Background and Objectives: There is increasing evidence that patients with dysphagia often have limited access to suitable oral dosage forms, especially when administered via an enteral feeding tube (FT). In addition, there is a lack of clear and readily available information from drug manufacturers on how to administer medications to patients with dysphagia. This study aimed to develop a practical guide for healthcare professionals to increase the safe and effective administration of oral medications to patients with dysphagia. Materials and Methods: The data were collected from existing English databases and handbooks available to develop an easy-to-use tabular guideline presenting all relevant information using keywords and short expressions. The working group differentiated 514 formulation types, and the information was collected and added to the guideline separately. In addition, the instructions for the patients taking the medicines orally or via FT were described separately. Results: The guideline consisted of 24 keywords or short expressions developed by the working group and described the instructions to use them. The guideline contained 343 active pharmaceutical ingredients and 19 fixed-dose combinations. Conclusions: Knowledge about proper medication preparation and administration for patients with swallowing difficulties is limited but essential. It is crucial to encourage drug manufacturers to provide this information as a standard to ensure the safe and effective use of medications for all patient groups. Oral administration is the most preferred way of medication administration by patients . HoweverThere is a lack of clear and readily available information from drug manufacturers on ways to administrate medications to patients with dysphagia ,5. AlthoThis study aimed to analyse the information availability and consistency on ways to administrate oral medications to patients with dysphagia. Furthermore, the final goal was to develop a practical guide to improve the safe an effective administration of oral medications to patients with dysphagia, either by mouth or via FTs.The information search and guideline development were initiated and performed by the Estonian Society of Hospital Pharmacists (ESHP). The working group consisted of hospital and clinical pharmacists from three major hospitals in Estonia , North-Estonian Regional Hospital (NERH) and Tartu University Hospital (TUH)). The final goal was to develop an easy-to-use tabular guideline, presenting the relevant information in the Estonian language using keywords and short expressions ,21, simiPromotion of the available international databases, handbooks, and guidelines was not considered due to the language barrier and insufficient selection for the required APIs or formulations ,22,23,24The complete guideline development and renewal process is described briefly in API selection was based on oral medicines used daily in hospitals , excluding the combination formulations except if the APIs were not available in single formulations and were relevant for in-hospital use. The collected information with short comments is presented in The first information source was the Estonian Registry of Medicinal Products (ERMP), where information on all the registered formulations is available . The infIn addition, the information from 4 publishers (as handbooks or databases) available to the working group was collected ,22,23,24All the collected information was added to the dataset created using Microsoft Excel.At least two pharmacists double-checked the data, which were added to the guideline if there were no uncertainties. All uncertainties were discussed among the working group members, and a joint decision was formed by mutual agreement. If needed, other HCP were involved in the discussions. Using keywords and short expressions, the guideline was formed as a Microsoft Word table. In addition, all records were cited. Finally, instructions for the use of the guideline were written, and the used keywords and expressions were defined. Before publishing, six Estonian hospitals agreed to pilot the guideline. The guideline draft was sent to hospital wards that often have patients with dysphagia. The local hospital pharmacists collected feedback from nurses in two months and sent it to the working group. The feedback and questions were analysed. After minor adjustments, the guideline was published as a PDF document in September 2020 on the ESHP website, available to all ESHP members who could distribute it in their hospitals.After the release of the first version, the users were encouraged to provide feedback to the working group. All questions and comments received in one year were documented in an unstructured way by the guideline contact person. Questions and comments were sorted by qualitative content analysis, analysed and discussed by the working group. Finally, it was decided that the information presented in The ESHP working group collected missing data. Procedures and references were like those of the first time. The guideline was developed as a table containing 11 columns: ATC-code, active substance, medicinal product, dosage form, oral administration guide and comment, administration by FT guide and comment, site of absorption/administration, administration with food, remarks; the entire guideline is presented as Online Resource 1.The keywords  or short expressions  were used. Twenty-four keywords or expressions were developed, and for clarity, these were defined in the guideline instructions for use. The instructions for use also contained column descriptions, some statements on the responsibility of the HCPs, things to consider when prescribing, preparing or administering medicines and some comments about occupational hazards. The guideline data statistics are presented in The APIs were listed according to the World Health Organisation’s ATC code system, which enables the grouping of similarly acting APIs and makes it easier for HCPs to find alternatives for unsuitable or unpreferable formulations. The alphabetic registry of APIs was added to the second version guideline to ease the search.The second version of the guideline consisted of 343 APIs and 19 fixed-dose combinations . The low number of fixed-dose combinations was due to their limited use in hospitals, primarily due to cost effectiveness. The formulation names were presented in the guideline as a request from nurses, and in addition, these enabled the demonstration of the known differences between formulations. Since each API might have more than one dosage form, 514 different formulation types (different APIs in various dosage forms) were identified.Altogether, 38 different dosage forms were presented in the guideline. On average, one API had 1.4 dosage forms . As expected, the conventional release tablets were the most common dosage form. Seven oro-mucosal formulations were added to the guideline since these could serve as an alternative to oral administration .Data about injection or infusion solution suitability for enteral use was also collected. The information was added to the second version with guiding comments in the instructions section. Although the information was available for 30 APIs, the injection formulation was added for 19 APIs; the others were left out since there were no parenteral formulations in Estonia, or it was found irrelevant. In the case of sodium chloride, injection form was the only option for oral administration. And theophylline could be substituted with an aminophylline injection solution.As mentioned previously, the working group differentiated 514 formulation types. The data about these formulation types were collected and added to the guideline separately (on a separate data line). In addition, the patients’ instructions for taking the medicines orally or via FTs were brought out separately. As we compared the oral and FT administration data, we observed that 163 times, the possibility of administering or preparing instructions were different .In addition to the specific guidelines , relevant comments were added. For example, in case of oral administration, information about the bitter taste of the medicine, the local anaesthetic effect in the oral cavity, and the possibility of mixing the medication with food were included. For FT administration, if known, the size of the suitable FT or a warning of the higher risk of FT obstruction was added.Since FTs can be placed in different locations, the information about absorption sites of APIs was also searched. In case of 16 APIs, the absorption in the gastrointestinal tract was not possible or was very low, and the therapeutic effect was local. From others, the absorption site was known for 28% of the APIs. The overall suitability of APIs for FT administration was also investigated, especially for duodenal and jejunal administration . HoweverThe relevance of food interactions with the selected APIs was also analysed . UnfortuTo ensure the drug and patient safety, the information about the stability of the API , consequences of the wrong alteration of the medication and possible side effects concerning swallowing difficulties  were collected and brought out . Occupational hazards due to tablets crushing and capsule opening were also analysed. For 23% of APIs, possible hazards to HCPs were mentioned in references, but not consistently. Since evidence on the occupational hazard was unclear, the information from the NIOSH List of Hazardous Drugs in Healthcare Settings (NIOSH list) was also collected and analysed . FinallyThe manufacturer information about drug administration to patients with dysphagia (including administration via FTs) was lacking for 183 (36%) formulation types. Additionally, in the case of 81  formulation types, all or at least some manufacturers stated that the formulation should be taken as a whole. In more than half of cases, the reason for that was unclear, especially for conventional release tablets and capsules (57 formulation types).In the case of other references, The NEWT Guidelines: for Administration of Medication to Patients with Enteral Feeding Tubes or Swallowing Difficulties did not have any information for 87 APIs; this number was 114 for the Handbook of drug administration via enteral feeding tubes (PPH), 62 for the Australian “don’t rush to crush” handbook (DRtC) and 33 for the UpToDate database. There were 15 APIs that did not have information in any selected references. However, the presence of APIs in the handbooks and databases did not ensure information availability in all dosage forms. The reference might have described its capsule’s handling, and the information was needed for the tablet or vice versa. In addition, the working group identified 151 (29%) formulation types for oral and 141 (27%) for FT administration, where only one of the four references had relevant information. However, if the information was available in more than one reference, the information could be controversial: 71 times (14%) for oral and 84 (16%) for FT administration. https://ehas.ee/juhendid, accessed on 1 March 2022) and is freely available.The second version of the guideline (Online Resource 1) was published as a PDF document on the ESHP website  ,7. With the instructions based on APIs and dosage forms, the construction of the guideline was relatively easy. However, since API same dosage forms may act differently in different medicinal products (can be differently manufactured and consist of various excipients), the confidence of the working group in the suitability of the instructions for all medicines was decreased. For example, metoprolol prolonged-release tablets from different manufacturers do not have the same instructions for use in the guideline. Some formulations can be dispersed, and others cannot , probably due to the different designs. In addition, information in different references was controversial in about 15% of the cases. In these cases, one reference stated that tablets could be dispersed, and the other suggested that the tablets should be crushed. However, no information was available if the difference in recommendations was based on the differences in formulations or tests or lack of relevant information. In such cases, the working group often recommended “dispersion of the tablet” as a safer way of preparing the medicines ,8. All the concerns described above increased a perception that the details about medicines administration should come from manufacturers. Moreover, providing such information should not be optional. Regulatory affairs should ask for this data from all drug manufacturers, which should be presented in PILs and SmPCs as a standard section. Stewart et al. 2016) and Shariff et al. (2020) even further recommended that the needs of patients with swallowing difficulties should be considered when the medicines are in the developing stage 6 and Sha.One of the most challenging parts of developing the guideline was the evaluation of occupational hazards while altering the medications. Although safety concerns are often discussed in the literature, the instructions for safety measures or medication lists of what should be considered harmful for handlers vary ,14,18,27The guideline is freely available for all Estonian HCPs to help in prescribing, preparing and administering medications for patients with swallowing difficulties, either by mouth or via FTsAlthough it is on the website of the ESHP, there is a need for an implementation plan . SimilarThe guideline is based on a limited amount of manufacturer information and instructions available in the stated handbooks and databases and practical experiences of hospital pharmacists in Estonia; a more comprehensive range of references should be used in the future. For example, information from the original research should be collected and analysed. In addition, further communications with drug manufacturers to collect the data available to them that currently are not included in PILs and SmPCs might increase the certainty of the recommendations. Also, well-planned in vitro tests, similar to Bessera et al. (2017), should be performed to see whether tablets can be dispersed reasonably . DissoluAlthough the entire guideline is available as In addition, the guideline contains mainly medicines with one API, but the fixed-dose combination formulations are included only as an exception (19 formulations). Since the prevalence of fixed-dose combination formulations is increasing, it is already planned to collect and publish the information in the next version of the guideline. Although the present suggestion, due to the limited data, is to use separate formulations, the working group members accept that it might be safer and more convenient to use one fixed-dose combination formulation instead of two different medicines.The ESHP guideline “Administration of Medicines to Patients with Swallowing difficulties: Orally or by Enteral Feeding Tube” (Online Resource 1) is the first freely available guideline for all Estonian HCP to help in prescribing, preparing and administering medications for patients with swallowing difficulties, either by mouth or via FTs. Knowledge about proper medication preparation and administration for patients with swallowing difficulties is limited but essential. It is crucial to encourage drug manufacturers to provide this information as a standard to ensure the safe and effective use of medications for all patient groups.


Professor Abla Mehio Sibai talks to Lynn Eaton about the need for cross-disciplinary approaches to supporting healthy ageing and the challenges posed by the collapsing public sector in Lebanon. Q: What drew you to focus on the health of older people in Lebanon?A: I graduated in pharmacy in 1977 and went straight into the profession I had trained for, but Lebanon’s atrocious civil war that ran from 1975 to 1990 changed my outlook. Witnessing the impact of the war on relatives and friends, and especially on vulnerable older people, made a big impression on me. My father was among those severely affected, losing a vibrant business in the prime of his productive years, being forced into early retirement, and eventually becoming ill. Because he was self-employed, he had no health coverage and no pension. His situation reflected broader challenges for the older Lebanese population that included huge inequities in pensions, and absurdities such as people covered by the National Social Security Fund losing their health insurance upon retirement.Having been exposed to all that, I decided to immerse myself in public health issues. I pursued a PhD in epidemiology and, in my dissertation, researched the impact of the war on vulnerable older people in terms of morbidity and mortality. It was harrowing in some ways but fascinating too, each study unearthing new questions. For example, I remember my very first publication on the association between war-related stressors and coronary artery disease leading to a subsequent investigation that revealed the alarming levels of unindicated cardiac catheterization in Lebanese hospitals. The data produced from this study informed stricter guidelines for cardiac catheterization imposed by the Ministry of Public Health, and set the stage for establishing the national Lebanese Interventional Coronary Registry, which serves to monitor and evaluate catheterization use and to compare clinical practices at the national and international level. I also examined the gaps in routine sources of data in the country and researched the reliability and validity of death certification. I later set out to capture the broader demographic and epidemiological transitions taking place in Lebanon, producing the first national report on older adults in 1998 and, in 2001, I co-led the country’s first ‘Global Burden of Disease’ project. That study set the stage for another nationwide survey of noncommunicable disease and risk factors.“Lebanon’s atrocious civil war […] changed my outlook.”Q: When did your focus shift to broader social and structural issues impacting older people’s health?A: It grew out of the work I did on chronic disease. It became clear to me that the well-being of older persons extends far beyond biology and disease. Consequently, I shifted my research focus towards comprehending the intricate connections between psychological experiences, including predictable and unpredictable life transitions, and the social and the physical built environment in shaping our health as we grow older. I researched the factors that drive older adults to self-rate their health as 'good or excellent', despite functional limitations or a lack of individual, social or economic resources, and also examined the impact of early-life displacements on a group of disadvantaged, ethnically diverse older people. That work involved an effort to characterize their socio-economic context and relevant geo-historical factors, which entailed the application of a more cross-disciplinary perspective.Q: You created the Center for Studies on Ageing in 2008 – to what extent does it encourage cross-disciplinary approaches?A: The Center was a deliberate effort to ‘walk the cross-disciplinary talk’. To create it I basically had to move out of my health research comfort zone, establishing a virtual platform committed to translating research on older adults into policies and programmes that bring together academics, service providers, heads of nongovernmental organizations, leaders, students and older adults in roundtable debates, conferences and workshops. The Center has yielded a range of policy briefs and country reports and also acts as a repository, archiving research on ageing in Lebanon and the Arab world. It has also played an important role in supporting the development of national, regional and international collaborations. For example, in 2014, we became a network member of HelpAge International, an international nongovernmental organization that helps older people meet challenges ranging from discrimination to poverty.Q: In 2010 you co-founded the University for Seniors at the American University of Beirut. Can you tell us about that?A: The university is a pioneering late-life learning programme made for and with older adults. The programme provides opportunities for seniors to stay intellectually engaged and socially connected. Because it is hosted within the university, senior students rub shoulders with younger students, benefiting both generations. We started small, but now offer more than 100 lectures, courses, and workshops, and enrol nearly 500 participants each year. The programme offers the strongest in-the-field evidence of the value of intellectual stimulation and social interaction in delaying cognitive and physical decline in older people.Q: Do you have plans to expand the programme?A: To date, the programme remains the only one of its kind in the Arab region, but during the COVID-19 pandemic we went online and witnessed significant participation outside the country, from Türkiye, Egypt, the United Arab Emirates, and even people in the United States of America. This digital expansion also promoted greater inclusion, increasing access to Arabic-speaking participants who are challenged by physical limitations or geographic location. The University for Seniors has been cited as a case study in several international reports, and been selected as one of the 10 most innovative social interventions for older persons in low- and middle-income countries globally. Such recognition is very encouraging and fuels our hope for greater expansion and impact in the future.Q: You have also led three mapping reviews of policies and programmes in the Eastern Mediterranean Region and the development of the National Strategy for Older Persons in Lebanon. To what extent has that work fed through into government policy?A: The regional reviews and the national strategy are only first steps towards identifying priority areas for action and evidence-based policy formulation; but with no political commitment, feasible action plans with targets, timelines and resources, there will be no implementation. Unfortunately, older people in Lebanon have historically been marginalized in the implementation of policies and programmes. With the ongoing financial crisis which started in 2019, including a total collapse of the public sector and retirement savings being eroded by the banks, older people are at higher risk of poverty and exclusion than ever. At the same time, the proportion of older people is growing.“Older people are at higher risk of poverty and exclusion than ever.”Q: What proportion of the Lebanese population is over 65?A: No recent data exist, but in 2020 it was estimated that around 11% of the population of 6 million people were over the age of 65. This is by far the highest among Arab countries. With increasing emigration of young adults, and an influx of retired older adults who had been working in the Gulf States where there is no prospect of naturalization, that percentage is likely to have increased. It is also important to note that life expectancy in Lebanon is relatively high at 79 years for men and 82 for women. These demographic trends, and the increasing prevalence of chronic and disabling degenerative diseases among older people, is putting tremendous pressure on the health and social care system.Q: How is the demand for care being met?A: It is not. The ongoing financial and economic crisis in Lebanon, described by the World Bank as one of the worst in recent history, is straining the already limited ability of the government to provide adequate social protection and health-care coverage. It is estimated that public funds can now only cover 10% of medical costs. As a result, older individuals are being pushed into catastrophic out-of-pocket expenditures and relying on family support. The caregiving landscape in the country remains largely unexamined, but evidence suggests that care for older disabled people is provided by their families. Female family members almost always fill the care gap, with many providing care simultaneously to both children and older family members. In the past, migrant workers used to be a source of paid informal care for older individuals in Lebanon. However, due to the depreciation of the Lebanese currency and increased poverty among once middle-class older adults, this is no longer a viable option. The situation is all the more precarious in the refugee population. Lebanon currently hosts the largest number of refugees per capita worldwide, with an estimated 1.5 million Syrian refugees and around 250 000 people of other nationalities. The collapse of the economy, along with the impact of the COVID-19 pandemic and Beirut blast have only exacerbated the challenges they face. These include extreme vulnerability relating to the sheer length of time they have been in Lebanon. Refugees are ageing here, and many are facing a syndemic of noncommunicable diseases and mental health issues. Medication shortages, and a lack of palliative care for those with life-limiting conditions, pose significant challenges that humanitarian agencies struggle to meet. Interventions to improve the care provided to refugees must be integrated into the overall health-care system of the country, without segregation between refugees and the host communities.Q: What plans do you have for the future?A: We have a number of exciting projects lined up at AUB. For example, we recently secured a 5-year grant from the National Institutes of Health in the United States of America to study the connection between learning and cognitive health, which will focus on seniors attending the University for Seniors. I am enthusiastic about the possibilities it will unlock, not only for future research questions but also for showcasing the impact of the University for Seniors, making it an attractive model to be emulated in other countries and in low-resource settings. Ultimately, my vision is to establish a Programme of Excellence on Ageing at our university—an ambitious initiative that would bring together various disciplines and foster interdisciplinary dialogue, driving research, education, policy development and advocacy on ageing issues. I am deeply passionate about this project and hope that funding agencies will respond to my call to actively support it.


All businesses that deal directly with clients need to observe ethics, but in the nursing profession due to its nature, compliance with professional ethics becomes more necessary. On the other hand, nurses face tensions and difficult conditions in their daily work environment. Resilience is one of the most important abilities of human beings, which in difficult conditions causes effective adaptation to stress-causing factors. Therefore, the relationship between resilience and professional ethics becomes important.The present study was conducted to investigate the relationship between resilience and professional ethics in nurses of Shahid Ganji Hospital, Borazjan 2022–2023.The current study is a cross-sectional descriptive-analytical study. The study environment was Shahid Ganji Hospital in Borazjan, Bushehr, Iran. The research method of the current study was census, so all 400 nurses of this hospital were invited to participate in the study. Finally, 340 of them were included in the study based on the inclusion criteria. Data collection tools included a demographic information form, Connor-Davidson questionnaire, and Cadozier professional ethics questionnaire. Data analysis was done using SPSS version 22 software.Most of the participants were between 25 and 30 years old. The average overall score of resilience and professional ethics of nurses participating in the study was 64.1 ± 16.3 and 34.3 ± 9.4, respectively. No significant difference was observed between the demographic characteristics of nurses with resilience and professional ethics. The Spearman correlation coefficient indicated a statistically significant and inverse relationship between professional ethics and resilience levels .The present study demonstrated a significant and inverse relationship between professional ethics and resilience among nurses. Furthermore, professional ethics were at a moderate level, while resilience was at a good level. Therefore, it is recommended that enhancing professional ethics skills through the organization of educational workshops for nurses should be considered by nursing managers. The discussion of ethics is one of the concepts that has received a lot of attention these days. For many professions, various principles, rules, and ethical standards have been developed at the organizational, national, and even global levels under the title of professional ethics, which the owners of that profession are required to comply with. Professional ethics is considered a basic element in all health professions, including nursing, and it plays an important role in the moral behavior of nurses with patients and strongly affects the improvement of patients’ health .Nursing ethics is the observance of professional ethics in providing nursing care. Therefore, compliance with ethics in nursing technical functions is more sensitive and important than general issues of care . ProfessSeveral studies have been conducted regarding the degree of observance of the principles of professional ethics from the point of view of nurses, and professional ethics have been examined in different departments , 11. In Resilience is defined as social and individual ability to recover, adapt and sustain in response to adverse conditions . AccordiAmerican Association of Colleges of Nursing (AACN) consider the resilience capacity necessary for the nursing job position, because in their opinion, otherwise the working conditions will be very difficult and will lead to psychological and biological injuries for nurses and the quality of care . ResearcResilience in nurses is achieved through knowledge, skill, and clinical experiences, which leads to the self-confidence and flexibility of nurses in dealing with and adapting to complex work environments . EnhanciTalebian et al. (2022) found that when moral distress increases, nurses use resilience mechanisms . AbdollaThe current study is a cross-sectional descriptive-analytical study. The research population was all nurses working in Shahid Ganji Hospital of Borazjan under the supervision of Bushehr University of Medical Sciences, Bushehr, Iran. This research was conducted for 3 months from December to February 2022–2023.The research environment of the present study was Shahid Ganji Hospital in Borazjan. This healthcare facility serves as the establishment for providing health care and emergency medical services for patient safety within the boundaries of Dashtestan City. To achieve a better result, all available nurses in the hospital were included in the study. The inclusion criteria were willingness to participate in the study, having at least one year of work experience, and having a bachelor’s or master’s degree in nursing. The exclusion criteria were the participant suffering from psychological problems and being treated by a psychiatrist according to the individual’s self-report, unwillingness to participate in the study, and incomplete questionnaires.Demographic information included age, gender, marital status, employment status, work experience, level of education, rotating or fixed shift.This tool was designed by Connor and Davidson (2003) . It contThe professional ethics questionnaire was designed by Cadozier (2003) . It has This study was reviewed and approved by the Ethics Committee of Shiraz University of Medical Sciences and has the ethical code “IR.SUMS.NUMIMG.REC.1401.088”. It was explained to the participants that participation in the research was optional and due to the confidentiality of the information, their names would not be included in the questionnaire. In addition, informed consent was obtained from the participants according to the Helsinki Convention.In this research, mean (and standard deviation) was used to describe quantitative data, and frequency (percentage) was used to describe qualitative data. Descriptive statistical methods  were used to describe the data, and independent t-test, one-way variance, Tukey’s post hoc test, and Pearson’s correlation coefficient were used to determine the relationship between variables and differences based on demographic characteristics. Meanwhile, in this study, based on the central limit theorem, parametric tests were used to examine all the objectives. The analysis of the study was done by SPSS version 22 software.Of the 400 nurses who were invited to participate in the study, 40 did not agree to participate and 20 questionnaires were excluded from the study due to not being completed, and finally, the questionnaires of 340 nurses were included in the study (response rate = 85%). The demographic characteristics of nurses are shown in Table The findings showed that the average overall score of professional ethics of the nurses participating in the study was 34.3 ± 9.4 with a range of 16 to 77, and the average score of resilience of the nurses participating in the study was 64 ± 1.16 with a range of 10 to 100.According to the t-test (independent), no significant relationship was observed between the variables of gender, marital status, shift work, and education level with the resilience score. Also, the analysis of the variance test showed that there is no statistically significant relationship between the age group, work experience, and employment status of nurses with the resilience score. Table There was no statistically significant correlation between the resilience score and the demographic characteristics of the nurses. According to the t-test (independent), no significant relationship was observed between the variables of gender, marital status, shift work and education level with the professional ethics score. Also, the analysis of variance test showed that the age group, work history, and employment status of the nurses had no statistically significant relationship with the professional ethics score. Table Considering that according to Kolmogorov-Smirnov Test, the score of professional ethics and resilience did not follow a normal distribution (P < 0.001), Spearman correlation coefficient indicated a statistically significant and inverse relationship between professional ethics and resilience levels . In other words, as the score of professional ethics increases, the level of resilience decreases and vice versa.The present study has been conducted with the general aim of determining the relationship between resilience and professional ethics in the nurses of Shahid Ganji Hospital in Borazjan, South of Iran in 2022–2023. The findings of the study showed that the resilience score of nurses was at a good level, while the overall score of professional ethics was average. Also, the results showed that there was an inverse and significant relationship between professional ethics and resilience in nurses.The present study showed that the average overall resilience score of the participating nurses was a good level and the resilience score did not show a significant relationship with any of the demographic variables.Guo et al. (2018) found that the level of resilience of nurses was at an average level . Hegney Manomenidis et al. (2019) reported that resilience among nurses was at an average level . Also, tIn the present study, the average resilience of the participants with a master’s degree is higher than that of a bachelor’s degree. But this difference is not significant. The results are in line with the study of Manomenidis et al. (2019), yet in terms of meaning, it is not aligned. Perhaps the reason for this difference is the sample size of the aforementioned study which is 3 times more than that of the present study. And when the sample size is higher, the differences between different groups are more visible.Aqtam et al. (2023) reported that the level of resilience of nurses was low and the resilience of female nurses was lower than that of men . AfshariThe present study showed that resilience in married nurses is slightly higher than that of single nurses. But this difference is not statistically significant. The results of Afshari et al.‘s (2021) study were similar to the present study . They alA study on the Covid-19 pandemic conducted by Saddik et al. (2021) also showed that the level of anxiety of healthcare workers was relatively high and the most concern was related to the infection of family as well as the health consequences of this disease . In factThe present study showed that resilience increases with age, education, and work experience. But in all three cases, these differences are not significant. The findings can be explained by the fact that as the age, work experience, and education of nurses increase, they experience more exposure to stressful situations and develop their abilities and skills to deal with critical situations. The development of such skills helps to create different coping strategies, which can facilitate their adaptation and enable them to act more effectively and flexibly in such situations , 43. AfsAnother study conducted in Iran on the mental health and job satisfaction of nurses in the face of Covid-19 showed that older medical staff had better mental health and the level of education was a predictor of physical and mental health . AlthougThe present study showed that the average score of the professional ethics of the nurses participating in the study was average, and the professional ethics score did not show a significant relationship with any of the demographic variables.In explaining this finding, it can be pointed out that the level of professional ethics in the researched nurses is influenced by many factors including the cultural atmosphere and the research area, the nurses’ motivation to continue working, the type of employment, the level of attention of the organization to the demands of the nursing community, and their mental and emotional state. These factors can affect the nurses’ commitments to the organization.Sadrollahi and Khalili 2014) in a study titled investigating the correlation of organizational commitment with the sensitivity of professional ethics in nurses in the west of Golestan Province, concluded that the level of sensitivity of professional ethics in nurses was average . Perhaps4 in a stThe present study showed that there was a significant inverse relationship between professional ethics and resilience. In other words, as the level of professional ethics increased, the level of resilience decreased, and vice versa. These findings align with Sala Defilippis et al.‘s (2019) assertion that ethics and resilience can often complement each other and both are crucial for the effectiveness and overall well-being of nurses . RushtonRecent study results do not align with the findings of the present study. It might be possible to elucidate the findings of the current study by considering that the level of professional ethics is average, and the level of resilience is good. It seems that inappropriate education could be a reason for the inverse relationship between these two variables. The methods used to enhance resilience may not be in harmony with ethical principles, or they may unintentionally promote behaviors that do not align with ethical standards. For example, if resilience training solely focuses on personal coping mechanisms without considering ethical decision-making, it might lead to a decrease in professional ethics. Furthermore, if the methods used to increase resilience primarily focus on nurses’ encounters with high-stress situations, it might inadvertently lead to desensitization or occupational burnout, potentially reducing sensitivity to ethical concerns. Additionally, nurses’ individual characteristics, such as values and personal experiences, may play a role in these findings.On the other hand, nurses who prioritize professional ethics may invest more time and energy in addressing ethical concerns, advocating for patient rights, and adhering to ethical guidelines. This increased focus on ethical considerations potentially leaves them with less time and energy to cope with personal stressors, which may reduce their flexibility. Moreover, ethical dilemmas and moral distress can have a significant psychological impact and potentially lead to symptoms of occupational burnout, fatigue, or stress, all of which can reduce resilience.Another possible reason for the lack of a direct relationship between professional ethics and resilience could be that as nurses gain more experience and expertise, they may become less indifferent to adhering to ethical principles, and conversely, less experienced individuals may, due to being more influenced by stressors, try to adhere more to ethical principles.Chenari and Behzadi (2019) also considered professional ethics as influential in enhancing some components of resilience. These findings do not align with the results of the current study. However, it should be noted that Chenari and Behzadi’s (2019) research was based on the experiences of researchers and books. In contrast, the present study was descriptive-analytical in nature and employed a questionnaire-based sampling method among nurses .Considering that the present study was conducted in a teaching hospital, the generalizability of the results to private hospitals should be approached cautiously. Furthermore, the use of self-report instruments could be one of the other limitations of this study. Also, it is suggested to conduct longitudinal studies to investigate how resilience and professional ethics change over time, using random samples. Conducting qualitative studies to investigate deeper feelings, experiences and the context of factors affecting resilience and professional ethics and conducting similar studies in other regions of the country are suggested to generalize the results to larger societies due to the different geographical regions, socio-economic status and cultures.The present study revealed that the professional ethics of nurses were at a moderate level, while resilience among nurses was at a good level. Additionally, professional ethics and resilience exhibited a significant and inverse relationship. The findings of this study can enhance our knowledge of the occupational resilience and professional ethics of nurses at a specific level. Furthermore, ongoing educational programs can play a crucial role in sensitizing nurses to ethical issues, thus improving their performance in line with ethical standards and enhancing their professional ethics. To better understand the results of this study, further research, including qualitative studies to explore the experiences and perceptions of nurses, is essential. Additionally, a cautious interpretation and generalization of research findings and potential limitations are of great importance.


Demographic change is leading to an increasing proportion of older employees in the labor market. At the same time, work activities are becoming more and more complex and require a high degree of flexibility, adaptability, and cognitive performance. Cognitive control mechanism, which is subject to age-related changes and is important in numerous everyday and work activities, plays a special role. Executive functions with its core functions updating, shifting, and inhibition comprises cognitive control mechanisms that serve to plan, coordinate, and achieve higher-level goals especially in inexperienced and conflicting actions. In this review, influences of age-related changes in cognitive control are demonstrated with reference to work and real-life activities, in which the selection of an information or response in the presence of competing but task-irrelevant stimuli or responses is particularly required. These activities comprise the understanding of spoken language under difficult listening conditions, dual-task walking, car driving in critical traffic situations, and coping with work interruptions. Mechanisms for compensating age-related limitations in cognitive control and their neurophysiological correlates are discussed with a focus on EEG measures. The examples illustrate how to access influences of age and cognitive control on and in everyday and work activities, focusing on its functional role for the work ability and well-being of older people. Here, we illustrate these interrelations by means of four selected activities and actions, all of which are of high, if not prototypical, importance for our everyday life and work. The focus in each case is on cognitive control, a mental function that plays a special role in all four areas, and on its neuro-physiological foundations. After a brief introduction to the topic of cognitive control, work, and aging, recent work will be reviewed in which specific functions of cognitive control have been investigated in close-to-reality everyday and work-related experimental settings. A special focus is on neuro-cognitive correlates of these processes and how they can be mapped using neurophysiological methods.2.Executive functions (EF) optimize goal-directed behavior and counters automaticity. Cognitive control is a term usually associated with the functioning of the prefrontal cortex PFC and associated regions such as the cingulate cortex  underlyiWith increasing age, changes occur in almost all areas of human cognitive functions  plays a special role, which is central for EF and several other cognitive functions , and forThe examination of assumptions within these theoretical frameworks have benefited in the past (and still do) from neuropsychological approaches such as lesion studies as well as from neurophysiological methods targeting the neuro-cognitive correlates of cognitive control. Cognitive control can be assessed by various neurophysiological measures such as fMRI and functional near-infrared spectroscopy (fNIRS). The present review focuses on the EEG signal, from which several measures can be derived that indicate increased cognitive control, for example, as a reaction to the handling of a demanding mental task. One such measure is the oscillatory activity over fronto-central brain areas, especially activity in the theta frequency band  evoked by synchronized postsynaptic neural activity are important correlates of cognitive control. Especially the N2 component, which occurs over frontocentral brain areas about 200–400 ms after a stimulus event, should be mentioned here . The intRegarding age-related changes in ERP correlates of cognitive control, there are mixed findings with respect to N2 amplitude. A reduction in N2 amplitude and increase in N2 latency with increasing (older) age is often found  competes with the task-relevant feature (namely speech content) for cognitive processing resources. While continuity in a speech scene facilitates speech comprehension independent of age , it seemper se more from visual language than younger people. For example, it was found that older people use visual speech stimuli less specifically to prepare for the subsequent auditory speech information . In dual-task walking situations, a decrease in cognitive control (N2) and stimulus updating (P3) were found for older compared to younger participants while also showing higher behavioral decrements  are not involved in more accidents overall than younger drivers . Howeversections . These aExperimentally, such situations can be simulated by confronting subjects during a driving task with unexpected stimuli to which they have to react quickly and adequately. In an EEG study, for example, younger and older drivers had to master a driving task in which they had to keep a vehicle in its lane and react to the brake lights of a vehicle in front . At the According to hierarchical Driver Behavior Model of 3.4.Modern work is characterized by high demands on human information processing and EF, such as mental flexibility, or working memory. This applies in particular to the simultaneous processing of several different tasks and the management of work interruptions, which, along with time and performance pressure, are one of the greatest stress factors in the modern world of work . In the In order to understand the nature of age-related deficits in the handling of interruptions, it is important to better understand underlying cognitive mechanisms. If there is a change from a currently pursued task to an interruption, the current processing status of the primary task and all information which will be required again later must be stored temporarily and attention must be directed to the processing of the interruption. Such a change in attentional prioritization between tasks can be studied very well based on retrospective cuing (retro-cue) paradigms. Here, information about tasks to be performed in the future is stored in working memory and attention is directed to specific working memory content by means of a cue presented during the storage phase . Thus, iTo date, there are only few studies investigating the neurocognitive mechanisms underlying the handling of task interruptions using the EEG or other neuroimaging techniques, especially with regard to age influences. Early work used the N170 component of the ERP as a correlate of the processing of face stimuli that either had to be ignored  or responded to during a working memory task . While the negative influence of distractions on working memory performance could be explained by a deficit in inhibiting the irrelevant face stimuli with age, a simple link between the handling of interruptions and an age-related influence on working memory functions could not be demonstrated . AdditioIn summary, it can be stated that the cognitive processes underlying the handling of task interruptions can be well explained when considering the principles of shifting attention between mental representations in working memory. On this basis, the studies presented show how the cognitive-psychological mechanisms and the associated neuro-cognitive processes can be analyzed, although the influence of age-related changes has been rarely studied so far. Since the ability to handle interruptions is particularly important in the context of work environments, and especially older adults might benefit from appropriate coping strategies, it will be very important in the future to establish a closer connection between the numerous application-oriented research approaches concerning interruptions and basic experimental research on age-related impairments in attentional and working memory processes.4.The presented examples of everyday and work-related activities have—as different as they may be—common features: They are all based on cognitive control and all show age-related changes. Accordingly, there are similar patterns in behavior  as well as in the described electrophysiological measures. Thus, a reduction of the N2 and P3b components or an increased midfrontal theta activity are often found as correlates of an increased mental effort under high workload in older compared to younger people. Common to all examples, however, is also the distress caused by loss or limitations in these activities. Difficulties in understanding speech are described as one of the greatest limitations in old age, falling while walking under distraction is one of the most common causes of accidents among older people, the loss of a driver’s license due to declining fitness to drive is experienced as a major threats to one’s own mobility, and limitations in managing interruptions at work can result in both high strain on the individual and an increased risk of error. Cognitive control may therefore play a key role when it comes to interventions and measures to maintain and improve cognitive functioning in old age e.g., .Notably, it is not only the individual who benefits, but also society as a whole. This is because each of the activities presented has a high relevance for work activities and safety. The extra effort required to maintain work performance despite age-related limitations in sensory, mental, and motor capabilities leads to a higher burden on older employees, which can increase the risk of absenteeism due to illness as well as early retirement. Given the increasing “workforce aging” , the groHowever, maintaining and improving cognitive control in old age should not be seen as an end in itself. Interventions as well as research on cognitive control could benefit considerably if more attention is paid to the functional aspect of cognitive control and its changes in everyday life of older people. Interrelationships in the field of ability—impairment—activity are highly individual and not necessarily linear. The quality of life of the individual does not necessarily increase with the improvement of his or her abilities. Possibilities for compensation and situational factors play at least as important a role (as assumed, for example, in the prominent SOC model of successful aging by The present findings clearly show how age-related changes interact in several of the core processes of cognitive control. This involves updating, shifting, and inhibition in language comprehension in dynamic cocktail party conditions as well as in driving under complex conditions, especially shifting and inhibition in dual-task walking, and shifting and updating in dealing with work interruptions. In contrast, classical experimental tasks such as the N-back task, task switching, the Go-NoGo task, and motor control tasks mostly target single isolated processes of cognitive control. This allows for a differentiated analysis of age effects on updating, shifting, and inhibition, but less for their holistic effects on everyday activities. This is also true for compensatory mechanisms. These are partly global and independent of the specific task, such as the allocation of additional mental resources under demanding task conditions. This is reflected in comparable EEG patterns across the different activities described, for example, in the form of increased theta activity over frontal areas. In some cases, however, compensation mechanisms are inherently linked to a specific activity, such as the use of visual speech in speech comprehension, the avoidance of driving in unfavorable weather conditions as strategic compensation, or reduction of speed as situational compensation in driving. This form of compensation cannot be fully captured in classical experimental tasks.The positive news is that for all presented examples more realistic experimental settings can be found, all benefiting strongly from the rapid development of analysis and neurophysiological methods in recent years. 5.The decline of cognitive control in old age is not alone of theoretical interest, but represents a serious limitation for the life and work of older people. The activities presented here make this very clear. Further development of laboratory-based study paradigms and linking the results of laboratory experiments to everyday live of older people appears to be an important, if not necessary, step in cognitive aging research in the coming years. The use of modern neurophysiological methods in the field makes this more achievable and obvious than ever before.SG and EW drafted the concept of the review article and drafted the manuscript. SG, JR, PG, MK, and DS wrote parts of the review article. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Schema therapy and its core constructs, i.e., early maladaptive schemas (EMSs) and schema modes, correspond to both directions. (2) Methods: This study compared the severity of EMSs and schema modes in a clinical group of suicide risk, a clinical non-suicidal group, and a control group. Intragroup comparisons were also conducted between times of crisis and psychological stability. The evaluation was supported by controlling for the psychopathological symptoms presented, following the dimensional concept. (3) Results: The unquestionable relevance of the disconnection/rejection domain in suicidality has been proven. The importance of EMSs from other domains, especially during psychiatric crises, was confirmed. Among the schema modes, child and Punitive Parent modes proved to be the most significant. There were changes in coping modes but of a lesser effect size. The protective importance of the Healthy Adult and Happy Child modes was also proven. (4) Conclusions: The results provide an indication for practitioners about the EMSs and schema modes most associated with suicide risk. They can also serve as a framework for deepening the issue of identifying and preventing suicidality in schema therapy. Each year, an estimated 703,000 people worldwide die by suicide, based on data from the World Health Organization (WHO). In 2019, 1.3% of deaths were the result of suicide. It is more than the percentage of deaths from malaria, HIV/AIDS, breast cancer, war, or homicide. The global mean is about nine suicide deaths per 100,000 people, with significant differences between countries  )The conclusions obtained may have broad clinical applications. They can be helpful in assessing suicide risk at the diagnostic stage. The diagnostician, seeing a profile of ESMs and schema modes dominated by schemas from the disconnection/rejection domain and the Vulnerable Child or Punitive Parent mode, should pay particular attention to further suicide risk investigation.In some cases, the use of questionnaires (such as the YSQ-S3 or SMI), which do not explicitly ask about suicidal thoughts or tendencies, will be more revealing to the patient (because they are associated with lower levels of anxiety) and may lead to a more authentic description of the mental state. However, it should be emphasized that testing ESMs or schema modes is not a strategy that can replace a reliable suicide risk assessment.Knowledge of the EMS and schema modes most associated with suicide can also guide psychotherapists–practitioners in assessing suicide risk. We would encourage extreme caution, especially with apparent changes in the profile over time, most notably an increase in schema modes from the disconnection/rejection domain, child and Punitive Parent modes, and decreasing access to healthy modes. Changes in the opposite direction to those discussed above achieved over time will also provide valuable information on the patient’s condition improvement and the reduction in suicide risk.Moreover, in the schema therapy practice, special attention is paid to the need to activate the Sensitive Child mode. In controlled conditions, this is a highly desirable situation. Through the therapeutic techniques used (including limited repeated parenting), we have a possibility to modify the patient’s automatic dysfunctional ways of responding. Outside the practice, however, activating this mode involves the risk of the patient experiencing very intense emotions with limited access to healthy modes, which can turn into a suicidal crisis. That is why it is of value to develop healthy modes simultaneously so that patients acquire the skills for self-care while experiencing difficult emotions.Besides the valuable conclusions drawn from this study for both theory and practice, at the same time, it is necessary to mention its limitations. It is the first study of its kind, and, therefore, it does not entitle us to generalize the results obtained. We should treat its conclusions with particular caution.The first issue is the weaknesses of the selection stage of the study group. The subgroups formed were not numerous enough and not fully matched regarding gender and age. Predominantly, they consisted of women and people between the ages of 25 and 35. In addition, the repeated measurement stage characterized a reasonably high dropout rate . All of the above shortcomings may have led to distorted results. Because few studies are showing the effect of gender and age so far on EMSs severity i.e., ,44) and  and 44])Similarly, there is a lack of information on the effect of seasonality on ESMs and schema modes, whereas the data in the present study were collected for about ten months. With knowledge of the impact of seasons, days of the week, or even time of day on suicidality , it wouAnother questionable issue was the respondents’ self-report of experienced psychopathological symptoms. Admittedly, this study tried to move away from a categorical approach to a dimensional approach (therefore not focusing on specific diagnoses); nevertheless, it would have been worthwhile to additionally introduce an external screening questionnaire for assessing psychopathological symptoms, thereby reducing the influence of the subjective feelings of the participants.Limitations certainly include the issue of an imagined crisis in the control group versus experiencing a real crisis (resulting in psychiatric treatment) in the other groups, which obviously could have undermined the reliability of the results. Weakened comparisons with the control group may also have resulted from the high number of dropouts during this study. Perhaps the feedback was not enough incentive to participate in this study in the case of this group. More effective motivators would need to be considered.Arbitrarily, it was also decided to perform a second measurement of EMSs and schema modes about four weeks after the first measurement. In most cases, this allowed for an improvement in psychological state and especially the cessation of suicide risk. At the same time, however, the crisis termination does not necessarily equate to stability. These conditions would need to be better specified in subsequent studies.The limitations mentioned above prompt us to improve this study with better sample selection. It would be worthwhile to conduct it on a larger, more diverse group, controlling for variables such as the severity of specific psychopathological symptoms, age, and gender. Meanwhile, this study can become the basis for further, more detailed scientific analyses, looking not only at correlation patterns but also checking for causality.In view of models considering the processuality of suicidality, it would be interesting to distinguish groups given different levels of suicide risk to compare them by severity of EMSs and schema modes, which was not possible in the present study due to too small a sample size. It seems that the first stages of the crisis should be associated with the activation of numerous EMSs , which would result in the behavioral dimension of increased use of dysfunctional schema modes and weakened access to healthy modes. However, this issue requires detailed empirical verification.Also noteworthy are the preliminary findings regarding coping with crises among psychiatric healthy individuals. In this study, the control group was based on an imaginary crisis, which could lead to distortions. Therefore, it is postulated that similar longitudinal analyses are to be conducted in an experimental model or in an actual crisis situation  after the stressor has ceased. This issue would require further study.Initially, this study also found a significant role for the impaired autonomy/performance domain as a differentiator between those with psychiatric disorders and those without disorders. It would be interesting to see if, for example, working in therapy on schemas from this domain correlates significantly with a decrease in the severity of psychopathological symptoms.To the best of our knowledge, the present study is the first in which the issue of suicidality was examined in connection with EMSs and schema modes, considering the variability of these constructs over time. Analyses were made after checking the level of psychopathological symptoms in each distinguished group (not limited to criterion diagnosis), following the approach postulated in the latest classifications of mental disorders .The results confirm the unquestionable significance of the disconnection/rejection domain in suicidality. They also point to the activation of EMSs from other domains, especially during a crisis of psychological distress.Among the schema modes, child and Punitive Parent modes are the most crucial for suicide risk. Some changes are noted within the coping modes, nevertheless of a lesser size. This study also confirmed the protective importance of the Healthy Adult and Happy Child modes. The described regularities are found in people with the severity of psychopathological symptoms, leading them to seek psychiatric treatment. Changes of this type do not appear in people without psychiatric treatment who have not experienced a suicidal crisis.In conclusion, the current study definitely broadens the knowledge of EMSs and schema modes in patients at risk for suicide. With the awareness of the above-mentioned limitations, its results can support both the diagnostic and therapeutic process, increasing the chance of identifying patients at high risk of suicide. In addition, the results obtained enrich the data on the scientific validation of the concept of schema therapy, laying the groundwork for further analysis.


Background. This paper reports on the implementation and evaluation of a strategy to promote collaborations and team science among investigators at the Research Centers in Minority Institutions (RCMI). The strategy presented in this paper was a hands-on workshop that allowed the application of strategic team science through structured dialogue, asset sharing, and systematic exploration of opportunities for collaboration. Methods. The workshop was attended by more than 100 participants, including RCMI and non-RCMI investigators, practice-based research network (PBRN) supplement program directors, and an NIH Institute on Minority Health and Health Disparities Program Officer. Results. A post-workshop survey was administered to collect participant feedback, assess the relevance of the workshop to the participants’ professional development goals, and gauge the applicability of the tool as a support strategy to promote collaborative research. Most of the participants acknowledged that the session met the conference objectives (95.8%), and 93.7% noted that the workshop, to a high degree, met their personal goals and objectives. During the workshop, participants shared 35 resources they were willing and able to offer for prospective collaborative projects. Conclusion. The experience reported and evaluated in this paper paves the way to understanding methods for disseminating effective strategies for inter-institutional collaborations for the sustainable growth and operation of PBRNs. Every facet of the scientific research enterprise, from basic laboratory research to clinical and translational research to policy formation, requires a wide range of skill sets and viewpoints combined with intellectual rigor and creativity. To increase the quality, competitiveness, and representation of diverse perspectives in US research, the NIH established the Research Centers in Minority Institutions (RCMI) program in 1985 .Another national strategy that expands the capacity for health equity research is the establishment of practice-based research networks (PBRNs) . Since tThis paper supports the goal of promoting the participation of RCMI institutions in practice-based research and provides the growing RCMI-PBRN community with an evidence-based strategy to promote team science and collaboration among RCMI investigators. Specifically, this paper discusses the role and promise of collaborative research and reports on the implementation and evaluation of a strategic team science workshop.Team science is an increasingly used strategy to address the exponential growth of technology, and the increasing complexity of biomedical research challenges . Team scA growing body of research provides information on what variables affect team development and functioning ,11,12,13Incentives to adopt a team science approach in research are increasingly documented in the literature ,20,21,22The purpose of this study is to report on the content and evaluation of a team science workshop that incorporated the principles of strategic team science and aimed to promote interdisciplinary collaboration and networking in practice-based research.A strategic team science workshop was organized and delivered at the National Conference of Research Centers in Minority Institutions in March 2022. The session was organized to support the development of practice-based research in RCMIs and was preceded by a panel of investigators who have received recent supplemental funding from the NIH for the development of new PBRN infrastructure at their institutions. The session was attended by more than 100 participants, including investigators from RCMI and non-RCMI, supplement program directors from the practice-based research network (PBRN), and an NIH Institute of Health and Health Disparities Program Officer. The workshop was part of a larger scientific session on developing the capacity for practice-based research. The first author is an experienced facilitator with extensive experience delivering the content of the workshop to trainees, practitioners, and academic scholars.The workshop was 60 min long and started with an overview of key concepts in strategic team science. Specifically, the facilitator introduced workshop participants to the idea that to participate in collaborations, they need to be intentional about three constructs: the power of networks ; equalitPower of networks. PBRNs are complex social entities consisting of organizational and individual stakeholders with dynamic needs and capabilities. Although individual actors within this network may not have sufficient resources or capacity to design and implement practice-based projects, capitalizing on the power of the network helps to build collaborative relationships and interactions in these complex entities to set up infrastructure effectively and promote effective operations. This approach is critical in addressing effectiveness because no single person or organization can implement PBRNs. Therefore, traditional hierarchical models of organizational structures would not be effective in implementing PBRNs. By implementing a network structure, the PBRN can focus on the resources, expertise, and talent of a variety of organizations.Equality of voice. Handling the complexity of PBRNs also requires equality of voice, the second concept that was discussed during the workshop. Equality of voice operationally means that participants are intentional and mindful of giving each other equal amounts of time to talk and present their ideas. It also may mean that structural elements, such as time monitoring, are consistently used to ensure that every member of a group or every participant in a dialogue has the opportunity to speak and be heard.Framing questions. The structure of the questions emphasizes the orientation toward solutions and provides a framework for moving discussions beyond the analysis of existing health and biomedical challenges and toward identifying possible opportunities that can be brought about by collaborative action. To provide an example of the limitations of focusing on problems, one can consider a problem such as “child wellness” and ask questions such as: How do we eliminate teenage pregnancy? Or, how do we minimize bullying in schools? While those are important and significant goals in and of themselves, discussions framed in this way focus on a particular problem and may potentially be limiting for the entry of participants whose research or practice interests lie outside of those immediate problems, whereas framing questions that focus on opportunities open doors for engagement and intentional inclusion. Following the example of child health, a framing question might sound like this: What if our town were the best place to be a child? Achieving this lofty goal can include solutions to multiple problems, including teenage pregnancy and bullying in schools. However, it does not focus specifically on those problems and allows for the exchange of ideas and actions in other areas.The didactic section of the workshop took about 12 min. After that, the participants broke down into small groups and were introduced to the structured dialogue technique . As theyThe second step of the discussion included combining the assets identified by the participants into new collaborative opportunities. Participants were reminded that new collaborations might not feel comfortable at first. Therefore, they were encouraged to explore the assets, ask each other questions, and be intentionally inclusive in combining the assets of multiple people. They were instructed to consider all the assets identified as available for sharing now or in the near future. They were also told to think of other potentially interested network members who were not at the table during the workshop and put it as an action item for future discussions. This activity had four active discussion groups, each identifying several assets, and then, participants were able to proceed to the discussion of opportunities.Once back as a large group, participants shared examples of collaboration opportunities and discussed their possible future steps. In one of the groups, one of the participants shared knowledge in community needs assessment and health equity research, another participant offered to facilitate access to a network of community clinical providers and experience with conducting practice-based research, and yet another participant has discussed her expertise in RNA sequencing analysis. Together, the group identified and started to outline a potential collaborative opportunity to engage community clinicians in a project involving a collection and analysis of samples and data that intersect genetic and social factors of health outcomes and possible epigenetic research.The session was concluded with a discussion of future steps, such as the identification of priorities for the groups and the necessary action steps to build on the work performed in the workshop. This conference workshop was designed as a demonstration of the method. Therefore, the workshop facilitator focused on sharing practical tips to support future collaborations. First, participants were advised to think about small actionable steps that they could commit to completing before the next meeting and gain momentum by committing to take specific steps and achieve incremental, small-scale progress. Second, participants were advised to schedule follow-up meetings for their emerging collaborative teams at the time of the current meeting to increase commitment to the nascent collaboration and facilitate follow-up for emerging leaders.Data for workshop evaluation came from three sources. First, a post-workshop evaluation survey was administered to collect participant feedback. The workshop evaluation questions were assigned to the reaction and learning levels of the Kirkpatrick evaluation model . The surA total of 97 participants completed a post-workshop survey. A post-workshop survey has shown that participants felt strongly engaged and satisfied with the workshop. Most of the respondents agreed that the content presented in the PBRN Awardee Workshop session was relevant and helpful. Among all respondents, 90% said the content was extremely or somewhat relevant, 95.8% of the participants stated that the content was helpful, and 93.7% said that they learned something new from the information presented in this session. Most of the participants acknowledged that the session met conference objectives (95.8%), and 93.7% noted that the session, to a high degree, met their personal goals and objectives. Regarding the future application of the content presented in this session, 85.6% of the participants said they would likely use the information in the management of embedded research activities within their clinical practice; another 12% reported that they might apply it but had not decided yet, and only 2% reported that they are unlikely to use it. After participating in this workshop, 86.6% expressed their willingness to recommend it to their colleagues, while 2% did not wish to do so, and 12.4% were undecided.The review of open-ended survey comments on the intention to use knowledge and strategy for embedded research revealed that the session was interactive and provided actionable tools for future collaborations. Participants have also noted that the session allowed them to practice translating their knowledge and research goals into application within practice-based research. Finally, participants noted that while an online workshop allowed for interaction, an in-person format would be preferred for a more in-depth discussion of prospective collaborative projects. These comments are in agreement with the facilitator’s observations and notes. Specifically, the facilitator noted that the workshop had achieved its goal of introducing a conceptually grounded and evidence-based strategy for team science and provided a model for the implementation of similar workshops for specific projects. To move conversations from idea and resource exchange to design and implementation of practice-based projects, prospective collaborators can continue to use the structured dialogue principles presented in the workshop and supplement them with action planning and regular follow-up.During the workshop, participants were encouraged to leave comments about research resources that they were willing and able to share with prospective research collaborators. In total, participants have recorded 35 resources on a Google Sheets document. These resources, which participants have offered as available for future collaborative projects, mostly included research expertise  and social capital, or willingness to share access to professional networks .The annual conference of Research Centers in Minority Institutions featured a hands-on team science training session, which was reported in this publication. The event was well received by academic and clinician scholars who considered it pertinent to their professional activities. More crucially, the implementation of this workshop provided a blueprint and led to active resource sharing among prospective collaborators interested in practice-based research. This was an innovative pilot workshop that permitted the use of strategic team science through a guided dialogue approach. As the workshop evaluations showed, this format was highly effective in providing structure to the initial team development in a variety of contexts and involving scholars from various academic areas. The structured nature of this workshop and approach allows for easy replication. It also provides a sense of what each group accomplishes and how the results of the workshop could be summarized and shared. Throughout the workshop, participants were encouraged to use Google Sheets, write down the assets that they proposed to share, and note the opportunities that they were discussing. Google Sheets served as a medium for distributed cognition, storing ideas that would otherwise be shared verbally and forgotten after the workshop. Such distributed cognition and planning for future meetings also allow new collaborators to join the conversations and onboard more quickly as active members of emerging networks and discussion groups.Conceptually, the experience reported and evaluated in this paper paves the way to understanding the methods for disseminating effective strategies for interinstitutional collaborations. Although research institutions invest in training activities and opportunities for interdisciplinary collaboration through pilot funding, the success of team science is not completely dependent on the efforts of individual researchers. Leadership engagement and participation (commitment) are critical to the success of team science collaborations and may require different levels of leadership  to advance future research . FinallyPBRNs are most often community-oriented and provide a diverse, real-world space to conduct research and identify potential research questions that arise during the delivery of patient care. However, to be sustainable, PBRNs also need access to research resources that the Clinical Translational Science Institutes and other research infrastructure entities can provide. The relationship between PBRNs and entities devoted to academic research amplifies the reach of both organizations. When partnering with PBRNs, academic researchers can increase their access to communities they would otherwise have difficulty reaching, have access to patient populations for study recruitment, and a way to move research findings into communities with which the PBRNs interact. PBRNs benefit through increased security and resources and access to a new pipeline of projects . HoweverParticipation of PBRNs in collaborative projects holds promise as an effective way to promote the translation of scientific evidence into practice. The approach presented in this paper can facilitate these relationships through structured dialogues, strategic asset sharing, and systematic exploration of opportunities for collaboration.


With an increase in both the number of mental health disorders people are experiencing and the difficulty in accessing mental health care, the demand for accessible mental health care services has increased. The use of mobile devices has allowed people to receive care in their daily lives without restrictions on time or location. However, the majority of publicly available mobile health apps are not evidence-based, and the top-rated apps are not always safe or user-friendly and may not offer clinically beneficial results.This study aims to create a cultural adaptation of the American Psychiatric Association’s comprehensive app evaluation framework in Japan using a web-based modified Delphi expert consensus.A web-based modified Delphi study includes developing the Japanese version of the comprehensive app evaluation framework and 3 Delphi rounds. In the first round, our working group sends a questionnaire to the panelists, who then complete it. In the second and third rounds, the working group sends a questionnaire and a summary of the panelists’ answers based on each of the previous rounds. The panelists answer the questionnaires based on this summary. The summarization procedure is automated to help reduce the biases that can be generated when panelists’ answers are summarized and when the panelists receive them. The working group sends only the result of the summarization with the next round’s questionnaire. All interactions between the working group and the panelists will be conducted on Qualtrics , a questionnaire platform. To culturally validate the comprehensive mental health app evaluation framework, participants from the following three categories will be recruited in Japan: (1) researchers, (2) practitioners, and (3) app developers.This study received funding from a crowdfunding campaign in Japan (April 2023). The Delphi study began in January 2023 and will be completed in December 2023. We had already completed the translation of the 105 original app evaluation item questions by December 2022.While the need for treatment using mental health apps is increasing, no framework that can be used to develop a centralized database for health apps is available or accessible, and no consensus has been reached among stakeholders in Japan about an appropriate framework. The results of the web-based modified Delphi method presented in this paper may provide direction for the development and use of mental health apps in the future among the relevant stakeholders. Furthermore, this study will enhance recognition of the framework among researchers, clinicians, mental health app developers, and users, in addition to devising new instruments to help users or practitioners efficiently choose the right app for their situations.PRR1-10.2196/44469 Problems with mental health, such as mental health disorders, affect people internationally. According to the Global Burden of Diseases, Injuries, and Risk Factors Study, the 2 most disabling mental disorders, depression and anxiety disorders, ranked among the top 25 leading causes of burden worldwide in 2019 . FurtherWith the rise of mental health problems and the increasing difficulty in access to in-person mental health care services, the demand for accessible mental health care services has significantly increased. The use of mobile devices, which are now owned by a majority of people, has made it possible for individuals to access care in their daily lives without being restricted by place and time -6. As ofRecent reviews have found that mHealth apps could be effective in reducing symptoms of depression and anxiety in adults and youth ,12. UnfoIt is difficult for service users  to ensure that apps are safe, evidence-based, usable, and offer clinically beneficial results . MultiplThe App Evaluation Model framework proposed by the American Psychiatric Association (APA) is useful for addressing this issue . This frCurrently, no framework that can be used to develop a centralized database for health apps is available and accessible, and no consensus has been reached among experts and clinicians in Japan about an appropriate framework. The aim of this paper is to describe the study protocol that will be used to validate the adaptation of the 105 objective questions in Japan and develop a Japanese version of the framework among stakeholders involved in mental health apps. In the absence of empirical evidence to reach such a consensus, various methods can be used to synthesize opinions based on expertise and scientific background. In this study, we will use the Delphi method, which ensures anonymity and allows opinions to be expressed without group pressure. The Delphi method has been used to formulate various guidelines and models ,23. Our Participation in this study is voluntary. The emailed Delphi survey invitation includes the following information for potential panelists: presentation of the researcher responsible for the study, description of the study, reasons for the selection of the expert, procedures to be followed to participate, estimation of the time required, expectations regarding the expert , the promise of anonymity and participation recognition, and rewards for participation . Before participation in this study, informed consent was obtained from all panelists.This research procedure is planned with reference to the Conducting and Reporting Delphi Studies (CREDES) guidelines  and reviThe 105 original evaluation items were translated in accordance with the guidelines provided by the International Society for Pharmacoeconomics and Outcomes Research task force . First, Panelists will complete evaluations in a 2-stage structure (the 105 items and the 11 key levels). The 105 objective questions are constructed by the following key levels: app origin, functionality, app store attributes, accessibility, privacy and security, inputs, outputs, clinical foundation, features, engagement style, and interoperability and data sharing. At the beginning of each key level, the questionnaire explains the key level, and panelists will be asked to assess the appropriateness of the item that comprises the key level. At that time, we will ask panelists to suggest additional items if needed. After the evaluation of key level, panelists will assess 105 objective questions and descriptions. Panelists will be asked to respond on a 9-point scale  regarding whether the item is appropriate to evaluate apps. When the panelists assign a score of 1-5, they will be asked to provide free-text feedback that includes suggestions for changing the wording.In keeping with the described methods, satisfactory agreement for each round will require both (1) all responses >5  and (2) 60% n=31) participation in voting in each round. These criteria were conservatively set with reference to several previous studies ,30. In a participThe panelists will consist of 51 researchers, practitioners, and app developers. Inclusion and exclusion criteria of the panelists in each category are as follows.Researchers who have experience contributing to at least 1 study for psychological assessment or treatment with mHealth apps will be included. The number of relevant publications, the manner in which they contribute to the research, and the degree of contribution are not required; however, if they are involved in assessment, treatment, development, usability or feasibility studies, protocol studies, reviews, preprints, conference papers, etc, they will be considered candidates for panelists.Any practitioner who has experience with at least 1 app that assists in the treatment of procedure to a patient or client who is facing mental health issues will be considered a candidate. Practitioners include psychiatrists and clinical psychologists. Clinical experience related to mental health care is not required. Given the state of app development in Japan, we anticipate that the panelists would be limited, which would undermine their inclusiveness. Therefore, we include those who have used an app for patients for treatment or assessment purposes, regardless of the mental health app.For app developers, candidates must have experience developing at least 1 app related to mental health care. There is no minimum requirement for years of experience in mental health app development that must be met. However, panelists who participated in the development of mental health app items will be excluded.Panelists will be recruited based on the inclusion and exclusion criteria that will be considered in the primary list. Subsequently, snowball sampling will be conducted to expand the pool of panelists.The preponderant involvement of various stakeholders throughout the study will offer the possibility of disseminating the results and progress of this study during the conduction of this study. Following that, diverse activities will take place to transfer knowledge. For example, scientific papers will be published, and conferences will be held to share the results with researchers. These activities could include working with the media to produce commentary papers, features, and stakeholder interviews on research findings. Workshops will be organized with professionals. A podcast will also be available for people interested in delving deeper into the results and related topics and listening to interviews and discussions with experts. Public lectures for citizens are also planned to disseminate the results of the study and explain how to use the app evaluation items to the general public. These activities will be conducted both on-site and on the internet, and records of the activities will be made available through the website and social networking sites developed for the study.We have already completed the translation of the 105 original app evaluation item questions in December 2022. We compiled a list of panelists willing to participate in the Delphi study. We anticipated the first Delphi round to commence in January 2023, and that all Delphi rounds will be completed by December 2023. Finally, the results of each Delphi round will be anonymously reported, and the report will be distributed among all panelists who participated in the Delphi study. This report will include an indication of the distribution of panelists’ ratings, including their comments and suggestions. The results will be presented both quantitatively and qualitatively. We expect this study to be published in a peer-reviewed journal and presented at national and international conferences.While the need for treatment using mental health apps and the development of mental health apps to meet this need are increasing , no framWe expect that this web-based modified Delphi method will incorporate many different stakeholders involved in mental health apps , facilitate the application of the comprehensive app evaluation framework in Japan, and provide valuable insights that will contribute to future developments in this field.Furthermore, we expect that this work will raise awareness of the framework among some stakeholders involved in mental health apps, in addition to leading to the development of tools that will enable users or practitioners to efficiently choose the right app for their situations.The majority of studies aiming at cultural adaptation of a survey have thus far failed to follow the CREDES guidance. This study is the second CREDES-based cultural adaptation of a scale in Japan. Furthermore, the panelist group in this Delphi study includes clinical experts, researchers, and developers to use diverse perspectives. This limitation will be due to the diversity of panelists, as there will be only 51 panelists in total, which is 17 participants for each domain. The CREDES prefers 50 participants for Delphi studies; therefore, the planned number of participants is acceptable. On the other hand, since this study plans to conduct the first round for 51 panelists at the time of study participation, it is possible that the number of panelists will decrease over time.This study will develop the Japanese version of the comprehensive app evaluation framework that has reached a consensus among some stakeholders involved in the mental health app. It will generate useful insights for people involved in research, clinical practice, and app development regarding mental health apps throughout Japan and suggest the direction of use and development of mental health apps in the future. Furthermore, this study will enhance recognition of the framework among researchers, clinicians, mental health app developers, and users, in addition to developing new instruments to help users or practitioners efficiently choose the right app for their situations.