Background: In conditions of intensive therapy, where the patients treated are in a critical condition, alarms are omnipresent. Nurses, as they spend most of their time with patients, monitoring their condition 24 h, are particularly exposed to so-called alarm fatigue. The purpose of this study is to review the literature available on the perception of clinical alarms by nursing personnel and its impact on work in the ICU environment. Methods: A systematic review of the literature was carried out according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol. The content of electronic databases was searched through, i.e., PubMed, OVID, EBSCO, ProQuest Nursery, and Cochrane Library. The keywords used in the search included: “intensive care unit,” “nurse,” “alarm fatigue,” “workload,” and “clinical alarm.” The review also covered studies carried out among nurses employed at an adult intensive care unit. Finally, seven publications were taken into consideration. Data were analyzed both descriptively and quantitatively, calculating a weighted average for specific synthetized data. Results: In the analyzed studies, 389 nurses were tested, working in different intensive care units. Two studies were based on a quality model, while the other five described the problem of alarms in terms of quantity, based on the HTF  questionnaire. Intensive care nurses think that alarms are burdensome and too frequent, interfering with caring for patients and causing reduced trust in alarm systems. They feel overburdened with an excessive amount of duties and a continuous wave of alarms. Having to operate modern equipment, which is becoming more and more advanced, takes time that nurses would prefer to dedicate to their patients. There is no clear system for managing the alarms of monitoring devices. Conclusion: Alarm fatigue may have serious consequences, both for patients and for nursing personnel. It is necessary to introduce a strategy of alarm management and for measuring the alarm fatigue level. In the conditions of an intensive care unit (ICU), where the patients cared for are in a critical condition, alarms are omnipresent . Their pThe ECRI (Emergency Care Research Institute) is a global international organization that publishes an annual ranking of the most important hazards caused by medical technology. For many years, their list included the subject of alarm hazards. This hazard has been described as the lack of an adequate reaction to an alarm and poor management of alarms or their settings . HoweverFatigue can be defined as a lack of energy to act. It can be acute, passing after a rest period, or chronic, characterized by irreversible physical and mental exhaustion . In the According to the guidelines of the World Health Organization, noise in the hospital environment should not exceed 35 dB. Noise disturbs communication and increases stress levels among personnel . UnfortuThe causes of fatigue from monitoring device alarms vary. The necessity to recognize the alarm and assess and confirm its source is burdensome . Under IIntensive care nurses feel irritation due to burdensome and false alarms every day, which generates a natural reaction in the form of subduing them or turning them off completely. As a result, important signals that require intervention may be ignored . MalfuncCurrent literature on alarm fatigue has three major limitations to be addressed. First, maintaining a safe hospital environment, both for patient and staff. Second, the dynamic development of technology. Third, the dynamically changing environment of the intensive care unit. The purpose of the study is to review the available literature on the perception of clinical alarms by nursing staff in the intensive care unit. This paper is a current synthesis of the scientific evidence in relation to alarm fatigue by ICU nurses.The systematic review of literature was carried out according to the PRISMA  guidelines. The content of PubMed, OVID, EBSCO (electronic databases), ProQuest Nursery, and Cochrane Library was searched. A written protocol of the review was not drafted.The keywords used in the literature review were as follows: “intensive care unit,” “nurse,” “alarm fatigue,” “workload with nurse,” and “clinical alarm.” In the course of the search, single words were used or their combinations with AND/OR or both. The number of articles obtained during every search test was limited to research carried out in 2010–2019. Strict inclusion and exclusion criteria were applied. Seven publications were included in the study altogether. The detailed search process is presented in ▪articles in English,▪research group consisting only of medical personnel,▪research carried out among nurses working at adult intensive therapy units, to assess alarm fatigue among personnel, ▪studies with adult patients, and▪studies describing acute and chronic fatigue.Inclusion criteria:▪articles in a language other than English or Polish,▪research where a study group consisted of members other than medical personnel,▪moreover, articles were eliminated that focused on the perception of alarms generated by a single device , and ▪studies concerning pediatric intensive therapy units.Exclusion criteria: All studies taken into account were assessed in terms of strength of evidence according to the Oxford Center for Evidence-Based Medicine 2011 Levels of Evidence .Two reviewers assessed the studies independently, using a formalized form of data collection, which included, but was not limited to, the following data: the first author, the year of publication, the place of study, the study group, the type of study, and the method of assessing the perception of clinical alarms. Any and all disagreements were resolved by means of consensus and in consultation with another author. Seven articles were included in the descriptive analysis. In addition, quantity data from the abovementioned articles were synthetized and analyzed by another researcher, who managed to separate four articles whose shared values were subjected to a statistical analysis.Descriptive data were presented in the form of a table showing: the author and the year of publication, the country of study, the ward of study, the study group, the type of research, the method of assessing alarm fatigue, and the conclusion .Quantity data were analyzed based on the HTF  study questionnaire. The abovementioned questionnaire was applied to four articles. Findings that describe the importance of clinical alarms were assessed using a five-point Likert scale with nine positions, in order establish the hierarchy of importance of barriers regarding the correct recognition of and reaction to alarms. Ranking statements on issues that inhibit the effective management of clinical alarms (Most important = 1 to Least important = 9) were calculated for the four articles . For the needs of this study and in order to strengthen data, a weighted average was calculated from these results . Seven publications were qualified for the systematic literature review. The studies came from five different countries, including three from the United States ,26,28, aIn studies carried out by Christensen et al., 59% of questioned nurses reported that the inconvenience of alarms results from incorrectly set alarm thresholds . In addiAccording to 93% of nurses, alarm fatigue may cause alarms to be excessively subdued or ignored. In the same study, as many as 81% of respondents stated that alarm fatigue results from the excessive number of false alarms . It is nWith regard to the main obstacle to alarm management, the results of the studies are not unanimous. According to Sowan et al., nurses consider the difficulty in recognizing the source and priority of an alarm to be the main barrier , where to alarms . Among tChristensen et al. administered their own 10-element questionnaire among Australian nurses. More than 50% of respondents thought that tiresome alarms result from the precision and incorrect settings of devices. Moreover, nurses suggest that more than half of alarms result from the absence of nurses at a patient’s bedside. On the one hand, this caused irritation and ignorance among other nurses, but on the other hand, some of them showed a sense of professional co-responsibility and reacted to the alarm signals of someone else’s patient . In the quality studies, nurses present a sense of responsibility for the correct and individualized setting of alarms ,29. HoweTwo quality and five quantity studies were included in the research. The results of the quality studies are the voice of healthcare personnel who assess alarm fatigue. They are a necessary element to describe the final results; however, they may cause bias, being of a different form to other articles.In this literature review, the focus was on publications that present the opinions and feelings of nurses regarding clinical alarms. After the analysis of results from studies conducted based on the HTF questionnaire, a simple conclusion can be drawn. Nurses from different parts of the world agree that burdensome alarms occur too frequently, disturb their care of patients, and reduce their trust in alarm systems ,11,26,27HTF  is an organization whose aim is to promote the safe use of technologies in healthcare. In 2005–2006, it conducted a national online questionnaire concerning the perception of clinical alarms by medical personnel. The same study was repeated in 2011 and in 2016. The latter one shows best how frequent such tiresome alarms are, accompanied by an increasing number of adverse events due to clinical alarms. The number of nurses who thought that burdensome alarms are too frequent amounted to 81% in 2006, 76% in 2011, and 87% in 2016 ,30. As cOn the other hand, in the quality study carried out by Poncette et al., in Germany, nurses thought that the introduction of additional technology, such as tablets or mobile phones, might improve patient safety. Owing to the ability to cancel clinically irrelevant alarms from any location, stress might be reduced and satisfaction with performed work might be increased . Nurses In 2013, the AACN  published guidelines concerning alarm management. One of the recommendations was induction and continuous training . An esseMonitoring the condition of a patient is one of the basic duties of nursing personnel. The results of the quality studies confirm that nurses are aware of that duty and feel responsible for the proper adjustment of alarms. Unfortunately, factors such as the overburdening number of duties; the insufficient number of nursing personnel; fear related to previous negative experiences, knowledge, and skills; or the lack of general aptitude in technologies very significantly influence the correct setting of alarms or alarm management in general ,27,28. IThe abovementioned literature review does not show the level of alarm fatigue but makes it possible to gain an insight into how alarms are perceived by nursing personnel and how they affect the daily work with patients. Only in the study by Cho et al. was a simple seven-element tool created for the needs of the project, outside the HTF questionnaire, in order to assess alarm fatigue. The obtained results show that Korean nurses felt fatigue on a moderate or higher level—69.4%. However, the tool was not completely reliable . Summarizing the analyzed studies, we can say that nurses are exposed to too many false alarms. Second, nurses are overwhelmed by the introduction of new technologies and a sense of ownership of monitoring systems without the support of medical staff. Third, many years of experience of the nursing staff allow for the recognition of dangerous situations with the patient, but it does not help to prevent fatigue with alarms. Finally, it is worth focusing on ongoing training for nurses to increase the level of knowledge about alarm management in ICU conditions.In practice, efforts should be made to develop common universal principles for alarm management in all ICU sites around the world. Due to the variety of equipment, each ICU should have procedures dedicated to each unit, including compulsory training for young nurses or people joining the profession. At each stage of education relating to the ICU, training programs should be supplemented with content around the development of new technologies, thus adapting to the global needs of ICU branches and the existing market needs. This is mainly true for the young generation of nurses joining the profession, who must not forget that ICUs are not only alarms but also the patient and that the alarm must not distract them from the patient’s problems.The main limitation of the study was its inability to pinpoint the type of fatigue caused by the alarms. There are no explicit literature records describing acute and chronic fatigue associated with alarms from monitoring devices. Another limitation was the small number of articles meeting the criteria, which forced the researchers to include both quantitative and quantitative studies in the review. An experienced research team made an attempt to systematize the data. It turned out to be problematic to match the appropriate tool to assess the quality of the studies included in the review due to their diversity. More research into alarm fatigue is needed. The above analysis showed that there are many gaps in this respect. Only global research by scientists around the world will allow guidelines to be developed based on scientific evidence.(1)Alarms are unavoidable in intensive care units. The dynamic development of technology makes their number grow drastically, and this will undoubtedly increase in the future as well. Therefore, it is necessary to introduce effective strategies of alarm management as soon as possible.(2)Nursing personnel feel overburdened with an excessive amount of duties and a continuous wave of clinical alarms.(3)Nurses often do not perceive the need for education regarding alarms, which is an important element of any alarm management strategy.(4)In the future, it is worth focusing on assessing the level of alarm fatigue. This would help provide safety both to patients and nursing personnel and verify the effectiveness of strategies that are introduced.


Lifestyle medicine domains, despite accounting for more than 78% of chronic disease risk, are infrequently taught as a part of the medical curriculum. Aspects such as nutrition are taught in less than 25% of medical schools, a statistic that continues to decline, and less than 20% of practicing physicians were required to take even a single course in exercise counseling during their medical school training. To combat this lack of training, the American College of Lifestyle Medicine annually awards the Donald A. Pegg scholarship to fund the development of Lifestyle Medicine Interest Groups (LMIGs) across medical schools worldwide. This scholarship was initiated in 2016 and utilizes private funds to support the development and expansion of LMIGs with the aim of increasing awareness of lifestyle medicine among training practitioners. There are four award winners per year. To date there are sixteen Pegg Award winners. This article will showcase the four 2019-2020 Donald A. Pegg award recipients and their impact on the LMIGs at their institutions. Furthermore, it highlights the ingenuity and adaptation of these LMIGs during the COVID-19 pandemic. Utilization of these key elements allows for lifestyle medicine practitioners to effectively and sustainably reverse and prevent chronic diseases such as type 2 diabetes mellitus, hypertension, dyslipidemia, and more.2Lifestyle medicine is defined as “The evidence-based practice of helping individuals and families adopt and sustain healthy behaviors that affect health and quality of life.”3 Aspects such as nutrition are taught in less than 25% of medical schools, a statistic that continues to decline, and less than 20% of practicing physicians were required to take even a single course in exercise counseling during their medical school training.4Lifestyle medicine domains, despite accounting for more than 78% of chronic disease risk, are infrequently taught as a part of the medical curriculum.To combat this lack of training, the American College of Lifestyle Medicine (ACLM) awards the Donald A. Pegg scholarship which funds the development of Lifestyle Medicine Interest Groups (LMIGs) across medical schools worldwide. This scholarship was initiated in 2016 and utilizes private funds to support the development or expansion of LMIGs in an effort to increase awareness of lifestyle medicine among training practitioners. Furthermore, the scholarship provides travel funds for recipients to attend the ACLM’s annual conference where their knowledge about lifestyle medicine as well as their international network are strengthened. There are four award winners per year. To date there are sixteen Pegg Award winners.5 As the field of lifestyle medicine continues to grow, the LMIG presents as a malleable and vital resource for the education and empowerment of future health care practitioners.Interest groups represent a unique opportunity to expand awareness, training, and education in the university environment, using relatively few resources. These groups are often organized and facilitated by students with minimal faculty oversight and encourage collaboration, academic development, and leadership among trainees with common interests. With these goals in mind, Harvard Medical School developed the first LMIG in 2009, which has since served as a model for the establishment of new LMIGs throughout universities worldwide.This article will showcase the four 2019-2020 Donald A. Pegg award recipients and their impact on the LMIGs at their institutions. Furthermore, it highlights the ingenuity and adaptation of LMIGs during the COVID-19 pandemic.In the last few decades, the role of the medical school in the students’ training has been reframed. Today, as there are numerous ways of acquiring medical knowledge, one of the new roles of the medical school is emphasizing what is most important for the professional lives of the future physicians. As such, the implementation of lifestyle medicine as part of the core curriculum is imperative, seeing as it is extremely useful to physicians and present in nearly all specialties. The surge of LMIGs in the United States and around the world is happening, in part, because students understand this new dynamic and take it upon themselves to fill this gap, while the vast majority of medical schools still lack a course in lifestyle medicine—showing they are not yet in the action stage of change.6 Therefore, Brazil is very much in need of solutions that contribute in terms of disease prevention and cost-effective, first-line treatments sparing hospitalization and unnecessary use of drugs.As a medical student in Brazil—learning at a university hospital that is part of the public health system—I quickly understood that it would be my generation’s duty to design strategies aimed at improving national health care. With 75% of Brazil’s population entirely dependent on the universal tax-funded health system, the main issues related to the imbalance of health care demand and provision stem from lack of capital.When I first heard of lifestyle medicine at a Semiology class by Prof Lucas Medeiros, MD—who is now the LMIG’s faculty advisor—it was easy to put things together in my mind, and I understood the importance as well as the potential impact of lifestyle medicine.Since starting our LMIG in early 2019, we have developed many activities—always looking to bring in International Board of Lifestyle Medicine–certified physicians—such as lectures of all kinds and talks in the “Questions and Answers” format in which students can freely discuss aspects of lifestyle medicine with specialists in the field. We are currently in the process of initiating culinary medicine activities for this school year, in an effort to bring information regarding the benefits of whole-food, plant-based diets and at the same time create a more dynamic and interesting way of learning. Having the opportunity to apply for Taste of Lifestyle Medicine micro-grants through the ACLM ensures that we will be able to bring culinary medicine experiences to our students.Currently, around 15 to 25 students attend each activity, which is more than what is usually seen in interest groups on our campus. In our first year, our main goal was to engage the students as much as possible and transmit to them the importance of continuing to involve future students, in order to assure the continuation of the LMIG after its founders have graduated—which is of the utmost importance.The COVID-19 pandemic and its quarantine came right after the summer break in the Southern Hemisphere. This has definitely imposed barriers, due to the impossibility of in-person activities, such as the new culinary medicine activities we had planned. However, we remain just as motivated and will work to make those types of activities a success as soon as the health situation allows. Meanwhile, our meetings are taking place online so that we can keep moving toward our goal. We always bear in mind our important mission to promote lifestyle medicine in our medical school.With the grant given by the Donald A. Pegg Award, we now have the funding to develop our LMIG further. We have the possibility of providing healthy snacks for regular activities that last longer and of acquiring material for the culinary medicine activities that we are planning for this year. Also, we can refrain from charging fees that discourage student attendance.Our LMIG is grateful to the ACLM for supporting future health professionals in their lifestyle medicine endeavors. I believe an award attests to the quality and effort of the team of people who have donated their time to the cause in the interest of improving medical training for students and making lifestyle medicine more present in the minds of future physicians and other health professionals. The Donald A. Pegg Award has definitely changed our LMIG and the visibility this award has brought has undoubtedly sparked more interest among students who have never attended an activity. The future of the LMIG at our medical school is promising, and we are extremely thankful for all the help.Before the foundation of Emory Lifestyle Medicine Interest Group in the fall of 2019, lifestyle medicine efforts at Emory University were rather disjointed. Emory did have an LMIG that existed here some years ago, but it since has dissipated and no active members were on campus any longer.My personal journey leading to joining ACLM and founding an LMIG was somewhat untraditional. I entered the workforce at Emory Healthcare almost 4 years ago. In parallel, on my own time, I was putting time and effort into educating myself on the power of plant-based nutrition inspired by my then recent transition to a vegan diet. I have attended several plant-based nutrition conferences  and after realizing the power and potential for integrating this knowledge in health care decided to enter the Executive Master of Public Health (MPH) program at Emory to gain the tools and knowledge needed to make a meaningful impact. I quickly learned about ACLM and joined as well.On my journey I have built a network of like-minded and motivated individuals at Emory who encouraged me to apply for the Donald A. Pegg Award and help further galvanize lifestyle medicine efforts at Emory. I was lucky enough to have the honor to receive the Donald A. Pegg grant at ACLM 2019, which gave the Emory LMIG the credibility and support needed to start the work, gain visibility, and create a platform for students, faculty, and practicing health care professionals to unite around the idea of lifestyle medicine. Sharon Bergquist, MD, Assistant Professor at Emory School of Medicine, Medical Director of Emory Lifestyle Medicine and Wellness, and a practicing primary care physician, became our faculty adviser.We started with the Kick-Off event on December 4, where Jonathan Bonnet, MD, presented about lifestyle medicine. We worked with our hospital Chef, Mike Bacha, to provide a beautiful plant-based spread and had 27 people join in person for the presentation and an engaging discussion after.Resilience followed by a discussion with Community Resiliency Model certified practitioner Linda Grabbe, PhD. We had a full schedule of monthly events planned through June , touching on different aspects of lifestyle medicine and partnering with other groups at Emory University and beyond. Our culminating event was supposed to be a talk with Michael Klaper, MD, on “Moving Medicine Forward.”Since then we have hosted 3 events (every 1 to 2 months), with average in-person participation of 25 to 30 people. Events included a working session to brainstorm and clarify Emory LMIG vision; a presentation and social gathering on the topic of “The Power of Plant-Based Nutrition” with Arvinpal Singh, MD, who is an ACLM board certified physician and a medical director of Emory Bariatric Center; and a screening of the documentary COVID-19 forced us to alter our plans and shift the focus and format of our efforts. With many of our core group members being closely involved on the front lines of the pandemic, some of the group activity has been temporarily paused. At this point we are reworking our schedule and are planning a number of virtual events for upcoming months .We have managed to establish, and plan to continue to develop, valuable relationships with various partners at Emory University, Emory Healthcare, and the community overall. The intention and unique trait of Emory LMIG is the multidisciplinary aspect of it—our hope is to unite students and health care professionals from School of Medicine, School of Nursing, School of Public Health, and Business and Law Schools to create a synergetic and multifaceted community of problem-solvers passionate about lifestyle medicine. So far, we have found key contacts at each of the schools and will work to keep each other engaged with collaboration opportunities. We have also established a close partnership with Emory University Hospital Nutrition Services team, and specifically Executive Chef Mike Bacha, who has diligently worked with us to provide locally sourced vegan and plant-based options for our events. Another partner is Emory Office of Sustainability, which provided guidance and support to make the Emory LMIG event zero waste.The Donald A. Pegg grant; personal support, guidance, and encouragement from Beth Frates, MD, and Sami Beg, MD; and help available from ACLM have served as both the resource and motivation to make this work possible.Throughout medical school and even two years into residency training, I remained frustrated with the traditional medical curriculum: one that focuses on disease treatment rather than health promotion. I felt that I continually put Band-Aids on my patients’ issues, only to have them return weeks later with the same cut rearing its angry head again. It was not until I began my personal search for effective medicine that I found the antidote to the underlying issue: lifestyle medicine. This practice, dedicated to the promotion of health, sat in stark contrast to my current understanding of symptomatic disease treatment. I immediately fell in love with the concept and retargeted my career to become a lifestyle medicine practitioner.As a preventive medicine resident, I was awarded the unique opportunity of focusing on prevention. Unfortunately, opportunities for lifestyle-based preventive measures still felt out of reach. Despite the robust medical community in the Denver metro area, including at the University of Colorado’s medical campus, lifestyle medicine training opportunities were rare. The close-knit lifestyle medicine practitioner community sponsored seminars when prompted, but otherwise training remained minimal. My passion for this field, in combination with the lack of training in traditional medical settings, spurred me to apply for the Donald A. Pegg scholarship.This grant will help award medical students, residents, nursing students, and pharmacy professionals an avenue to explore evidence-based and effective treatments for the chronic diseases plaguing our community. While formally developing an LMIG as a resident remains challenging, we are developing the infrastructure for a robust and successful group. Currently, we have outlined six bimonthly meeting agendas interspersed with evidence-based resources and surveys for data tracking. The grant money from the Pegg scholarship is allowing our leadership the opportunity to develop a culinary medicine seminar where participants will cook and enjoy a plant-based meal in the Anschutz Health and Wellness Center’s commercial kitchen. Additionally, it is providing funding for plant-based refreshments at the other five meetings where participants will interact with like-minded practitioners, learn business skills for practicing lifestyle medicine, and work with the local Walk with a Doc chapter.While I was beyond excited for these innovative in-person meetings, the development of the COVID-19 pandemic in early 2020 prompted a need for innovation and a change of plans. In preparation and response to the pandemic, we shifted our LMIG to a virtual platform. While these changes were unprecedented, we are excited to develop a webpage for the University of Colorado’s LMIG where seminars, talks, and resources for interested students will be housed. Additionally, we hope to develop support groups that can meet virtually to promote wellness through and after the pandemic. As everyone learns to adapt to a new normal, we are confident our lifestyle medicine practices will flourish in helping students, residents, and patients alike in doing so.While development of the formal interest group remains a challenge, awareness of the practice of lifestyle medicine continues to grow across our campus. We have piloted a lifestyle medicine residency training track that has been made available to preventive, family, and internal medicine residents and allows for dual board certification upon completion of the track. As educational opportunities such as this continue to develop, interest in the field ignites and spreads. The University of Colorado’s LMIG looks forward to creating a robust continuing education curriculum offered virtually, and hopefully in-person in the future. We are grateful to have the funding of the Pegg grant to help us continue to expand awareness of lifestyle medicine!7 It was commonplace for the members of my community to communicate that many of these chronic diseases  were “inevitable,” or simply the “reality of aging.” I embraced this understanding of chronic disease as insoluble and carried it with me into the beginning of undergraduate experience at The George Washington University (GWU). At GWU, I began to engage with courses, faculty members, and clinical experiences that motivated me to look more closely at the etiology of chronic disease and the modifiable lifestyle factors—nutrition, exercise, stress, social support, and sleep—that could fundamentally affect the trajectory of chronic disease.8 I have since elected to dedicate my medical career to the study, practice, and perpetuation of this knowledge, formally termed “lifestyle medicine.”9I grew up in a region of North Carolina that was—and is—devastated by chronic disease.10 GWU’s proximity to innovative health care delivery systems  and public health institutes , in conjunction with its exemplary international faculty and diverse intellectual community, render the university an optimal incubator for thought leadership, collaboration, and academic and professional excellence. The institutional culture of GWU emphasizes these strengths, and delineates the importance of this established framework being mobilized by students to develop and manipulate sustainable solutions to the intractable challenges that affect our nation and world.11 The LMIG at GWU is a product of this framework and culture, incepted to function as a platform for the cultivation of service-oriented lifestyle medicine professionals united to address the burden of chronic disease.The Donald Anderson Pegg Student Leadership Award has buttressed my passion for lifestyle medicine, and generated an avenue through which I and other students of medicine, health sciences, and public health, faculty members, and health care professionals have been able to mobilize the strengths of the GWU learning environment to enhance the opportunities available to learn about and experience lifestyle medicine. GWU, located in Washington, DC, maintains an enrollment of 6054 undergraduate, graduate, and certificate candidate students across the School of Medicine and Health Sciences, School of Public Health, and School of Nursing.Formally established in the Spring of 2020, the LMIG at GWU maintains a student body of approximately 50 undergraduate, graduate, and certificate candidate students organized under the tutelage of faculty advisor Kaylan Baban, MD, Chief Wellness Officer for GWU. The primary objective of the GWU LMIG—to provide opportunities for the acquisition and application of knowledge in the tenets lifestyle medicine—bifurcates to inform the development of the GWU LMIG’s dual, service-oriented objectives: to cultivate health and wellness within the GWU community and throughout the greater communities to which members belong. For this reason, all of the lectures included in the GWU LMIG’s Fall 2020 curriculum, which will feature leaders in the field of lifestyle medicine—Dr James S. Gordon, Dr Joel Kahn, Dr Joel Fuhrman, and Dr Zeeshan Ali—are accessible and free to all student, faculty, and staff members of GWU.Prior to the emergence of the COVID-19 pandemic, it had been determined that the lectures included in GWU LMIG’s Fall 2020 curriculum would also be webcast to further augment viewership and enable online-only degree students at GWU to benefit from and participate in these lectures. As of May 2020, GWU’s plan for campus reopening during the Fall 2020 has not yet been established, so this previously auxiliary option may be transmuted to function as the primary avenue of delivery. Moreover, as the relationship between chronic disease status and COVID-19 related death and disability becomes more fully delineated, it may be necessary to collaborate with lecturers to enable the modification of content to more appropriately demarcate this connection and provide a sounding board from which GWU’s LMIG cohort can begin to develop accessible, practical, and sustainable solutions to address projected student and community needs.12A project that is, concurrently, underway at the GWU LMIG, with the support of Leigh Frame, PhD, Director of Integrative Medicine at the GWU School of Medicine and Health Sciences, is the development of a multidisciplinary wellness initiative focused on mindfulness-based self-care and group support for the graduate students of the School of Health Sciences at GWU. To date, the scope of this project has included identifying the needs of this population, designing an appropriate curriculum, and planning the implementation of this program to support student emotional and social health and resilience. In the context of the COVID-19 pandemic, a new needs assessment will be conducted during the Summer of 2020, with the intention of more appropriately delineating the unique challenges that students may now be experiencing.13 Through a series of virtual gatherings, the GWU LMIG seeks to restore connectivity and community among members and provide accessible, practical, and evidence-based resources for stress management and reduction. It is the ultimate intention of the GWU LMIG that this initiative be expanded throughout GWU by enabling GWU LMIG members to function as “self-care” peer counselors, thus continuing, even in this time of physical distancing, the service-oriented mission of GWU LMIG.In the interim, the GWU LMIG is actively responding to the stress and trauma of the COVID-19 pandemic by implementing an initiative designed to provide immediate social support to student members.Identify “champions” in varying training levels—medical students, faculty, practicing physicians, residents, and so on—to help promote LMIGs.Utilize technology to track metrics on everything—you never know what will be needed in future research or write-ups!Identify a technology champion who can help manage social media, webpages, archive presentations, and so on.Find partners (other groups in different schools) who share similar interests and partner up on events.Gain visibility for an LMIG through newsletters and other social media formats.The Donald A. Pegg scholarship has created an atmosphere of education, innovation, and growth among these four campuses. Not only has the scholarship allocated funding to help start and support these much-needed LMIGs, but the recipients have developed a strong, collaborative community of like-minded individuals. Through the wonders of current technology, the recipients have enjoyed face-to-face online meetings where ideas were discussed, shared, and expanded; conference calls where challenges and successes are reviewed; and continued correspondence of support during the COVID-19 pandemic.Despite the challenges presented by the COVID-19 pandemic, the leaders of these LMIGs persevered. In many cases, the LMIGs thrived as the pandemic highlighted the importance of wellness, social connectedness, and self-care during these particularly stressful times. We look forward to seeing what these innovative LMIGs continue to develop throughout the remainder of the pandemic in the hopes that lifestyle medicine practices become the norm during this challenging time and beyond.


To better understand the wide variation of performance among county health systems in Kenya, this study investigated their performance determinants. We selected five counties with varied performance and examined their performance across five domains containing 10 thematic areas. We conducted a stakeholder analysis, consisting of focus group discussions and key informant interviews, and administered a quantitative survey to quantify the magnitude of inefficiency. The study found that a shortage of funding was one of the most common complaints from counties, leading to inefficiency in the health system. Another major reason for inefficiencies was the delay in disbursing funding to health facilities, which affected the procurement of medical supplies and commodities essential for delivering healthcare to the population. In addition, lack of autonomy in procuring commodities and equipment was repeatedly mentioned as a barrier to delivering quality health services. Other reported common concerns contributing to the performance of county health systems were the lack of lab tests and equipment, low willingness to join health insurance, rigid procurement policies and lengthy procurement process, lack of motivation and incentives for service delivery, and poor economic status. Despite the common concerns among the five counties, they differed in some schematic areas, such as the county’s commitment to health and community mobilization. In summary, this study suggests various factors that determine county health system performance. Given the multifaceted nature of inefficiency drivers, it is necessary to adopt a holistic approach to address the causes of inefficiencies and improve the county health systems Kenya committed to providing Universal Health Coverage (UHC) to its citizens to improve their health status by 2022. To fulfil this goal, a series of health reforms have been carried out. The Kenyan National Hospital Insurance Fund (NHIF) established in 1966 has been reformed to expand insurance coverage. As of 2018, NHIF provides health insurance to 16.7% of the total population in Kenya .Despite the unprecedented achievements so far, the Kenyan government’s financial constraints create significant challenges in providing affordable quality healthcare services to its citizens. In the fiscal year 2018/2019, the health sector, including the national and county levels, shared only 5.4% of the national budget. The health sector budget ranked 6th among 10 sectors reported in a recent budget analysis , with thTo improve efficiency, Kenya has undergone a series of reforms over decades. One of the major reforms is the devolution of health service provision from the national level to the local level of government. In 2010, Kenyans overwhelmingly voted for a constitution that introduced a new governance framework with a national government and 47 county governments. Under the devolved system, the national government is responsible for health policy and national teaching and referral health facilities, while the county governments are entrusted with all functions related to health service delivery up to health facilities Level 5 . The devolved health system was expected to improve efficiency, stimulate innovation, improve access to and equity of services, and promote accountability and transparency in service delivery . HoweverEmpirical studies, using data envelopment analysis (DEA) and/or stochastic frontier analysis (SFA), show that there is a wide variation in the efficiency of county health systems after the devolution . DEA andThe findings of these studies suggest that to sustain and implement its health strategies, Kenya needs to focus on enhancing health system efficiency. However, such studies do not provide concrete evidence on where inefficiencies are, nor do they offer direct and implementable recommendations to address inefficiencies in the health system. Furthermore, these studies used the same production frontier for each type of health facility, an assumption that may not be correct. Consequently, policymakers should be cautious of interpreting efficiency scores. Efficiency scores from DEA or SFA are not intuitively understandable for policymakers given the complexity of the production process of healthcare. There-fore, the efficiency scores are generally indicative .To better understand the inefficiencies at the county level and address the limitations from DEA or SFA-type efficiency studies, this study aims to complement a typical DEA or SFA study with an in-depth analysis of county health systems to explore causes of inefficiencies in five selected counties and identify potential mechanisms to improve their performance.To help understand the causes of inefficiencies in health systems, several frameworks have emerged in the last few years, including the health system framework  and inpuWe purposively selected five counties for the study representing different levels of performance based on the efficiency scores from DEA and SFA : Two couWe used a qualitative approach to solicit opinions on drivers of county health system performance and a quantitative approach to measure the extent of the impact of determinants. This study comprised two major components: (1) a stakeholder analysis, consisting of focus group discussions (FGDs) and key informant interviews (KIIs), and (2) a quantitative stakeholder survey to assess the magnitude of inefficiency.All counties had a similar health delivery system structure in Kenya, from Level 1 to Level 5, which were communities, dispensaries, health centres, sub-county hospitals and county referral hospitals, respectively. We conducted a stake-holder analysis consisting of FGDs and KII to county health management teams (CHMTs) and staff at service delivery points. We used FGDs and KIIs to gather information from key stakeholders of the county health system. The key stake-holders included the CHMT, which generally consisted of the county executive committee member for health, chief health officer, and county director for health and head of health-related departments (e.g. head of human resource and head of procurement), and staff of health facilities . For each FGD, all available CHMT members were invited on the day of the visit, including director of health and heads of various health departments. Generally, there were 7-10 participants in an FGD. In counties where there were fewer than 10 CHMT members shown in the FGD, one FGD was conducted. If there were >10 members in the FGD in a county, then two FGDs were carried out. Additionally, we also selected CHMT members and health providers  to attend KIIs based on emerging themes of (in)efficiencies. One hospital, two dispensaries and two health centres were randomly selected to be included in the study. The directors of health facilities were invited in the KIIs. For FGDs and KIIs, the interview guide was organized into five domains of inefficiencies, with additional interview questions on recommendations to address inefficiencies. The interview guide for FGDs and KIIs is provided in To measure the potential for performance improvement in the county health system, we developed survey instruments that were consistent with the qualitative interview guide. For participants to better identify the causes and magnitude of inefficiencies, we separated the five domains into 10 thematic areas. The relationship between the five domains and the 10 thematic areas is illustrated in In the stakeholder survey, we first assessed the existence of inefficiencies in the 10 thematic areas using the Likert rating scale from 1 to 5 indicating ‘strongly disagree’ to ‘strongly agree’, with one Likert item per area. It is important to note that while Likert scales offer a straightforward way to quantify inefficiencies, they do not provide the most accurate method of estimation. A higher score indicated the presence of inefficiencies. We regarded a score above 3  to indicate an inefficiency concern in that area. For areas identified as being affected by inefficiencies, we further prompted participants about in-depth causes and asked them to rank the magnitude of the inefficiencies ranging from 0 (no efficiency gains) to 5  based on their perception. There were multiple items in each area. A simple average score was generated from the items in each area. A higher average score would suggest higher potential to achieve efficiency gains if the inefficiency were addressed and indicated a higher level of inefficiency. We used a cut-off of 3 to determine the magnitude of inefficiencies. A total of 104 individuals participated in the stakeholder surveys.A local team collected quantitative and qualitative data from the five counties. The survey instruments and interview guide were piloted in Kajiado County in October 2018 and then were finalized based on the feedback from the pilot. Before the FDGs, KIIs and stakeholder survey were conducted, informed consent was obtained from each participant. FDGs and KIIs were recorded, and the stakeholder survey was collected.A codebook was developed for data coding and cleaning. Quantitative data from the stakeholder survey were entered through Epi-info and converted into Microsoft Access. The data analysis was carried out using Stata version 15.0 . We calculated means and standard deviations for most variables and generated inefficiencies scores. Qualitative data from the audio recordings for the FGDs and KIIs were transcribed and imported into ATLAS.ti software  to facilitate coding, categorizing and analysing. The initial codes were based on the interview guide. Priori codes were consistent with the five domains and 10 thematic areas. Under prior codes, sub-codes were developed to indicate whether the participants were neutral, positive or negative to the existence of potential inefficiency concerns. We used ATLAS.ti to apply the codes to the associated quotes. We then extracted and categorized quotes and analysed the potential relationship among them.It should be noted that the stakeholder survey, FGDs and KIIs were conducted almost at the same time. Thus, findings from FGDs and KIIs might not necessarily cover all the inefficiency areas identified in the stakeholder survey.Regarding output indicators , the aveBelow we provide a detailed analysis of inefficiency for each of the 10 thematic areas.Among the five counties, there was a wide variation of performance in the 13 items on governance . ImplemeSince the devolution, counties enjoyed the autonomy that was given in budgeting and providing health services. However, interviewees felt that the constraint in autonomy was primarily at the health provider level regarding autonomy in procuring commodities and hiring professional staff. While health facilities sometimes were able to use their funds to purchase less expensive equipment or commodities, overall, they did not have the autonomy to procure pricy equipment and commodities. Health facilities were required to compile and submit their requirements to the county procurement department, which then procured and made payments on their behalf. The procurement process could be very long, sometimes due to procurement staff being unfamiliar with procurement products.Stakeholders had different views on the county’s commitment to health. In County 2, the commitment seemed high, which was reflected in the share of the county’s budget for health . County 3, however, had contradictory opinions regarding its commitment to health. At the county-management level, stakeholders pointed out a previous disconnection between the County Assembly and the Health Executive as the County Assembly often opposed proposals from the DoH. The relationship between the two parties had improved since the new government came into power in 2017: funding for health had been increased, and the county government put health as the priority of the county’s development.From One of the challenges, of course, is the budget. If we do not have enough budget, you cannot employ [staff], and start the process of determining how much budget is needed for health in terms of human resources. It seems that people do not have the capacity to come up with [such an estimate]. They do it on [a] historical basis (County 2).Shortage of funding was one of the most common complaints from the counties, and one of the leading causes of inefficiency in the health system. Funding shortages often led to other inefficiency concerns, such as the shortage of human resources, lack of essential lab tests and equipment, and poor maintenance of equipment. All counties expressed the issue of funding shortages, although several counties stated that the budget had been significantly increased since the devolution. In County 2, the county budget for health was ∼36% of the total county budget. However, it is evident that a significant share of the health budget was devoted to paying salaries and allowances for health personnel. In County 3, ∼75% of the recurrent budget went to salaries and remuneration, leaving only 25% of the recurrent budget for service delivery. Another key barrier to executing the budget was the over-all shortage of staff. Although human resource management had improved substantially, stakeholders emphasized that the shortage of clinicians and nurses was the central issue in the county health system. This issue existed particularly in the lower level of the health system, such as dispensaries, where clinicians (i.e. nurses) experienced excessive workload. Besides the shortage of nurses, there was also a shortage of other specialists, such as physiotherapists, orthopaedic clinicians and medical engineers. The reasons for the shortage were multifaceted. The most common explanations included funding shortage and restricted hiring autonomy at health facilities. In addition, there were other reasons contributing to the shortage of clinical or supporting staff, such as the pursuit of further education, expansion of health facilities and lack of financial incentives. In County 2, medical personnel who had left posts to attend training or education had significantly affected the service delivery.Payment mechanisms to health facilities are critical in improving health system efficiency. Because we usually rely on the national treasury to release the funds to the Counties. So, you find that most of the time [national treasury] delays in dispersing the funds, so some-times we get a delay in procuring our health commodities. In such instances we get shortages but somehow, we try to curb by using the Facility Improvement Fund (FIF) for the bigger facilities (County 4).Delays in payment were repeatedly mentioned during the interviews in all five counties. They experienced delays in payment of salaries from the national treasury, and some experience delays in getting funding from conditional grants or the NHIF. Thus, there was a delay in paying for procurement of commodities, which resulted in an interruption in service provision, such as stock-outs of medicines. The delay in payments seemed to result primarily from a shortage of funding in the national treasury.Kenya uses three purchasing arrangements, including public integrated, public contract and private contract  was not involved in procurement throughout the process. Health facilities requested certain goods or products, but the county procurement unit might not know where to obtain them or did not understand the urgency of the need. Such centralization within decentralization has caused significant delays in providing requested goods to health facilities; they have even procured products not suitable for use.Sometimes there are delays and we are never quite sure when drugs will come. …You do an order; you don’t know when they’ll come. Maybe an order takes a month until the day you finish your payment as you had promised. … if we had no debts, then they supply very fast once you make your order. they do not communicate and tell us when the drugs will be in County 3 (County 3).All five countries had complaints concerning delays in procuring and receiving drugs. The reasons for delays were multifaceted: (1) some delays were due primarily to a shortage of funding resulting in health facilities being in debt to their suppliers. Thus, suppliers refused to supply any drugs or shipped a reduced order; (2) delays could sometimes be caused by an irregular supply chain of the suppliers and the lack of communication between suppliers and health facilities; and (3) the shortage of pharmaceutical personnel and lack of capacity to quantify and forecast drug needs could lead to inaccurate projections in the health facilities and an over- or under-supply of drugs. One [thing] we need to improve on human resources, the technical team in every department, we need to improve, like in this facility…we have a physiotherapist, we also need to have an occupational therapist, we also need to have a nutritionist, so that patients who come from those remote areas, with a simple issue like nutrition, we do not have to refer this patient to other facilities and it is an issue that can be handled in this facility (County 5).Health facilities did not have the authority to hire or lay off technical staff, although they have the autonomy to hire supporting staff, such as drivers and cleaners. The responsibility of hiring technical staff resided in the county public service board. The county DoH played a role in giving the public service board the parameters on hiring the number and type of staff, budget and cost implications. Sometimes, a disconnection among health facilities, the county DoH and the public service board led to (1) a mismatch of skills and (2) over- or under-hiring of staff. Additionally, PFM Act 2012 stipulates that the wage bill should not exceed 35% of domestic revenue , aiming to leave more resources for service delivery. In counties that require investment in human resources due to health facility expansion, such a rigid hiring policy restricted the recruitment of needed human resources to deliver health services. That is also a challenge, being an urban city… cosmopolitan city, we train the community health workers…because this is something that they are only volunteering, so when they get jobs they leave, but again issues of attrition are very high and we keep on selecting some new people, training them and when they get good jobs they leave. That is the challenge with urban places unlike when you go to rural because they are always there so the retention is very high (County 5).Most stakeholders realized the importance of community engagement in delivering quality health services to needed populations. However, the degree to which the community was engaged in health services seemed low. In County 5, despite developing a community health strategy, efforts to establish community units were insufficient according to the strategy and the work plan. There were only 44 community units at the time of the survey, compared to 80 community units that were supposed to be established. The high cost of establishing community units was the primary reason for the delay. Additionally, attrition of CHWs was more prevalent in County 5, jeopardizing the sustainability of the CHW programme. Additionally, CHWs were often volunteers without payment, and, as a result, their engagement in health delivery was irregular and not sustainable. On affordability and acceptability, Counties 1 and 2 had an average score higher than 3.0 . The couThe greatest challenge for people not to afford health care are the charges. They are charged by the private facilities and the Coast General Hospital. Because they don’t have money, sometimes they just get paracetamols from her, not antibiotics (County 5).In health facilities that charge user fees, such as sub-county hospitals or those ranked above that, affordability became an issue, particularly for the poor, although there was a waiver system. Some patients had to sell crops to seek care. In Kenya, Level 2 and Level 3 facilities are not allowed to charge user fees. Some patients were unable to distinguish the different levels of health facilities and did not expect to pay when seeking care in the higher level of facilities . Even without user fees, transportation costs and productivity loss from seeking care could pose substantial financial barriers for the poor seeking healthcare.That is where I still have a problem [on affordability] …these people, we have told them, you can register with NHIF, and pay 500 every month. It will be about kshs.6000 a year and you can get all the services plus your family. The willingness to register with NHIF is very low. Yes, it is very low (County 1).Four counties scored higher than the cut-off of 3 in the survey question concerning the lack of financial protection mechanisms Kenya has a national health insurance scheme called the NHIF. It has a low enrolment rate: as of 2016, population coverage under NHIF was ∼16% of the total population .Survey takers from several counties reported the lack of lab test kits and equipment, as well as problematic maintenance of equipment in health facilities. Sometimes, patients received care without needed lab tests and equipment examination, leading to misdiagnosis and low quality of care. Some health facilities have experienced difficulty in maintaining equipment and supplies of lab reagents. The shortage of equipment and lab tests was more salient at health centres/dispensaries. The challenge may rest on the lack of funds to purchase or delay in purchasing equipment/equipment parts and lab reagents, or the lack of capacity to perform the lab tests. Sometimes, the equipment was too old for maintenance. This study examined potential causes of inefficiencies in five selected counties in Kenya and identified several common themes pertinent to the performance of those counties’ health systems The perceived common themes are as follows: (1) lack of implementation autonomy, (2) shortage of funding, (3) delays in payments, (4) rigid procurement policies and lengthy procurement process, (5) lack of autonomy in procurement and hiring, (6) shortage of personnel, (7) lack of motivation and incentives to provide services, (8) lack of lab tests and equipment and (9) poor county economic status. The main causes of these inefficiencies are poor economic development, lack of autonomy, funding limitations, and delays in payment and procurement.One important factor that possibly differentiates county health performance is the county’s commitment to health. County 1 had the highest per capita health expenditure, and County 2 had the highest share of the county budget for health. These two counties were among the best performers in achieving health outcomes. Government financial commitment to health plays a vital role in ensuring needed services are provided at the appropriate levels. From the health financing perspective, the government contributed the most in financing health, accounting for 33.1% of the total health expenditure in 2015/2016 . AdditioCommunity engagement is perceived as another critical factor distinguishing county health performances. Studies conducted in Sri Lanka and Bangladesh show that the successful mobilization and use of CHWs are instrumental for an efficient health system . At the health-facility level, line-item budgets place significant limits on the autonomy of health providers to respond to urgent needs of the population, particularly for dispensaries and health centres where the government’s line-time budget is the major source of funding. Switching from a line-item budget to a programme-based budget or global budget, in combination with other mechanisms (e.g. with or without budget cap), should be considered to improve the autonomy of health providers in the financial management. To encourage health facilities to provide essential maternal and health services, a performance-based financing programme was implemented in some counties in Kenya . The proIn summary, as Kenya is moving towards UHC, it is critical that county health systems maximize the benefits of the devolution reform and address bottlenecks of health system efficiency concerns that impede the counties from achieving their health goals. This study shed light on areas that could be further strengthened.A few limitations of this study should be acknowledged. Firstly, the stakeholder survey and FGDs and KIIs were conducted almost simultaneously and thus we could not use the stakeholder survey results to inform FGDs and KIIs. Thus, findings from FGDs and KIIs might not necessarily cover all the inefficiency areas identified in the stakeholder survey. Secondly, some inefficiency items are not mutually exclusive to a certain domain, and there exist some duplications when examining inefficiencies. Thirdly, due to the complexity of the inefficiencies of health systems, we were not able to completely link county’s performance to its potential drivers. In this study, we singled out two factors  that may contribute to the county’ health performance. There might exist other factors that affect their performance. Due to the exploratory and primarily qualitative nature of the study, this study may miss some other factors that differentiate the health performance among counties.Supplementary data are available at Health Policy and Planning online.Appendix


Loneliness is a highly prevalent, harmful, and aversive experience which is fundamentally subjective: social isolation alone cannot account for loneliness, and people can experience loneliness even with ample social connections. A number of studies have qualitatively explored experiences of loneliness; however, the research lacks a comprehensive overview of these experiences. We present a protocol for a study that will, for the first time, systematically review and synthesise the qualitative literature on experiences of loneliness in people of all ages from the general, non-clinical population. The aim is to offer a fine-grained look at experiences of loneliness across the lifespan.We will search multiple electronic databases from their inception onwards: PsycINFO, MEDLINE, Scopus, Child Development & Adolescent Studies, Sociological Abstracts, International Bibliography of the Social Sciences, CINAHL, and the Education Resource Information Center. Sources of grey literature will also be searched. We will include empirical studies published in English including any qualitative study design . Studies should focus on individuals from non-clinical populations of any age who describe experiences of loneliness. All citations, abstracts, and full-text articles will be screened by one author with a second author ensuring consistency regarding inclusion. Potential conflicts will be resolved through discussion. Thematic synthesis will be used to synthesise this literature, and study quality will be assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. The planned review will be reported according to the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) statement.The growing body of research on loneliness predictors, outcomes, and interventions must be grounded in an understanding of the lived experience of loneliness. This systematic review and thematic synthesis will clarify how loneliness is subjectively experienced across the lifespan in the general population. This will allow for a more holistic understanding of the lived experience of loneliness which can inform clinicians, researchers, and policymakers working in this important area.CRD42020178105.PROSPERO  Loneliness has become the focus of a wealth of research in recent years. This attention is well placed given that loneliness has been designated as a significant public health issue in the UK  and is aWhilst an ever-increasing body of research is situating loneliness at its centre, there is relatively little work which focuses on the lived experience of loneliness: how loneliness feels and what makes up experiences of loneliness. Phenomena that might appear to describe loneliness, such as social isolation, are distinct from the actual experience of it. Whilst loneliness is generally characterised as the distress one experiences when they perceive their social connections to be lacking in number or quality, social isolation is the objective limitation or absence of connections . Social A number of qualitative studies of loneliness experiences have been carried out. In perhaps the largest study of its type, Rokach  analysedThere are a number of available definitions of loneliness offered by researchers. The widely accepted description from Perlman and Peplau , for exaA recent systematic review report  has explThe proposed research aims to offer a holistic view of the experience of loneliness across the lifespan through a systematic review and thematic synthesis of the qualitative literature focusing on these experiences. To address this aim, there is one central research question: How do people describe their experiences of loneliness?This research question concerns aspects of loneliness which participants discuss when describing their lived experiences. Whilst we expect that this would concern emotional, social, and cognitive components of the experience, we understand that these findings may also come to reflect perceived causes or effects of loneliness.This review will also consider the age groups that have been studied and how experiences of loneliness might vary across the different age groups examined in this literature. Loneliness research is often weighted towards investigations of older adults, despite the fact that the prevalence of loneliness is high across the lifespan; recent UK research found a prevalence of 40% in 16- to 24-year-olds and 27% in people over 75 [Furthermore, given the relatively small number of qualitative studies into the experience of loneliness compared with quantitative research in this area, this review will also consider the reasons that study authors may offer for the relative shortage of qualitative work. This is an important point given that the review will inherently be constrained by the number of studies that exist and the focus that has primarily been given to quantitative loneliness research thus far.The review protocol has been registered within the International Prospective Register of Systematic Reviews (PROSPERO) database from the University of York (registration number: CRD42020178105). This review protocol is being reported in accordance with the reporting guidance provided in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement   or if loneliness experiences are clearly explored and described (e.g. relevant questions are present in an appended interview guide). At the title and abstract screening stage, at least one relevant sentence or information that indicates likely relevance must be present for inclusion. The decision to exclude articles which do not primarily or equally focus on these experiences was made in order to gather meaningful data about loneliness experiences specifically and to capture experiences identified as loneliness by participants as much as possible, rather than related phenomena which may be grouped and labelled retrospectively as loneliness by researchers.The primary source of literature will be a structured search of multiple electronic databases (from inception onwards): PsycINFO, MEDLINE, Scopus, Child Development & Adolescent Studies, Sociological Abstracts, International Bibliography of the Social Sciences (IBSS), CINAHL, and the Education Resource Information Center (ERIC). The secondary source of potentially relevant material will be a search of the grey or difficult-to-locate literature using Google Scholar. In line with the guidance from Haddaway and colleagues  on usingThe search strategy for our primary database (MEDLINE) was developed in collaboration with an information specialist. In collaboration with a specialist, the strategy will be translated for all of the databases. The search strategy has been peer reviewed using the Peer Review of Electronic Search Strategies (PRESS) checklist . StrategFirstly, the main review author (PMP) will perform the database search and hand-searching and will screen all titles to remove studies which are clearly not relevant. PMP will also undertake abstract screening to exclude any which are found to be irrelevant or inapplicable to the inclusion criteria. A second author (JG) will independently screen 50% of the titles and abstracts. Finally, full-text versions of the remaining articles will be read by PMP to assess whether they are suitable for inclusion in the final review. JG will independently review 50% of these full texts. In cases of disagreement, the two reviewers will discuss the study to reach a decision about inclusion or exclusion. In case agreement cannot be reached after discussion between the two reviewers, a third reviewer will be invited to reconcile their disagreement and make a final decision. The reason for the exclusion at the full-text stage will be recorded. After this screening process, the remaining articles will be included in the review following data extraction, quality appraisal, and analysis. The PRISMA statement will be followed to create a flowchart of the number of studies included and excluded at each stage of this process.The articles to be screened will be managed in EndNoteX9, with subsequent EndNote databases used to manage each stage of the screening process.Data will be extracted from the studies by PMP using a purpose-designed and piloted Microsoft Excel form. Information on author, publication year, geographic location of study, methodological approach, method, population, participant demographics, and main findings will be extracted to understand the basis of each study. JG will check this extracted data for accuracy.For the thematic synthesis, in line with Thomas and Harden , all texQuality of the included articles will be assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Qualitative Research . This quThere are various accepted approaches to reviewing and synthesising qualitative research, including meta-ethnography , meta-syAs well as its successful application in similar systematic reviews, thematic synthesis was selected based on its appropriateness to the research question, time frame, resources, expertise, purpose, and potential type of data in line with the RETREAT framework for selecting an approach to qualitative evidence synthesis . The RETGuidance from Thomas and Harden  will be After this stage, similarities and differences between the codes will be examined, and they will begin to be organised into a hierarchy of groups of codes. New codes will be applied to these groups to describe their overall meaning. This will create a tree structure of descriptive themes which should not deviate largely from the original study findings; rather, findings will have been integrated into an organised whole. At this stage, the synthesis should remain close to the findings of the included studies.At the final stage of analysis, higher-order analytical themes may be inferred from the descriptive themes which will offer a theoretical structure for experiences of loneliness. This inferential process will be carried out through collaboration between the research team (primarily PMP and JG).After the synthesis is complete, a sensitivity analysis will be undertaken in which any low-quality studies (as identified through the JBI checklist) are excluded from the analysis to assess whether the synthesis is altered when these studies are removed, in terms of any themes being lost entirely or becoming less rich or thick . SensitiRisk of bias in individual studies will be taken into account through utilisation of the JBI checklist, which includes ten questions to assess whether a study is adequately conceptualised and reported . PMP wilThe Grading of Recommendations, Assessment, Development and Evaluation – Confidence in the Evidence from Reviews of Qualitative Research  approach , 45 willThe proposed systematic review will contribute to our knowledge of loneliness by clarifying how it is subjectively experienced across the lifespan. Synthesising the qualitative literature focusing on experiences of loneliness in the general population will offer a fine-grained, subjectively derived understanding of the components of this phenomenon which closely reflects the original descriptions provided by those who have experienced it. By including non-clinical populations of all ages, this research will provide an essential view of loneliness experiences across different life stages. This can be used to inform future research into correlates, consequences, and interventions for loneliness. The use of thematic synthesis will enable us to remain close to the data, offering an account which might also be useful for policy and practice in this area.There are a number of limitations to the planned research. Primarily, this review will be unable to capture aspects of loneliness experiences which have not been described in the qualitative literature, for example, due to the sensitivity of the topic, given that loneliness can be stigmatising, or aspects that are specific to a given unstudied population. Moreover, by focusing on lifespan non-clinical research, we aim to offer a general synthesis which can in future be informed by insights from clinical groups, rather than subsuming and potentially obscuring the aspects of loneliness which might be unique to them. Whilst primary empirical studies are not themselves extensive sources, with books in particular often offering rich descriptions of loneliness , thBy providing a thorough overview of how loneliness is experienced, we expect that the findings from the planned review will be informative and useful for researchers, policymakers, and clinicians who work with and for people experiencing loneliness, as well as for these individuals themselves, to better understand this important, prevalent, and often misunderstood phenomenon. Mansfield et al.  have offAdditional file 1. PRISMA-P 2015 Checklist.Additional file 2. Search executed in MEDLINE ALL (OVID) 16/11/2020.Additional file 3. PRESS Guideline — Search Submission & Peer Review Assessment.


Critical thinking is an essential skill that nursing students need to develop. Technological tools have opened new avenues for technology-supported guidance models, but the challenges and facilitators of such guidance models, as well as how they stimulate the development of critical thinking, remain unclear.We developed a protocol for a mixed methods systematic review to investigate the use of technology-supported guidance models that stimulate the development of critical thinking in nursing education clinical practice.A convergent integrated design following the Joanna Briggs Institute Manual for Evidence Synthesis will be employed. A pair of authors will select the articles by screening titles and abstracts, and the methodological quality of the articles included in the review will be assessed by a pair of authors according to checklists for specific study designs. The data will be extracted using the standardized Joanna Briggs Institute mixed methods data extraction form and following a convergent integrated approach. The thematic synthesis for data transformation will be used.Development of a comprehensive systematic search strategy was completed in October 2020. The database searches were performed on October 21, 2020. As of January 2021, analysis and synthesis is ongoing. Completion of this review is expected by January 2021.By combining evidence from studies with varied methodological approaches, the results should provide broad insight into the use of technology-supported guidance models for clinical practice in nursing education with a focus on the development of nursing students’ critical thinking. The results of this mixed methods systematic review can also be used to develop or improve current technology-supported guidance models for clinical practice in nursing education.PRR1-10.2196/25126 Critical thinking is an essential element of the skill set of all health professionals as it enables them to address complex problems and make informed evidence-based decisions ,2.This is especially true in the nursing profession as nurses provide complex, prolonged care to a diverse group of patients . Thus, cCritical thinking is a broad concept, and terms such as clinical decision making, analytical thinking, creative thinking, problem solving, reflective thinking, diagnostic reasoning, and clinical judgement are often used interchangeably to describe critical thinking . NursingIn addition to cognitive skills, self-awareness, creativity, and risk taking are also deemed important . AccordiClinical practice is an ideal context in which to develop critical thinking ,13. ThisNovel technologies afford new opportunities for supporting nursing students in clinical practice and developing their critical thinking ,18, but In a meta-analysis, Ismail et al  reviewedAnother study, conducted by Lee et al , revieweRegarding guidance models, Jayasekara et al  identifiIn conclusion, the existing systematic reviews and meta-analyses are limited to the development of critical thinking in nursing education  without the use of technological tools ,22,23. CThis study outlines a mixed methods systematic review with an overall aim of synthesizing available knowledge about various technology-supported guidance models that employ technological tools in clinical practice to stimulate the development of critical thinking among nursing students.Which technology-supported guidance models are used to stimulate the development of critical thinking in the context of clinical practice in nursing education?What is known about the challenges and facilitators of such technology-supported guidance models?This mixed methods systematic review will be guided by the Joanna Briggs Institute Manual for Evidence Synthesis and will have a convergent integrated design . The conWe will include evidence that addresses preregistration or undergraduate nursing students in clinical practice; further details on the inclusion and exclusion criteria are provided in A systematic, comprehensive search strategy will be built through an initial search in MEDLINE and CINAHL by an experienced research librarian, the first author, and the last author using subject terms, Medical Subject Heading terms, CINAHL headings, and text words. The search strategy includes terms chosen based on an initial search and discussion within the review team. The search will be limited to publications in English, Slovak, Hungarian, Czech, Spanish, Portuguese, Finnish, Norwegian, Swedish, and Danish. To capture the studies most relevant to current and emerging technologies in nursing education, the search strategy will be limited to articles published from January 1, 2010 through December 31, 2020.The search strategy will be tested and retested  in the iIn addition, forward and backward reference searches will be conducted. A search for unpublished studies and other grey literature will not be included. The rationale for not conducting a search for grey literature is the lack of a standard, accepted systematic procedure for such searches . This laRecords will be managed through EndNote  , and RayTitles and abstracts will be screened independently by pairs of authors  based on the inclusion and exclusion criteria for the review. From this selection, the full-text articles will be assessed independently by pairs of authors against the inclusion and exclusion criteria for the review. The final decision on whether to include or exclude articles will be made by consensus between the team of authors. An overview of the selection process that will be used is shown in a PRISMA  flow diaStudies eligible for inclusion will be critically assessed for their methodological quality. The critical assessment will be conducted by pairs of authors  according to checklists specific to the study design. The tools used to assess the methodological quality of the studies are shown in All studies, regardless of the results of the assessment of methodological quality, will be included in the data extraction and synthesis, but the results of the assessment of methodological quality will be elaborated on in discussion, and the results will be displayed in appropriate tables.Quantitative and qualitative data will be extracted by pairs of authors  from studies that meet the inclusion criteria using the standardized Joanna Briggs Institute mixed methods data extraction form and following a convergent integrated approach . The extcritical thinking, as defined in The primary outcome is critical thinking, as defined by Facione , as wellTo facilitate combining qualitative and quantitative data, quantitative data will first be transformed into qualitized data. The process of qualitizing data refers to converting quantitative data into themes through textual description of quantitative data in relation to the review question . This wiAccording to the Joanna Briggs Institute Manual for Evidence Synthesis, the assessment of the certainty of evidence using GRADE  is not recommended for mixed methods systematic reviews .A comprehensive systematic search strategy was developed by a research librarian in MEDLINE and CINAHL and reviewed by a second research librarian (completed in October 2020). Initial database searches were performed on October 21, 2020, and resulted in 7307 publications. After the removing 3861 duplicates, we began screening the titles and abstracts of 3446 publications in addition to conducting manual searches and contacting researchers in this field. From the results of this selection, we will assess the full-text articles. We anticipate that the review will be completed by January 2021. In this mixed methods systematic review, we will discuss the contribution of technology to guidance models that are employed in nursing education clinical practice settings, focusing on the stimulation and development of critical thinking among nursing students.Technology is an important part of nursing education that has the potential to significantly improve it, especially in clinical practice . EarlierOne of the limitations of this study is the exclusion of unpublished studies and other grey literature. Such material can potentially benefit a systematic review, but the challenges of searching for grey literature and including its findings  outweigh


When attempting to provide lessons for other countries from the successful Israeli COVID-19 vaccine experience, it is important to distinguish between the modifiable and non-modifiable components identified in the article by Rosen, et al. Two specific modifiable components included in the Israeli program from which the US can learn are (a) a national  strategy for vaccine distribution and administration and (b) a functioning public health infrastructure. As a federal government, the US maintains an often complex web of state and national authorities and responsibilities. The federal government assumed responsibility for the ordering, payment and procurement of COVID vaccine from manufacturers. In designing the subsequent steps in their COVID-19 vaccine distribution and administration plan, the Trump administration decided to rely on the states themselves to determine how best to implement guidance provided by the Centers for Disease Control and Prevention (CDC). This strategy resulted in 50 different plans and 50 different systems for the dissemination of vaccine doses, all at the level of each individual state. State health departments were neither financed, experienced nor uniformly possessed the expertise to develop and implement such plans. A national strategy for the distribution, and the workforce for the provision, of vaccine beyond the state level, similar to that which occurred in Israel, would have provided for greater efficiency and coordination across the country. The US public health infrastructure was ill-prepared and ill-staffed to take on the responsibility to deliver > 450 million doses of vaccine in an expeditious fashion, even if supply of vaccine was available. The failure to adequately invest in public health has been ubiquitous across the nation at all levels of government. Since the 2008 recession, state and local health departments have lost > 38,000 jobs and spending for state public health departments has dropped by 16% per capita and spending for local health departments has fallen by 18%. Hopefully, COVID-19 will be a wakeup call to the US with regard to the need for both a national strategy to address public health emergencies and the well-maintained infrastructure to make it happen. The article by Rosen et al.  outlinesFortunately, Rosen and colleagues also provide several modifiable components of the Israeli experience that can serve as a framework for countries currently struggling with their COVID-19 immunization programs. With specific regard to the United States, I believe there are two components that stand out as important lessons to be learned and for which both short and long term action can be taken. These actions could directly impact the effectiveness of the current COVID-19 vaccine program and increase the readiness and capacity of the US to address any future pandemic. The two components are (a) a national  strategy for vaccine distribution and administration and (b) a functioning public health infrastructure, potentially operationalized through a combination of components of the public, private and not-for-profit sectors in a coordinated mechanism as needed.As a federal government, the US maintains an often complex web of state and national authorities and responsibilities. The fundamental authority of the states in many matters stems from the 10th Amendment to the US Constitution: “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people” . OriginaThe federal government assumed responsibility for the ordering, payment and procurement of COVID vaccine from manufacturers. However, the formula for the amount of vaccine allocated to specific states remains opaque . FurtherThis strategy resulted in 50 different plans and 50 different systems for the dissemination of vaccine doses, all at the level of each individual state. State health departments were neither financed, experienced nor uniformly possessed the expertise to develop and implement such plans . As a reThe second modifiable component is the development and maintenance of a strong, well-trained public health infrastructure. The US public health infrastructure was ill-prepared and ill-staffed to take on the responsibility to deliver > 450 million doses of vaccine in an expeditious fashion, even if supply of vaccine was available. In the US, public health operates at a national, state and local level. The degree of coordination among those levels is highly variable across the nation. However, the failure to adequately invest in public health has been less variable, and is ubiquitous across the nation. Although investment in public health has not been a priority for decades, the problem has only grown more acute in recent years. Since the 2008 recession, state and local health departments have lost > 38,000 jobs, resulting in a skeletal workforce with insufficient staffing to meet many everyday needs, much less that of the increased demands of a population-wide immunization program [The public health infrastructure has also suffered from decreasing in funding for more than a decade, having an impact on the degree of preparedness it can maintain. Just since 2010, spending for state public health departments has dropped by 16% per capita and spending for local health departments has fallen by 18% . This isIn contrast to the US, the article by Rosen and colleagues points to a highly developed and motivated public health infrastructure guiding the success of the Israeli immunization program. Of significance is the coordinated role of both public agencies and a not-for-profit health plans in delivering public health services in Israel.Governments often can underfund preventive and public health efforts without consequence until a serious event occurs that lays bare the implications of that neglect. Hopefully, COVID-19 will be a wakeup call to the US with regard to the need for both a national strategy to address public health emergencies and the well-maintained infrastructure to make it happen.