the development of community and trust over the extended time period of the study was essential to building relationships. The ethnicity and gender of session leaders and interpreters was a relevant finding. During the program, it was learned that the women viewed an unmarried interpreter as unacceptable for discussions of pregnancy. To address this, a female, married interpreter was used for all the interviews to be culturally consistent and better ensure the women would feel comfortable. In addition, the primary author was viewed as marginally acceptable at the beginning of this program, although married, as she did not have any children.Dialog and pattern recognition: the sessions attended by the women and the research team were intentionally designed to share personal stories and to have open dialog. This sense of privacy was enhanced in the individual interviews. The interviews allowed the women to express their individual opinion in private, separate to those expressed during the sessions. In sessions, the women generally did not express individual opinions, but rather expressed a community opinion. From continued interaction, it became clear that the women respected a cultural hierarchy, in which one older woman was looked to for guidance. The women who did not follow the guidance of the elder woman were not blood relatives or relatives by marriage. It is likely that the women followed the opinion of the female authority figure during the sessions, but in the individual interviews expressed their own opinions. This allowed for a greater understanding and exploration of shared experiences that both participants and research team had as women, daughters, wives and mothers.The final stages of CBCAR illustrate the actions that transform and impact community health .Dialog on meaning of pattern: to understand the influences of life experiences on health, shared discussions allowed for a deeper mutual appreciation of all participants and authors for each other’s lives, which facilitated success of this project.Insight into action: to identify a path forward, recognition of community concerns and knowledge gaps will allow for better planning for future sessions with this community.Reflection on evolving pattern: to evaluate programmatic success, and consider new understandings within the community, the research team and women reflected on the outcomes and future directions. The formation of a meaningful relationship was communicated by the participant community as the most important study outcome and success.The results of this qualitative study hold promise for further research and implications of future educational programs and action planning with these Somali Bantu refugee women , 11. To The small sample size and non-randomized design of this qualitative study limit the generalizability of the findings for other refugee populations. The authors also recognize the limited external validity of this study, and the need for future studies with a larger sample size. Partnering with populations small in number is challenging, however, it is important to better understand the health knowledge and attitudes of this and other small populations , 17. Fut


Consumers have become increasingly demanding about the quality of the meat they eat; they want healthy, natural, and palatable products, but are also concerned about animal welfare during production, transport, and slaughter. The way we handle animals does not only affect animal welfare, but also the quality of the meat produced. In this study the main factors affecting the welfare of lambs for slaughter in Chile are reviewed and the implications on meat quality shown. Factors like long distance transport due to difficult geographical reasons, bad roads, and lack of adequate local slaughterhouses appear to have a major impact on the welfare of lambs and also in reducing the quantity and quality of meat produced. Some deficiencies in terms of the handling of the lambs by untrained stockmen and drivers appear, and also inadequate infrastructure for transport in terms of vehicles and loading/unloading ramps. The problems observed are common for other South American countries and should be addressed firstly by educating and training all people involved in the lamb meat chain regarding animal welfare. In Chile there is legislation, ongoing since 2013, regarding the protection of animals during production, transport, and slaughter, including compulsory training of the people involved, which should improve animal welfare and meat quality.Consumers have become increasingly demanding about the quality of products of animal origin, particularly regarding animal welfare during production, transport, and slaughter. The aim of the present study was to review the factors affecting the welfare of lambs for slaughter in Chile and show the implications on meat quality. Rounding up and driving the lambs from the fields in large extensive production systems and long distance transport through difficult geographical routes affect the blood variable indicators of stress and reduces muscle glycogen reserves, increasing the risk of high pH of meat. In small farmer sheep production conditions there is a lack of appropriate installations for loading/unloading and deficiencies in vehicle structure specific for lambs; this together with the work of untrained handlers results in a high percentage of mortality and bruised carcasses, compared to European studies. These problems are common for other South American countries and should be addressed firstly by educating and training all the people involved in the lamb meat chain regarding animal welfare. In Chile there is legislation, ongoing since 2013, regarding the protection of animals during production, transport, and slaughter, including compulsory training of animal handlers and livestock transporters, which should improve animal welfare and meat quality. Festuca gracillima in the form of tussocks). The rest of the sheep are kept in the central-southern part of the country, mainly in flocks of 50 to 500 ewes owned by small farmers; they are from the Suffolk, Hampshire, and Texel breeds, are also kept on pasture (ryegrasses and legumes) but are usually collected in pens at night to protect them from predators.Chile has a population of 3,938,119 sheep [Although the sheep population is small compared to China, Australia, and New Zealand, Chile has some comparative advantages in terms of the sanitary condition of livestock and potential insertion in international markets. Chilean sheep meat exports have demonstrated a great variability over-time regarding volume of product and countries of destination. Forty percent of Chilean sheep meat exports are sent to Europe , reaching 6047 tons of frozen products in 2013 [Consumers have become increasingly demanding that products of animal origin are not only healthy, natural, and palatable, but also result from animals that are produced, transported, and slaughtered in a humane way . AccordiThe aim of the present study was to review the factors affecting the welfare of lambs for slaughter in Chile and show the implications on meat quality. This review is based on a series of studies, mostly concerning commercial transport, undertaken by the authors in collaboration with under- and postgraduate thesis students between 2005 and 2018. The results have been disseminated at conferences, but very few have been published in scientific journals.Animal transportation is an important and necessary process in sheep meat production systems. It includes several stages, starting with rounding up or gathering of animals on farms, driving them to the corrals or pens close to loading ramps, loading them onto vehicles, transporting them to the slaughterhouse, unloading them, and then driving them to lairage pens and to slaughter. It is important to handle animals carefully, considering the welfare of the animals throughout the chain of events .The whole process could be repeated several times if animals go through livestock markets for commercialization, instead of being sent directly from farm to slaughter. Gallo and Tadich  showed tAlthough in sheep the effects of poor transport and handling on the quality of the meat produced does not seem as evident as in cattle and pigs , geograpSelling lambs for slaughter starts by rounding them up from the grazing fields and driving them into corrals (pens); then they are weaned and, immediately afterwards, loaded onto a vehicle. In the extensive production conditions of the Chilean Patagonia, it is common that lambs are driven with their dams for several kilometers, coming from distant fields in groups of thousands of sheep at the same time. This requires the aid of people on horseback and trained dogs a,b. BasiBrito  and TapiIn the central-southern region of Chile, where farms are smaller and the distances the lambs have to be driven are shorter, although lambs are also weaned just before loading, the concentrations of the same variables are lower ,14. RegaIn order to handle the lambs correctly during rounding up and driving, it is important to have trained handlers and dogs, the driving aids should be used correctly in order to avoid unnecessary stress and injury to the animals. Mera  describeIt was often observed that some driving aids were not used correctly: hitting animals with driving aids or more commonly, grabbing lambs from different parts of the body (like ears and legs), and pulling them from the wool. This will stress and hurt the lambs and probably produce painful bruises, hence affecting animal welfare and meat quality . SimilarThe Chilean regulations for the protection of animals cover livestock in industrial production systems , livestoLoading of animals onto a transport vehicle is one of the most stressful procedures and a critical point within the general transport process ,25. In oRegarding the unloading of lambs at slaughterhouses, the same aspects for loading should be considered. Special care should be taken when unloading vehicles of two or three floors. Most slaughterhouses, where unloading of lambs was observed, had mobile metallic ramps  with rubIn order to improve animal welfare and lamb meat quality in Chile, as well as in South America in general, it is necessary to improve farm facilities at the level of small producers, and train stockmen and transporters about behavioral principles and proper handling of lambs to reduce stress, as well as about the consequences of bad handling on product quality. Further enforcement of the legislation for the protection of animals during transport  should lProviding appropriate vehicles for livestock transport that are built and equipped according to the specifications of the species, size, age, and physiological conditions of the animals transported is an unquestionable principle for the protection of animals during transport . The EurChilean Patagonia sheep transport vehicles a,b are cThe livestock vehicles used for lambs in the central-southern part of Chile are much more rudimentary. Two floor vehicles with a trailer are more common in this region, usually used primarily for the transport of pigs ; these hStocking density during transport can be defined as a certain amount of live weight of animals within a vehicle compartment; it is expressed as kg live weight per square meter . Nowaday2/100 kg lamb. In the Chilean Patagonia, where the live weight of lambs is between 28 and 32 kg, Tarumán and Gallo [2/100 kg per unshorn lamb, for journeys between 4 and 12 h. Mera [2/100 kg per unshorn lamb for journeys between 46 and 75 h . 2/100 kg lamb, however a high variability between loads was observed due to the fact that transport vehicles do not take a full load of lambs to the slaughterhouse, because lambs are produced mainly by smallholders [The space allowance recommended by the European Commission  for sheend Gallo  and Strand Gallo  observed h. Mera  and Cart h. Mera  found allholders , and theA decrease in terms of space allowance was observed over the season , a fact 2/100 kg lamb) and at a higher space allowance (1.0 m2/100 kg lamb), using two pens in the same vehicle; the experiment was repeated four times during the long distance terrestrial–maritime commercial transport. Lambs at the higher space allowance were also provided with drinking water, in specially designed troughs. The groups of lambs with more space registered a higher frequency of individuals that lay down during the journey, but also more lambs walked and slipped , total fasting time for lambs can reach up to 74.5 h, since the moment of collection of the animals on the farms and the actual slaughter ,12. A loThe effects of transport and related preslaughter operations on the welfare of animals can be measured directly on the individuals through changes in both their behavior and physiological indicators ,38,51. HIn Chile, as in South America in general, studies in cattle are mainly concentrated on looking at the quantitative and qualitative effects of transport and handling on the meat products, because these measures are easy to use and have direct economic consequences on the producers; therefore, they are easier to demonstrate to the handlers and producers ,8,53,54.Death of animals is the worst consequence that inadequate handling and transport previous to slaughter can have and provides clear evidence of poor welfare during the process. Death will occur particularly in those animals with previously compromised health due to the additional stress of the handling ,55. KnowFrom the moment sheep are collected from the fields to be loaded and transported they are, in general, deprived of water and feed; when arriving at the slaughterhouse they are provided with water but continue without feed during lairage. Deprivation of feed and water in animals produce changes in the blood variables related to stress and inanition , and alsTo investigate the weight losses in lambs, four commercial loads transporting 2106 lambs (mean 29 kg live weight), bred and loaded at the same farm were followed and studied; two of these loads of lambs were slaughtered at a local slaughterhouse after a terrestrial journey of 12 h and the other two loads were transported to a slaughterhouse in the central-southern region of the country, after a 46 h of terrestrial plus maritime ferry crossing journey . In eachIn sheep, as in cattle, bruises are not visible in the live animal due to the thickness of the skin and wool, hence they can only be detected at postmortem inspection of the carcass . The preKnowles et al.  found thp < 0.05) association of transport time and live weight with bruising, with the most exposed animals being those transported for more than 4 h and those that were heavier. The latter could be due to the higher actual stocking density found for lambs of higher weights during transport, because transporters consider number of lambs per pen instead of kg live weight per pen [The percentage of bruised carcasses found in Chilean studies with long transport distance varies between 33%  and 64%  per pen .The characteristics of the bruises in lamb carcasses were classified by Tarumán and Gallo  accordinDue to the small size of lambs, there is a risk of lesions in the transport vehicles as their legs could be easily trapped in floor or wall cracks in the vehicle and also open spaces between the vehicle and the ramps. According to Anderson and Horder , externaSeveral authors in Chile ,40,63 haTarumán et al.  found thConsidering that compared to international studies there is a high prevalence of bruised lamb carcasses but the lesions are mainly small and superficial, it is suggested that handling the animals appropriately by training stockmen and transporters could reduce this problem.Meat pH is one of the main measures used to monitor quality, however, in Chile it is not a routine measurement at lamb slaughterhouses. Physical and physiological stress of animals before slaughter in general affects animal welfare and also meat pH . Factorsp < 0.05). Due to this association, both bruising and meat pH could be used at slaughter plants as indicators of meat quality, and also of animal welfare.Watanabe et al.  categoriLongissimus thoracis (LT) muscle showed the highest values. The mean concentration of muscle glycogen in LT at 32 h of fasting was similar to the values reported by Vargas [In order to try and elucidate the effect of fasting on muscle glycogen, we  measuredy Vargas  and Baezy Vargas  in lambsy Vargas .In general, the relationship between muscle glycogen concentration and pH in lambs seems less clear that in cattle, where many more studies have been performed and pH is regularly measured at slaughterhouses, which is not the case in Chile at least. Notwithstanding this, within the practical recommendations to address high pH problems are reduction of exercise and stress to the minimum possible on farm before transport, and reducing transport and lairage times, because this stops lambs from using their energy reserves before being slaughtered. In Chile, as in many South American countries, lamb is still mainly consumed fresh (refrigerated) and for special occasions only; therefore, there has not been much research in terms of the technological quality of lamb meat for further processing or the use of techniques like vacuum packaging to increase shelf life. The development of new techniques will require further knowledge about the biochemical processes involved in the transformation of muscle to meat in lambs and should also help improving lamb welfare and meat quality.Rounding up and driving suckling lambs from distant fields in extensive sheep farming systems, like the Chilean Patagonia, is stressful and reduces energy reserves of the animals; a possible solution to reduce stress before loading in these cases could be rounding up the animals some days before the expected transport, leaving them close to the loading point.Although facilities for the loading and transport of lambs are appropriate in the Chilean Patagonia, deficiencies were observed at the level of small producers particularly in the central-southern region; creating awareness to farmers and transporters about animal welfare and the appropriate infrastructure; developing good handling practices at this level should receive assistance by governmental institutions.Mishandling the lambs, as it was often observed when using driving aids incorrectly, grabbing them from different parts of the body or pulling them from the wool, not only has consequences on the welfare of animals but also on product quality in Chile, as determined by the high percentage of bruised carcasses. Further enforcement of the legislation for the protection of animals in industrial sheep farming systems and during transport should lead to improvements in this respect.The duration of lamb transport in Chile is often increased due to geographical reasons and bad roads; the space allowances used for lambs are similar in long and short distance transport. The dehydration and increased concentration of betahydroxybutyrate in the lambs after transport of 24 h confirm that lambs should be fed and watered during these journeys. More emphasis on enforcement of the law is needed to improve the welfare and reduce losses in terms of mortalities, live and carcass weight, as well as meat quality of lambs.Efforts should be made to reduce the time lambs have to remain in lairage at the slaughterhouses in order to improve animal welfare and meat quality; although the relationship between muscle glycogen concentration and pH in lambs seems less clear than in cattle. Within the practical recommendations to address high pH problems in Chile are reduction of exercise and stress to the minimum possible on farm before transport and reducing transport and lairage times. This stops lambs from using their energy reserves before being slaughtered and mainly requires efforts in better planning of the timing of transport and slaughter operations. Meat pH measurements and bruising should be used at slaughter plants as indicators of meat quality and also of animal welfare.


Through a systematic review of reports where swine were used as animal biomodels for testing or researching new surgical techniques, we sought to determine the quality of the report of the methodologies carried out on the basis of the ARRIVE guidelines  in a total of 108 studies from 2013 to 2018. In a large percentage of the articles, the information presented in the methodology of the studies showed incomplete data according to the ARRIVE guidelines recommendations for reporting the use of animals. There was a strong focus on descriptions of surgical techniques; however, sample size calculation, description of maintenance conditions, animal handling, and anesthetic and pain management protocols used were not very detailed. This could lead to the inability of others to replicate the described experiments. For this reason, we encourage authors to implement the ARRIVE guidelines to improve the quality of scientific reports and ensure animal welfare.Over the last two decades, pigs have become animal biomodels widely used for the investigation and practice of surgical techniques because of their great physiological and anatomical similarities to humans. Even though many of these studies must be carried out later in humans, the description of basic information is limited, making exact repetitions of the reported experimental methods impossible. In this review, 108 studies from 2013 to 2018 were considered to determine the quality of adherence to the ARRIVE guidelines in the reports of the methodologies. The majority of the studies lacked the details recommended in the ARRIVE guidelines regarding data directly related to the welfare of animals undergoing surgery and those about anesthetic protocols and analgesics. Information related to sample size calculation and housing and husbandry conditions was also very limited. We believe that the ARRIVE guidelines are an excellent tool for good-quality reporting. We encourage scientists to consistently use them as a tool to improve the quality of their scientific reports and, consequently, ensure animal welfare. Swine have become popular animal models for preclinical trials for medical research because of their size and anatomical and physiological similarity to humans. For this reason, these animals are widely used for research on physiopathology and new surgical techniques. Over the last 20 years, swine have replaced dogs as the general surgical model for both training and research .A scientific and moral argument is that if pigs are used to ‘model’ human beings undergoing surgery, then they should receive the equivalent standards of perioperative care humans would; however, most bioscience journals provide little or no guidance on what information to report when describing animal research, and many details are omitted . UnfortuThe National Centre for the Replacement, Refinement and Reduction of Animals in Research (NC3Rs), a UK government-sponsored scientific organization, has led an initiative to produce guidelines for reporting animal research. In 2010, the Animal Research: Reporting of In Vivo Experiments (ARRIVE) guidelines were published  to addreRecent publications focused on the quality of reporting revealed very little improvement in reporting standards since the guidelines were introduced ,8. ReseaA literature review was performed of articles that were published from January 2013 to December 2018. An internet search was performed using PubMed, Google Scholar, Scopus, and Science Direct as electronic databases. The keywords used were: Swine OR Pig OR Minipig AND Surgery.Original articles published in EnglishUse of swine models in vivoStudies that included surgery as an experimental procedureStudies published between 2013 and 2018. This period was selected to sample the recent biomedical literature (for the last 5 years), considering a suitable period for the ARRIVE guidelines to be implementedStudies that described painful experimental surgical procedures like skin incision, craniotomies, thoracotomies, laparotomies, laparoscopies, dental surgeries, and orthopedic surgeriesArticles included had these characteristics:Review articles, commentaries, or communications were excluded. Studies without in vivo experiments were also excluded.We used the ARRIVE guidelines to analyze the articles, focusing on the “Material and Methods” section to evaluate the degree of compliance of publications with these guidelines.We established a score based on 3 levels for the evaluation of the categories of the guidelines. They were defined as follows: Score 0: not mentioned, total absence of any type of information, Score 1: unclear/not complete, items not mentioned completely in the category assess, Score 2: adequate/clear, complete information for all items corresponding to the category evaluated.Data were extracted from the articles and presented into tables, and the information of each ARRIVE’s category, subcategory, and evaluated item was calculated and expressed as percentage.Forty-three subcategories or items were evaluated as the levels of greater detail indicated for the ARRIVE guidelines. The frequency for each year was calculated and expressed in percentage according to the maximum and minimum percentage presented for each subcategory or item.From a total of 2775 articles, 145 articles were eligible by the analyses of the title and abstract. After this, a complete review of each article was done, and 37 articles were excluded for the following reasons: surgical procedures not included in the aforementioned list (n = 18), surgical procedures just cited without description (n = 6), procedures performed on dead animals (n = 6), non-original articles (n = 4), surgical procedures were not performed (n = 3) . FinallyIn general, the studies included some information related to the methodology used with the animals. However, most of the literature lacked quality on the basis of the ARRIVE guidelines, even though 27 of the journals consulted encouraged other publishers to use the ARRIVE guidelines. All categories of reporting information in all articles were unclear or incomplete, except the category of experimental outcomes, for which most of the journals gave very little or no information .Of all articles analyzed, those published in 2014 and 2015 provided more information in the “Material and Methods” section . Articles published in 2013, 2016, and 2018 presented less information (around 30% of the 43 subcategories/items presented minimum mean of report for the years considered) .The most reported subcategories/items were the following: surgical procedure (100%), total number of animals used (94%), and approval by an ethical committee (92%). Several subcategories/items were not mentioned in all articles  or little mentioned  .Most reported surgical procedures in the articles were laparotomies, orthopedic surgeries, and thoracotomies .The drug used for anesthesia was reported in 81% of articles; however, the doses of each of these drugs were only recorded in 71% of articles, and the route of administration in 68%. Most commonly used drugs were ketamine (in 58.3% of articles), isoflurane (in 44.4% of articles), xylazine (in 31.5% of articles), and midazolam (in 25% of articles). These drugs were used alone or in combination with other drugs, reaching up to 55 different anesthetic protocols.Intraoperative or postoperative analgesia was only reported in 41% of articles. Doses of the analgesic drugs used were reported in 32% of articles, and the route chosen for administration was reported in only 24% of articles. Fentanyl (reported in 14.8% of articles) and lidocaine (reported in 13.9% of articles) were the drugs used for intraoperative analgesia in most studies. The most used drugs in postoperative analgesia were buprenorphine (reported in 11.1% of articles) and meloxicam (reported in 8.3% of articles).The “Materials and Methods” section of research papers should provide basic information about how research was performed. Comprehensive reporting is essential to understand how investigations were undertaken, to interpret findings properly , and to PLOS and Nature journals and observed very little improvement in reporting standards since the ARRIVE guidelines were published in 2010. In fact, they observed in this review a better report of the methods in the years 2014 and 2015 , but then the quality of the reports decreased . The reproducibility of these studies in similar studies can thus be affected [After examining articles from 2013 (three years after the creation and implementation of the ARRIVE guide), we found that the report of all data describing the used methodology according to the ARRIVE guidelines did not improve through the years, even though 27 of the 81 journals consulted request the authors to use these guidelines. The outcomes obtained resemble those found by Barker  et al. iaffected ,10,11.The high percentage of reports of ethical review permissions is an indication that projects were previously reviewed by ethical institutional committees to ensure the welfare of the animals; however, many articles did not indicate the protocol numbers or the guides on which their protocols were based. These data should allow tracking the approved protocols and the guides that justify the care provided to the animals used in each investigation .The report of study design showed a relative increase in the number of subcategories of experimental and control groups and experimental units; however, a detailed description of the methods to avoid bias was undermentioned (it was present only in 27% of articles). The lack of randomization and blinding can affect the scientific validity because biased—both conscious and unconscious—factors with no relation to the biological action can influence the results; therefore, mentioning the way an experiment was done is critical .Considering the experimental procedures, the journals did not require important data such as the time at which the experiments were performed, in all the articles. Probably, because of the scope of these studies focused on surgical procedures’ description, this factor may not have been considered. The circadian cycle might change animal physiology, leading to different results, which makes it important to provide the time of day the experiments were done to ensure experiment reproducibility . Other lThe least mentioned data in the category of experimental animals were the source, sex, and race of the animals. These data should be mandatory in any report of experimental procedures using animals because genetic and/or hormonal characteristics of the animals might influence the results. Most articles also inadequately detailed information about housing and husbandry. Although the studies were not specifically on animal welfare issues, these data must be mentioned, so that other researchers can reproduce the same conditions. The experimental animals should not be unnecessarily stressed and should be kept under appropriately controlled conditions. Poor animal welfare is likely to result in poor science .Most of the studies reported the number of animals; however, almost none reported the statistical method used to calculate this number. Determining the sample size by power size or simple calculations helps to design animal research with an appropriate number of animals to detect important biological effects. Omission in reporting means potentially flaws on a research .The statistical methods were not mentioned in 24% of the studies. This section should not be omitted because it shows the way data were analyzed. Likewise, much of this information reported in journals was not detailed, and thus, its lack raises doubts on the validity of the statistical methods chosen to evaluate the results. While focusing on technically challenging research and on generating innovative science, many journals fail to ensure compliance with the basic standards of experimental design and data analysis. One solution to this problem is to have an additional statistical review of submitted manuscripts . In addition, learned societies might suggest methods of analysis of standard outcomes and data reporting to their members .All the surgical procedures generate pain at different intensities, according to tissue invasiveness . In thisIn this review, the drugs used to anesthetize the animals were generally reported at a high level of (81%). The great variety of anesthetic protocols and administered doses showed the absence of standardization for these protocols. This may be due to the type of procedure developed and the local availability of products. However, it was reported that ketamine, which is classified as a N-methyl D-Aspartate (NMDA) antagonist that causes a dissociative anesthesia, , was theOn the other hand, the under reporting of analgesia is a concern because it reveals an inadequate management of pain in pigs, which has not being improved over the years . These results are like those of the Bradbury study, in which the authors also conducted a review of pain management in swine in articles from 2012 to 2014. The need to control pain, particularly in animals used in research, is not only for ethical reasons, but also because pain side effects may occur in the used animals . Along wAnother factor is that the selected drugs should be the best choice for a good pain management in the experiments. The few articles examined in this review that reported analgesics looked for adequate options for pain management. Fentanyl  is a strong opioid that can generate excellent analgesia. Lidocaine, on the other hand, is a local anesthetic widely used to generate local anesthesia in dental and orthopedic surgeries. For postoperative analgesia, buprenorphine (an opioid agonist drug that has been shown to have a longer duration of action in pigs compared to other opioid drugs)  was the Our review reveals poor reporting in studies of surgical procedures in swine, which has worsened over the years, especially for data directly related to the welfare of animals undergoing surgery, such those regarding anesthetic protocols and analgesics. We believe that the ARRIVE guidelines are an excellent tool to achieve high-quality reports. However, their underutilization may be due to a lack of commitment on the part of many authors to use this guide and to the fact that many journals do not require that this guide be followed, especially by those whose main objective is not animal welfare. Increasing the methodology details can lead to increased article length, and many journals have a maximum word limit. However, details can be added as


This disease is characterized by joint damage and systemic involvement that lead to general physical and mental impairment with consequent worsening of quality of life. Rheumatoid arthritis is also associated with a large economic burden to healthcare systems. The evidence from the literature indicates that, despite available treatments, several unmet needs still interfere with rheumatoid arthritis management. Based on this evidence, some of the unmet medical needs currently present in the management of the rheumatoid arthritis were identified and a Delphi questionnaire was submitted to 60 Italian Rheumatologists. The aim of this Delphi was to achieve a broad consensus on the most relevant Rheumatoid arthritis (RA) is the most common autoimmune arthritis in adult population, with an estimated prevalence of 0.3-1% worldwide. Joint damage and systemic involvement of RA lead to general impairment of physical and mental, as well as of psychological wellbeing, with a consequent worsening of quality of life (QoL).  FurthermThe evidence from the literature indicates that, despite available treatments, several unmet needs still interfere with RA management , 4. ConcRemission is the primary target in RA management, even though there is a high heterogeneity in the definition of disease remission in clinical practice. In addition to the concepts of clinical and radiological remission, the new insight into tissue and molecular heterogeneity and the presence of nonresponders to available therapies emphasizes the importance of also including the concept of persistently active disease  that neeThe EULAR guidelines recommend MTX as first-line treatment in monotherapy and if response is not achieved, a switch to biologics or combination of conventional therapies is recommended.  CombinatLow adherence may lead to suboptimal response to treatment, late recovery, disease progression, and the need for a more aggressive therapy with the risk of adverse events. . SeveralRegardless of adherence, clinical response to treatment varies between individuals and it is not easy to predict. The underlying mechanisms of nonresponse are probably linked to the heterogeneity of the disease itself. Heterogeneity is not only clinical but also linked to the pathogenic pathways responsible for the disease in a given patient. For this reason, the need to develop predictive instruments of therapeutic response and personalized therapies, choosing the most efficacious and safest drug, for each patient even in long-term treatment, has been highlighted . unmet needs identified, in order to depict the Italian reality in view of the availability of new molecules that could provide an effective therapeutic option in the treatment of patients with RA.Based on this evidence, we identified some of the unmet medical needs currently present in the management of the RA. The aim of this project was to achieve a consensus within a group of expert Italian rheumatologists on the most relevant unmet needs, recognized by the international scientific community, were identified in the following 9 areas: (1) optimal pain control; (2) significant fatigue improvement; (3) satisfactory levels of physical functioning; (4) maintain workability; (5) social functioning; (6) treatment adherence; (7) prognostic factors of treatment response; (8) best conditions for an effective monotherapy; (9) disease remission.A selection of the relevant literature of the last 10 years, concerning unmet medical needs in the management of the RA, was carried out. This selection was shared among and validated by a board of experts. The board included clinicians with several years' experience in the field of RA from different Italian areas and, hence, representative of the Italian rheumatology community. Among the selected papers, the most relevantA first Delphi 1) round among the board components: the board ranked the identified areas according to a 5-point Likert scale, based on research evidence and their clinical judgment. In each area, a list of statements was identified. Finally, the list of the proposed statements was reviewed and approved, to then submit to six rheumatologists, experts in RA treatment. After the evaluators' feedback and comments, the final questionnaire was prepared, where each unmet need was detailed in 1 or 2 statements and each statement was then extended into 4 or more specific items, as specified in the results section. . Tables  and 4 ThThe experts involved in the study agreed that, for optimal pain control, a drug therapy, based on DMARDs and anti-inflammatories (associated with corticosteroids) and psychological/educational support, is both necessary.Participants agreed that, in order to optimize physical functioning, the treat to target therapy is needed. However, they did not agree with regard to the chronic use of low doses of corticosteroids in association with DMARDs. This reflects the EULAR recommendations.As far as the prognostic factors are concerned, the interviewed clinicians mainly focused on clinical factors. In fact, the consensus was not reached on the use of specific biomarkers  or on the possible presence of antidrug antibodies if the patient was a secondary failure.With regard to monotherapy, a lesser degree of agreement was reached on the use of bDMARD monotherapy or tsDMARD (targeted synthetic DMARDs) to remedy the high proportion of patients who withdraw from MTX intake.Concerning the concept of remission, participants identified all criteria proposed  as criteria to be reached in order to achieve complete remission.Regarding the remission criteria used in clinical practice, almost all clinicians agree on the use of SDAI or CDAI and DAS. They also agree on the use of composite criteria but to a lesser extent.The primary goal of this Delphi consensus study was to identify the unmet medical needs in the management of patients with RA in Italy. The analysis of literature pertaining to this topic highlighted that, despite recent advances in both diagnosis and treatment of rheumatic diseases, several unmet needs are still present in RA management , 3, 4.The results of this Delphi consensus confirm that the above evidence is also applicable to Italy. Consensus was reached for almost all statements with few exceptions. Statements that did not reach consensus  Tables  and 4 wiPhysical Functioning . Statement 4.6. Physical functioning levels depend on disease activity, structural damage, and fatigue. Current therapies do not often provide satisfactory levels of physical functioning. Therefore, to improve physical function, I always consider adding glucocorticoid at a low dose to DMARDs treatment.The answers to the questionnaire were consistent with EULAR guidelines that recommend that short-term glucocorticoids should be considered when initiating or changing csDMARDs but should be tapered as rapidly as clinically feasible, due to the potential risk of adverse events .The use of steroids in combination with csDMARD is justified as they have a supportive role for the efficacy of csDMARD in the early stages of treatment, until the csDMARD reaches its maximum effect. With the availability of molecules characterized by faster action, it can be hypothesized that there will be changes in the use of steroids in patients with RA. The most recent EULAR guidelines already state that glucocorticoids are typically not needed as a bridging therapy when drugs with a rapid onset of action (bDMARDs or tsDMARDs) are used and their association can increase the risk of infections . Only clPrognostic Factors for Treatment Response . Statements 8.3 and 8.4. There are no clear prognostic factors for response to therapies. In the choice of treatment, I rely on the prevalent biological pathway to choose the most suitable MoA drug by searching for specific biomarkers  and the possible presence of anti-drug antibodies if the patient is a secondary failureRegarding the identification of prognostic factors and mechanisms underlying therapeutic failure, some studies, especially on TNF-is, have suggested that individual patient's characteristics and disease features could predict response to treatment , 12. HowConcerning ADA, a recent review of the literature highlights that evidence-based recommendations on how to guide biologic therapy on the basis of drug levels and immunogenicity are lacking and that none of the assays available to detect ADAs are acceptable for routine clinical use. Therefore, according to the authors, the use of ADA seems to be indicated essentially to modulate dosage and route of administration of the drug . In the Disease Remission . Statement 10.3. The “treat to target” approach has been proposed since 2010 for RA patients, with remission as the best treatment outcome possible. However, high heterogeneity in the definitions of disease remission exists in clinical practice. I believe that to achieve complete remission it would be necessary to reach immunological remission.Another controversial aspect in the management of RA is the concept of remission. According to recent recommendations, remission is a primary target of RA treatment . HoweverThe American College of Rheumatology (ACR) and EULAR have recently developed new remission criteria based on a Boolean approach or on an approach based on SDAI and CDAI criteria, which provide continuous numerical scales that reflect the activity of the disease and are closely related to the absence of residual inflammatory activity .Furthermore, Baker et al. assert that remission as defined by ACR/EULAR is not the optimal particularly in clinical practice and in nonresearch settings and it does not always equate to absence of disease .Consistent with this evidence, participants agreed that achieving full persistent disease remission is an unmet need in the treatment of RA.Some reasons could be the absence of validated biomarkers that can measure remission  and the Consistent with this heterogeneity, in 97% of cases participants identified both clinical and radiological remission as those preferentially used in clinical practice. Regarding the concept of immunological remission, almost 30% of the participants did not identify it as preferential, underlining how the definition of immunological remission is still unclear and is not supported by robust evidence. Although some evidence concerning the use of T-cell subset to objectify the phenotype of patients in remission has introduced the concept of immunological remission , objectiDespite available therapies, many unmet medical needs are still present in the treatment of RA patients. By addressing them, we could improve patients' RA management. In particular, the high heterogeneity among both the patients and the disease as well as the poor achievement of clinical remission can lead to the observation that additional drugs will be needed to meet the needs of all patients and health care professionals.