Healthcare is a field in which the benefits of virtual reality (VR), such as risk-taking without consequences, direct experience, and service outcome prediction, can be utilized. VR technology has been used to help clients face environmental barriers by implementing a home environment in virtual reality without a home visit by an expert. This scoping review was conducted to identify the areas and implementation methods of the home modification process supported by VR technology. Twelve studies met the research criteria. The following three types of tools supported by VR technology for the home modification process were identified: educational tools for clients or specialists, home environment measurement tools, and intermediaries for decision making and collaboration between clients and specialists. Most of the studies reported positive results regarding the usability and acceptability of the technology, but barriers have also been reported, such as technical problems, inappropriate population groups for technical use, cost-related issues, the need for training, and fear that the technology could replace home visits. Thus, VR technology has potential value in the home modification process. However, for future clinical applications, additional studies to maximize the benefits of these VR technologies and address the identified problems are required. Home modification, as part of occupational therapy (OT) interventions, is a general compensatory strategy used to improve occupational performance and reduce environmental barriers in the home environment of clients with functional limitations ,2. It haHome modification services are organized in various ways in different countries; however, they share the involvement of multiple stakeholders such as paying authorities, builders, and interdisciplinary healthcare team members . To modiVirtual reality (VR) is an immersive and interactive technology that marks new milestones in the ways people interact with their environment and envision new approaches in their relationship to reality . The immE-health technologies, such as VR, enable user-centric access to healthcare. Clients receiving healthcare services can practice and experience target behaviors, and VR is useful in predicting service outcomes . RecentlNinnis et al.  reviewedThis review of VR technology use for home modification has applied a scoping review approach. According to the Arksey and O’Malley framework , scopingWhich areas of the home modification process are supported by VR technology and how is the technology implemented?How are the VR technologies evaluated in terms of usability, acceptability, and participant outcomes?What barriers to using the identified VR technologies were identified?The following three research questions present a broad scope of VR technology use for the home modification process:Related studies were identified according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines  Figure . We searThe inclusion criteria for the research articles included research emphasis on the use of VR technology for home modification and availability of quantitative or qualitative data in full-text English. We excluded protocol studies, dissertations, theses, conference abstracts, and viewpoints. We did not limit the subjects of the study  or the specific purposes of the use of VR technology , and we included studies in which VR technology was used in the home modification process. This review also included interventions using VR technology that are considered perspectives of OT practice in the home modification process, even if the technology developer or provider was not an occupational therapist.The study titles and abstracts were examined after the initial search, and full texts of eligible studies were obtained. The manuscripts were searched for the presence of inclusion and exclusion criteria. A consensus to include each study in the scoping review was reached between the authors.Data on the author, publication date, study design, home modification area, purpose, method, participants, main outcomes, and barriers were extracted from each article. One of the two authors performed data extraction, and the other verified that the data synthesis strategy was followed. A qualitative synthesis of the studies selected for this review was conducted. A tabular form was organized to compare the thematic information extracted from each study, and after analyzing the themes and barriers, textual descriptions were created for each study. The identification and extraction of thematic information was undertaken based upon areas of the home modification process supported by VR technology and the barriers in practice. Textual descriptions of each study are followed by the tabulation of results, grouping studies according to areas of VR technology use for home modification, the purpose and results of each study, how the technology was implemented, and VR technology barriers in practice. In The research literature on the use of VR technology for home modification was sparse at the time of this review, with only 12 articles meeting the inclusion criteria . Figure A total of 297 participants were included in the 12 studies. Sample sizes varied across the studies, ranging from 3  to 69 paThree VR-supported areas of the home modification process were identified from these studies. Four studies ,27,28,29Threapleton et al.  applied Palmon et al.  evaluatep ≤ 0.05 for 9/10 items). In addition, the participants improved their awareness of home hazard detection and became more aware of future modifications required in their own homes.Falls Sensei is a first-person 3D exploration game aimed at educating the elderly on external fall risk factors within the home environment. Users play a game to find all the risk factors present in each of the four areas  in the home. If they find a risk factor successfully, they are congratulated and a confirmation with an explanation of the risk factor is displayed on the screen. Money et al.  conducte® is a web-based virtual environment used as an educational tool for clinical evaluation and intervention in the home environment. It provides undergraduate students with educational opportunities for home modification interventions outside of the classic classroom environment. Sabus et al. [Second Lifes et al.  applied In other studies, VR programs were used to measure and evaluate the home environment, such as room size, furniture, and door width, for structural change to improve the accessibility of the client’s home and the selection of suitable assistive equipment. The potential for home measurement using an adapted commercial MagicPlan mobile application (MPMA) and laser distance measurer (LDM) was explored by Tsai et al. . They inThe 3D measurement aid prototype (3D-MAP) proposed by Hamm et al.  was desiMapIt, developed by Guay et al. , allows In five of the twelve studies, the virtual environment was used as a tool to help clients understand home modification choices and facilitate communication with practitioners in the home modification process.In three studies, 3D interior design applications were used. They supported the process of exploring a variety of potential interior designs and home modifications and allowed users to evaluate the relative benefits and challenges of these modifications before their implementation. Atwal et al.  exploredAoyama et al.  investigUnlike studies investigating cooperation and decision-making facilitation among stakeholders in the home modification process, Chandrasekera et al.  used AR Most studies reported technical problems, such as difficulty with the navigation controls ,28; a laThis scoping review was conducted to examine the areas of the home modification process supported by VR technology, the areas of VR technology that support the home modification process, use of VR technology, perceptions of outcomes such as usability and acceptability by users, and the manifestations of barriers in practice.The studies included in this review were either qualitative or descriptive studies to identify the problems and explore the feasibility of VR technology in the home modification process. It can be seen that VR currently requires further preparation for widespread use and future studies. The following three primary areas of VR technology for home modification support have been identified: educational tools for clients receiving home modification services and students learning home modification, tools for home environment assessment, and intermediaries for collaboration between the client and specialist. Home modification specialists in rehabilitation include an occupational therapist, physical therapist, and rehabilitation teacher responsible for determining home modification requirements and counsel throughout the environmental modification process, and a rehabilitation engineer, an architect with sufficient knowledge of disability-related accommodation and construction to develop bid-ready specifications, a contractor, or other individuals .Home modification VR for educational purposes was primarily implemented as computer simulation presenting a scenario in which the user experiences environmental barriers in a virtual home environment through an avatar and solves problems by trying potential solutions. Such computer simulation software makes it possible to transfer and apply the learned information to the physical environment and to predict dangerous situations or unintended consequences that may exist in the real environment . The occVR-based home measurement software is used to measure and evaluate the environment for structural changes to improve the accessibility of the client’s home and to select suitable assistive devices. In particular, the measurement of the client’s space is one of the processes necessary for the prescription and application of assistive devices, such as mobility aids  or commodes. This provides a justification for the need to purchase assistive devices to clients and related parties involved in financial supporting the health and welfare systems . The parVR can be a useful tool to help clients understand their environment modification choices and improve communication with specialists in the home modification process. A key task in the integration of healthcare and technology is to create opportunities for healthcare providers and clients to collaborate in the decision-making processes. To realize this, it is necessary for healthcare professionals to integrate and apply new technologies and services ,44. The Most of the studies included in this review described the development of software to support home modification and investigated the usability of the software. The studies reported the need for improvement and additional studies on the technical problems of the software. Thus, VR software requires further preparation and testing before it can be implemented in the home process in general. Although the studies included in this review reported positive results in usability evaluations, a number of technical problems and modification recommendations have been raised in studies that applied software to support home modification. Many technologies that have been developed in the healthcare field are not adopted or are abandoned for various reasons . While tOnly 12 studies were included in this review, and although some included quantitative data such as surveys, most studies were qualitative and focused on exploring the feasibility or usability of VR technology to support home modification. Therefore, it is not possible to demonstrate broad and general aspects of the usability or the effectiveness of VR technology for this purpose. Further studies on usability, feasibility, and the effectiveness of VR technology in the current home modification support system are also required. Furthermore, as the study sample was limited to the selection strategies described in the materials and methods section, it is possible that relevant studies were missed. Future research could extend the search to include additional databases or map the field over time.This review primarily explored findings in the area of VR technology applications in the home modification process and their aspects, such as usability and acceptability. VR technology has the potential to improve client awareness of home safety, provide important information on home modification, and could be used as a useful educational tool in training home modification specialists. VR-based home measurement software can be used as an alternative or complement to in-person measurements through home visits. It also has the potential to be utilized as a tool to help clients understand their home modification choices and improve communication with specialists in the home modification process. Although most of the studies showed positive responses in the usability evaluations, perceived usefulness, and acceptability, technical problems and correction recommendations were also identified according to the VR application area. Further studies on VR technologies that effectively support the home modification process by maximizing the usability and benefits of software and addressing the identified technical problems of the software should be considered.


The rapid development of artificial intelligence (AI) has brought many opportunities and challenges to organization. Some studies have shown that AI can improve organizational creativity. However, the existing research lacks an effective transformation path. This paper makes an innovative approach from the perspective of knowledge sharing, establishes an integration model of artificial intelligence capability, knowledge sharing and organizational creativity. Based on 189 questionnaire data, we use multi-level regression analysis and bootstrap method to analyze the influence mechanism. The results show that artificial intelligence has a positive effect on knowledge sharing, knowledge sharing has a positive effect on organizational creativity, knowledge sharing mediates the relationship between artificial intelligence and organizational creativity, and organizational cohesion has a positive moderating effect on the relationship between artificial intelligence and knowledge sharing. The results supplement the existing research on the relationship between artificial intelligence capability and organizational creativity, expand the theoretical boundary and application space from the perspective of knowledge sharing at the organizational level, and provide reference for organizations to improve creativity. Artificial intelligence (AI) has been regarded by many as the next source of business value, as a strategic technology leading a new round of technological revolution and industrial transformation. Its rapid development brings many opportunities and challenges to organizations. To acquire key artificial intelligence technologies . ArtificKnowledge sharing (KS) is very important for firms to achieve strategic goals because it can help firms generate new sources of knowledge through collaboration and creation, significantly update firms’ problem-solving skills and increase awareness of sharers’ decision-making process. Creativity is the basic feature of human intelligence and also the inevitable challenge of artificial intelligence. At present, scholars have applied artificial intelligence into practice and made wonderful movie trailers that generally require the assistance of human creativity, promoting the possibility of artificial intelligence to increase personal expertise and creativity .In order to solve the impact of artificial intelligence on organizational creativity, some scholars creatively proposed the concept and framework of artificial intelligence capability, designed its scale, and studied the impact of artificial intelligence capability on organizational creativity and organizational performance . HoweverIn order to make up for the shortcomings of the above research, we have done the following unique work: Firstly, we introduce the concept of artificial intelligence capability and examine its relationship to organizational creativity. Secondly, we explore the influence path between AI capability and organizational creativity from the perspective of knowledge sharing. The improvement of organizational creativity from the perspective of knowledge is the key to the embedding of AI. Finally, we think that the knowledge sharing as one of the critical paths, need to be taken seriously in the organization, so we explore the effect of group cohesion, further explore whether it helps to promote AI capability for knowledge sharing, this has important implications for complementing the combination of artificial intelligence and organizational behavior.This paper has the following contributions: At the theoretical level, it promotes the understanding of the AI capability and explores the improvement path of organizational creativity. In addition, we emphasize the new influencing factor that promotes the improvement of organizational knowledge sharing under the embedding of AI, which refers to organizational cohesion. This is consistent with the previous thought that managers can better understand team cohesion, so as to help managers play the best in the team . At the This paper mainly carries on four levels of research: firstly, studies the relationship between AI capability and knowledge sharing; Secondly, the relationship between knowledge sharing and organizational creativity is studied. Thirdly, the mediating role of knowledge sharing between AI capability and organizational creativity is studied. Fourthly, the positive moderating effect of organizational cohesion on AI capability and knowledge sharing is studied. Based on the above theories, the theoretical model and hypothesis of this study are shown in With the rapid development of science and technology, artificial intelligence technology has been infiltrated in all walks of life. Therefore, the concept of AI capability is put forward, which refers to the ability of a firm to select, orchestrate, and leverage its AI-specific resources. Scholars put forward the concept by referring to IT capability, resource-based theory that provides explanations for sustainable competitive advantage , and artFor an organization, knowledge plays a very important role in its development, and knowledge management (KM) is a basic process that can promote its development from the perspective of long-term sustainable development . KnowledRecent research on artificial intelligence and business value argues that organizations must cultivate a culture of teamwork, collective goals and shared resources in order to give full play to the value of AI technologies . Strong H1:Artificial intelligence capability has a positive impact on knowledge sharing.Knowledge management refers to all the processes of organizational knowledge from creation to sharing, from transfer to transformation, and from explicit to implicit integration . KnowledH2:Knowledge sharing has a positive impact on organizational creativity.AI capability means the extent to which a firm can make good use of and master its AI-specific resources . ResearcAI capabilities enable organizations to invest in flexible data storage, technologies that process data quickly and run complex algorithms, and technologies that facilitate knowledge sharing . In addiH3:Knowledge sharing mediates the relationship between AI capability and organizational creativity.It has been pointed out in the literature that AI contributes to the innovation process, and may even contribute to the knowledge base and innovation results of firms, while social cohesion around relationships will affect individuals’ willingness and motivation to share knowledge with others . In todaH4:Organizational cohesion has a positive moderating effect on the relationship between AI capability and knowledge sharing.To test our hypothesis, this research adopts a questionnaire survey. At present, more and more firms have mastered artificial intelligence technology. Artificial intelligence technology has been widely used in various organizations, people from all walks of life can access to artificial intelligence technology. This paper mainly selects the Chinese high-tech firms as the survey object.First, we get the information of high-tech firms from several large innovation ecosystems in China , including name, address and contact persons. After that, we use e-mail, media software and other means to contact the firm and invite employees to fill in the questionnaires. We will state that the questionnaire is only for scientific research and there is no potential conflict of interest. After obtaining the consent of firms, we will officially send the network link address of the questionnaire. The data collection process lasted for 4 months, and 204 questionnaires were collected. However, in order to ensure the high quality and validity of the questionnaire, the invalid questionnaires need to be removed. The reasons include too short time of filling in the questionnaire (less than 5 min), empty and invalid information. Finally, a total of 189 high-quality questionnaires were obtained. The descriptive statistics of the sample are shown in In order to ensure the reliability and validity of the measurement scale, mature measurement scale projects were selected in this study, and appropriate adjustments were made to the research scenarios.Referring to the relevant researches of scholars, artificial intelligence capability consists of 38 questions , and knoThe items in question in this paper were all scored on a 5-point Likert scale, that is, from 1 to 5 indicating never to complete agreement.r = 0.715, p < 0.01), knowledge sharing was positively correlated with organizational creativity , this result preliminarily supports hypothesis 1 and hypothesis 2.Descriptive statistics and correlation coefficients are shown in As shown in SPSSAU was used to directly test its validity through confirmatory factor analysis of the maturity scale see . The resKaiser-Meyer-Olkin (KMO) and Bartlett test results are shown in This study aims to explore the impact of AI capability on organizational creativity. Multi-level regression analysis is used to analyze the correlation between variables and their moderating effects. The core of multiple regression analysis is regression analysis, the difference is that hierarchical regression can be divided into multiple layers, with each layer adding more polynomials above the previous one. This method can solve the problem of whether more polynomials have explanatory power to the model. In addition, bootstrap sampling was used to test the mediating effect. The basic idea of bootstrap sampling is to construct the estimated confidence interval through multiple sampling and partial sample release when the complete sample is unknown. This method has high testing efficiency and does not impose restrictions on the intermediate sampling distribution.In this paper, SPSSAU software is used to perform multi-level regression analysis on the hypothesis.As shown in F = 1.333, p > 0.05). This indicates that the four control variables of gender, education level, firm nature and firm scale have no significant influence on the logical path of knowledge sharing.The explanatory variable of this study is knowledge sharing. Model 1 tested the effect of control variables, and the model’s F-test showed that the model did not pass the F-test (p < 0.05). This means that AI capabilities add explanatory meaning to the model. In addition, the R2 value increased from 0.028 to 0.509, suggesting that AI capabilities could explain knowledge sharing with a 48.1% power. Among them, the regression coefficient value of artificial intelligence capability is 0.735, significant , indicating that there is a significant positive correlation between artificial intelligence capability and knowledge sharing, supporting hypothesis 1.The results of model 2 show that after artificial intelligence capability is added to model 1, f value changes significantly . This indicates that the four control variables of gender, education level, firm nature and firm size have no significant impact on the logical path of organizational creativity.The explanatory variable of this study was organizational creativity. Model 1 tested the effect of the control variable, and the F-test of the model showed that the model did not pass the F-test (p < 0.05). This means that knowledge sharing adds explanatory meaning to the model. Furthermore, R2 increased from 0.012 to 0.231, suggesting that knowledge sharing accounted for 21.9% of organizational creativity. Among them, the regression coefficient value of knowledge sharing is 0.734, significance , indicating that there is a significant positive correlation between knowledge sharing and organizational creativity, supporting hypothesis 2.The results of model 2 show that after knowledge sharing is added to model 1, f value changes significantly  and knowledge sharing for the regression coefficient of the organizational creativity(b) were significantly, and the direct effect(c’) is significant, a * b and c’ prime are both positive signs.These results suggest that knowledge sharing plays a partially mediating role in the positive impact of AI capability on organizational creativity, H3 confirmed. The mediation role test results are shown in In this study, the influence of AI capability on knowledge sharing was studied to see whether the variable of organizational cohesion could play a moderating role, that is, whether there was a significant difference in the influence range of artificial intelligence capability on knowledge sharing when the variable of organizational cohesion was at different levels. And put four control variables into the model. Before the analysis, AI capability and organizational cohesion are first treated centrally, and dependent variable knowledge sharing and control variable are not treated.Adjusted using multilevel regression analysis function test, this paper will be divided into three models, the model 1 variables including AI capability, model 2 on the basis of model 1 to join the organizational cohesion variables, model 3 on the basis of model 2 to join the interaction of the two items .t = 13.765, p = 0.000 < 0.05), indicating that artificial intelligence capability has a positive and significant influence on knowledge sharing. The interaction between AI capability and organizational cohesion was significant . This means that when AI capability affects knowledge sharing, the impact range of organizational cohesion is significantly different at different levels, indicating that organizational cohesion plays a positive moderating role in the impact of AI capability on knowledge sharing.As can be seen from Based on the concept of artificial intelligence capability, this paper develops a research model of artificial intelligence capability on organizational creativity, which is mediated by knowledge sharing and moderated by organizational cohesion. This model deepens the research on AI capabilities, and improves the research on artificial intelligence capabilities from the perspectives of knowledge sharing and organizational cohesion. According to the data, this model can well explain the influence of AI capability on organizational creativity under the mediation of knowledge sharing. The research results can be summarized into the following four aspects.First of all, this paper introduces the concept of AI capability, explores the impact of AI capability on organizational creativity, and finds that AI capability contributes to the improvement of creativity. Artificial intelligence is hailed by many scholars and practitioners as a revolutionary and game-changing set of technologies in the business world . Some scSecond, this study explores the relationship between knowledge sharing and organizational creativity at the organizational level. Most of the existing researches study knowledge sharing and organizational creativity from the individual level , but lacThird, this paper explores the mediating role of knowledge sharing between AI capability and organizational creativity. Knowledge sharing within an organization can enable people to share and accept knowledge flow to improve individual and team performance, thus benefiting the entire organization . Some scFinally, this paper confirms the positive moderating effect of organizational cohesion on AI capability and knowledge sharing. From the organizational level, higher organizational cohesion will promote the impact of AI capabilities on knowledge sharing, which is of great significance for promoting knowledge sharing from the organizational perspective. We have emphasized the new influencing factor that promotes the improvement of organizational knowledge sharing under the embedding of AI, which refers to organizational cohesion. This is consistent with the previous thought that managers can better understand team cohesion, so as to help managers play the best in the team .To summarize, at the theoretical level, we establish an AI capability model, verifies the relationship between AI capability and knowledge sharing, and verifies the relationship between knowledge sharing and organizational creativity. In addition, the mediating role of knowledge sharing between AI capability and organizational creativity, and the moderating role of organizational cohesion between AI capability and knowledge sharing are also studied. It complements the influence of artificial intelligence capability research on organizational creativity, and expands the boundary and application space of organizational cohesion and knowledge sharing theory at the organizational level, thus providing reference for improving organizational creativity from the perspective of organizations.At the practical level, we provide suggestions on how to cultivate the ability of artificial intelligence and how to avoid the loss in the development of artificial intelligence; At the same time, this paper also provides a path to promote organizational creativity, and advocates the organization’s attention to knowledge sharing. This study puts forward necessary enlightenment for firm managers to cultivate organizational atmosphere and knowledge evolution under the virtuous circle. we also provide valuable suggestions for the development of AI capability in order to improve product innovation.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Jilin University. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.NL: designing. YaY and YuY: writing. AG: providing revised advice. 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.


P < 0.05). The SCL-90 scale scores of patients in both groups were not significantly different on the day of admission as verified by t values, and the SCL-90 scale scores of patients in both groups changed to a certain extent after hospitalization. The difference between the two groups was verified by t value.ENT patients have different types of diseases and clinical symptoms, and generally, patients have a low level of understanding of their professional knowledge about their ENT diseases. In this paper, quality nursing interventions in otorhinolaryngology require nursing staff to implement relevant nursing interventions in the process of implementing relevant nursing care, which should be based on patients' needs, and guide patients to perform rehabilitation exercises according to their individual conditions, in addition to establishing continuous nursing interventions with patients at the time of discharge with the help of modern technology. By comparing the nursing satisfaction of patients in the observation group and the control group, it was found that the nursing satisfaction of patients in the observation group who received humanistic nursing was higher, and the difference was statistically significant compared with that of the control group ( With socioeconomic development and increased demand for medical care, the need to provide better and better nursing care has become a new nursing requirement. Evidence-based nursing refers to the careful, accurate, and wise application of the best currently available research basis by nursing staff, followed by the development of a valuable, credible and complete care plan based on the nursing staff's own acquired knowledge, skills, and clinical work experience, taking into account the patient's values, wishes, and actual situation. Evidence-based nursing, developed on the basis of traditional nursing concepts, is a branch of evidence-based medicine, and evidence-based nursing is considered to be the best nursing approach at this stage and has gained importance in various departments –5. PatieSurgical patients are prone to various unsafe events after surgery due to a series of blows such as anesthesia and surgery. Among them, there is a category of “potentially critically ill” patients, whose condition is not very serious on the surface, and there is no obvious clinical manifestation of a specific organ failure, but if the condition of these patients is neglected and effective interventions are not taken in time, it is likely that their condition will deteriorate rapidly within a few hours or days and turn into critically ill patients and even endanger their lives . EnsurinEvidence-based nursing initially originated from evidence-based medicine, and then with the development of evidence-based medicine and the inspiration of ideas, the nursing discipline also began to adopt the approach of evidence-based medicine and the concept of evidence-based nursing emerged. Traditional nursing is disease-centered nursing, while evidence-based nursing is person-centered, so nursing thinking is completely different from traditional nursing. The urgent nursing problem of the ENT patient is the lack of knowledge of the patient's disease, the risk of airway obstruction, pain, negative psychological emotion, and lack of patient compliance, and the relevant literature search was carried out on the above problem, and 22 literature papers were selected to be highly scientific and reliable to create and personalize nursing plans, combining them with patient needs. The study showed that the observation group improved the rate of patients' health knowledge and satisfaction rate of nursing care. The SAS, SDS, and VAS scores of patients in the observation group were lower than those in the control group after care, and patient compliance was better than that in the control group, showing that evidence-based care is effective and more suitable for clinical care. In conclusion, the use of evidence-based nursing in ENT nursing can better solve the nursing problems that patients need to solve, and the nursing effect is better than traditional nursing methods.Patients with nasopharyngeal carcinoma often have two or more stable symptoms that coincide, interact, and influence each other as a cluster of symptoms that affect the patient's quality of life. In the sleep disorder symptom cluster, cancer and its treatment modalities can affect sleep quality, which can lead to depressed mood and reduced cognitive function . In contIn some nasopharyngeal cancer survivors, dental shutdown and dry mouth are chronic problems that may lead to malnutrition. Depression in cancer patients was also found to be significantly and positively correlated with their malnutrition, and patients' depression may reduce their desire to eat, thereby affecting their nutritional status. Poor nutritional status during treatment is a significant predictor of mortality in HNC, and its adverse consequences also include impaired immune function, reduced vitality, and decreased resistance to the disease, which leads to increased morbidity and increased complications due to the side effects of treatment . In orden = 47) and a usual care group (n = 47), with case management consisting of care consultations, telephone contact, home visits, health education, and appropriate referrals, with care plans modified as necessary, resulting in case management. The intervention group with case management was more effective in controlling hypertension than the control group and improved in waist circumference, weight, and treatment compliance compared to the control group [The use of conventional continuity of care is highly discretionary, with an incomplete care program, lack of relevance, and no timely and effective evaluation and feedback mechanisms. Case management is widely used in the healthcare service industry as a cost-effective strategy for coordinating individual health needs, bridging the gaps in routine continuing care. It includes the management of a wide range of chronic diseases, such as hypertension, chronic obstructive pulmonary disease, and breast cancer, and has been used with significant success in practice. Researchers conducted a randomized controlled trial with 12-month follow-up in a primary care clinic in southern Brazil, where adult hypertensive patients were randomly assigned to an intervention group (ol group .A study of 103 patients with chronic obstructive pulmonary disease (COPD) found that patients who went through a case management intervention had a significantly higher quality of life than the control group . ResearcThere is a group of patients who are easily overlooked in clinical practice. They are apparently not seriously ill and do not have obvious clinical manifestations of a specific organ failure, but if they do not receive timely and effective interventions, they are likely to experience rapid changes in their condition within a short period of time and become critically ill or even their life becomes threatened. For this reason, healthcare professionals in various countries have been exploring various early warning scoring systems to quickly and accurately assess patients' conditions and identify potential risks at an early stage. Among them, the calibrated MEWS is gaining attention and recognition among healthcare professionals because of its easy availability, simple and quick assessment method, and high sensitivity in predicting changes in patients' conditions, as shown in At the end of the 20th century, due to a severe lack of medical resources in the UK, critically ill patients were unable to receive proper placement and timely and effective intensive care, resulting in a series of medical errors. In order to improve the situation, the UK government asked clinical staff to establish a faster and more convenient scoring system to help them identify the disease risk of critical patients early, so as to provide reasonable early medical intervention for patients with a certain risk index as soon as possible. To this end, the UK government has established the Patient at Risk Emergency Team to comprehensively assess the condition of “potentially critically ill” patients and recovering patients and to provide timely medical intervention or referral to a more appropriate medical unit. The early warning score (EWS) was first proposed by researchers and then, after extensive clinical research, the early warning score based on the EWS was endorsed by the National Health Service (NHS) in the United Kingdom as a method of assessing patients' conditions in healthcare settings. It was subsequently recommended and used by the British Intensive Care Society and the Royal College of Physicians of London to assess the risk of patients on integrated wards. A Severity of Illness Scoring Group, established by the NHS in the UK, developed the SEWS, which researchers applied to 848 acutely admitted patients and found that the SEWS was better able to identify high-risk patients. EWS and MEWS were gradually introduced into China and are widely used in emergency medicine, ICU wards, internal medicine, and other areas. Researchers added oxygen saturation to MEWS to form the corrected MEWS and compared MEWS with the corrected MEWS and found that the corrected MEWS was more accurate and sensitive than MEWS in assessing the condition and prognosis of patients with “potentially critical illness” in prehospital emergency. The accuracy and sensitivity of the calibrated MEWS were found to be better than the MEWS in assessing the condition and prognosis of “potentially critically ill” patients in prehospital emergency.The MEWS is an objective index tool for early identification of patients' risk of deterioration, and the patient's condition is evaluated by scoring 5 indicators and assigning a certain score to physiological indicators within a certain range , among wIn the corrected MEWS, temperature parameters were assigned a score in the range of 0 to 2. Respiratory rate, systolic blood pressure, heart rate, consciousness, and oxygen saturation were assigned a score in the range of 0 to 3. The total score was obtained by adding up the scores of individual parameters according to the parameter table, with the lowest score being 0 and the highest score being 17. The higher the total score, the more severe the condition. The scoring is done mainly by nurses. The scoring interval is related to the optimal trigger value for correcting the MEWS score. Some investigators used the following scoring interval: after the patient is admitted to the hospital, the nurse starts scoring and dynamically monitors the patient's vital signs every 4 h for a score of 1 to 3; every hour for a score of 3 on any single variable; every 30 min for a score of 3 to 5; and every 15 min for a score of 6 and above. Vital signs are monitored every 15 min for a score of 6 and above. The scoring system is easy to use, and medical staff can quickly obtain the relevant index parameters at the bedside and complete the patient scoring and condition assessment within minutes, as shown in Nurses can take appropriate action with patients based on optimal trigger values and a specially tailored early warning process. Applying the corrected MEWS to 300 prehospital emergency patients, researchers found that a corrected MEWS score of 5 or more increased the likelihood of patient admission to the ICU, and a corrected MEWS score of 8 or more increased the risk of patient death. Using the corrected MEWS, researchers retrospectively analyzed 171 patients admitted to a specialty inpatient unit after surgery on a surgical ward and found that the corrected MEWS was highly accurate in predicting patient transfer to the ICU, with a cutoff point of 5 being optimal: with a corrected MEWS score of 5 or less, most patients were treated in the surgical inpatient unit; with a score of 5 or more, patients were potentially at risk for change. Patients with a score of 5 or higher are potentially at high risk for change and need to be admitted to the ICU for treatment and increased level of care. The researchers applied the corrected MEWS to 275 patients with acute poisoning and found that a corrected MEWS score of ≥5.5 was the optimal cutoff point for criticality in patients with acute poisoning. Currently, most of the studies on the corrected MEWS score have been used clinically for acute and critical care, prehospital emergency care, pretest triage, and postoperative patient transport. Some scholars have explored the combined application of the corrected MEWS score with the addition of some relevant important physiological parameters, and some scholars have also explored the comparison between the corrected MEWS score and the MEWS score.P < 0.05) and were comparable.Sixty-four patients, 31 males and 33 females, aged 21–69 years with a mean age of 45.3 years, who were hospitalized for ear, nose, and throat diseases between September 2015 and September 2020 were selected. The primary diseases were mainly nasal polyps, chronic rhinitis, tonsillitis, rhinorrhea, otitis media, and acute laryngitis. The patients were randomly divided into observation group and control group, 32 cases each. In the observation group, there were 16 males and 16 females, aged 44.8 ± 12.0 years; in the control group, there were 15 males and 17 females, aged 45.5 ± 11.0 years, as shown in Patients in the control group were given conventional nursing care, including keeping the ward environment quiet, advising patients to get more rest, eating a diet with easily digestible food, and controlling the occurrence of infection complications. The observation group implemented evidence-based care on the basis of the control group, which mainly consisted of finding urgent nursing problems, and the nursing staff of the department searched for urgent nursing problems according to the type of disease and nursing experience and the needs of patients and categorized them as follows.After the patient is admitted to the hospital, we explain the relevant disease knowledge for the disease suffered and the treatment to prevent recurrence. For example, patients with chronic rhinitis should wear masks when going out in cold weather, avoid going to crowded areas as much as possible, etc. The causes of persistent rhinorrhea are more complicated, and once bleeding occurs, first apply local pressure to stop bleeding on your own and call medical personnel quickly, etc.Reasonable treatment measures should be taken immediately for acute laryngitis, and nursing staff should strengthen inspection, 1 time/30 min, and pay more attention to patients prone to tracheal tube dislodgement and take strengthening fixed intubation.For pain care, the ward can be configured with newspapers, play soft music, read newspapers, and listen to music to divert attention; do not let the patient endure in case of heavy pain; timely report to the doctor to be given appropriate analgesic drug intramuscular injection to reduce the patient's pain.Patients were psychologically assessed upon admission, and psychological assessment was performed with the Self-Assessment Scale for Anxiety (SAS) and the Self-Rating Scale for Depression (SDS) to find out patients' psychological problems. Nursing staff should work in an amiable and enthusiastic manner, learn to think differently about patients with more obvious psychological problems, and actively give psychological support.We should explain to patients the possible consequences of inadequate compliance and encourage them to cooperate with medical staff in all medical and nursing treatments and also explain to their families and friends so that they can obtain more social support and improve compliance.SAS scale: there are 20 items with 4 levels under each item, and a score of <50 is normal, with higher scores indicating more severe anxiety.SDS scale: there are 20 items, and a score of <53 is considered normal, with higher scores indicating more pronounced depressive symptoms.Pain level: the VAS visual analog scale was used, with 11 levels from 0 to 10, with higher scores representing more severe pain.Patients' compliance with treatment and care: we designed our own assessment criteria, including whether patients could take medication on time, whether they could cooperate with treatment, and whether they could cooperate with care. Adherence was scored on a scale of 1 for not at all, 2 for occasionally, 3 for basically, and 4 for completely.We observed the improvement of SAS and SDS scores, patients' knowledge of disease health, patients' satisfaction with nursing care, treatment and nursing care compliance, and pain level using visual analog score (VAS) before and after nursing care in both groups.x ± s) using t test, and the count data were expressed as (%) using χ2 test, and the difference was considered statistically significant at P < 0.05.The statistical analysis was performed using SPSS 17.0 statistical software, and the measured data were expressed as , and the satisfaction rate of patient care in the observation group was 93.75% higher than that of the control group, 68.75% ; see The knowledge rate of ENT diseases in the observation group was 84.38% higher than that of the control group, 46.88%  A literature search is conducted to find valuable and credible literature on the problem. (3) The value of the retrieved information is evaluated by nursing staff with expertise in the field. (4) Develop a plan that incorporates the screened and valuable empirical literature and the patient's needs. (5) Begin implementation of the care plan and assess the effectiveness of implementation through dynamic observation.The urgent care problems of ENT patients are the lack of patients' knowledge about their diseases, the danger of airway obstruction, pain, negative psychological emotions, and the lack of patient compliance, so we conducted a literature search for the above problems, selected 22 literature papers with high scientific credibility, and combined them with patients' needs to develop an individualized care plan. The study showed that the observation group improved the rate of patients' health knowledge and satisfaction rate of nursing care. The SAS, SDS, and VAS scores of patients in the observation group were lower than those in the control group after care, and patient compliance was better than that of the control group, showing that evidence-based care is effective and more suitable for clinical care, as shown in The calibrated MEWS is an objective tool for early identification of patients at risk of deterioration. In this study, we used the calibration MEWS used at Freeman Hospital in the United Kingdom and combined it with information technology and embedded it in an electronic nursing documentation system to achieve a simple and rapid application for early warning monitoring of the condition of patients undergoing general anesthesia and to objectively assess the degree of criticality and the potential risk of deterioration of the patient's condition by scoring the patient's pulse, systolic blood pressure, respiratory rate, body temperature (axillary temperature), consciousness, oxygen saturation (with sufficient oxygen), and urine output. Seven indicators are scored to enable early and objective quantitative assessment of the criticality of patients after general anesthesia and the presence of potential risks. Studies have demonstrated the ability of the calibrated MEWS score to determine the criticality of patients and to identify “potentially critically ill” patients. The corrected MEWS score is a tool used by health professionals to identify clinical deterioration of a patient's condition and can be considered a safety barrier in care, in addition to complementing clinical judgment. This study found that the early warning monitoring program, which clarifies the trigger criteria and interventions for nursing staff at all levels of monitoring precautions, can guide nurses to take appropriate interventions in a timely manner according to the scoring results and has been recognized by nursing managers and clinical nurses. In this study, it was found through interviews with nurses that nurses can assess patients' vital signs directly at the bedside with the help of the corrected MEWS score and that, after combining it with informatization, it can be imported directly into the paperwork records automatically, avoiding duplication of work and improving work efficiency to a certain extent, as shown in P < 0.005) and, at the same time, improved physician satisfaction with nursing care (P < 0.005) and patient satisfaction with nursing care (P < 0.005). This is consistent with the findings of Schwartz et al. [This study analyzed the occurrence of nursing adverse events in both groups, mainly including misaspiration, catheter slippage or blockage, unscheduled extubation, and fluid extravasation. The results of the study showed that the information-based condition alert monitoring program based on the corrected MEWS reduced the incidence of nursing adverse events , as shown in Patient condition monitoring is one of the important duties of nursing staff. At present, the clinical workload is large and junior nurses undertake a large amount of nursing work, but their relatively low mastery of professional knowledge and insufficient work experience lead to weak foresight of condition changes as well as observation ability, problem identification, and problem solving. The corrected MEWS score, as an objectified condition early warning scoring system, overcomes the defects of previous nursing staff's reliance on subjective judgment for condition observation, enables rapid and accurate identification of patients' conditions, and helps nursing staff obtain real-time and dynamic information about patients' condition changes. In this study, with the advantages of accuracy, efficiency, and convenience of computers, the corrected MEWS score was embedded into the nursing information system, and the corresponding parameters were automatically matched and the score was calculated, which not only can give full play to the advantages of high condition recognition of the corrected MEWS score and achieve dynamic assessment of the condition changes of elderly postoperative patients, but also avoid the risk of incorrect judgment of the condition due to manual calculation errors and improve the accuracy of the assessment. It improves the accuracy of assessment, reduces the nursing workload, and also provides strong support for nurses to dynamically monitor the changes in patients' conditions. The results of this study found that the informatization-corrected MEWS scoring system was able to reduce the postoperative vital sign monitoring of patients, but the difference was not statistically significant (P > 0.05), as shown in Corrected MEWS scores provide a rapid and accurate quantitative assessment of the criticality of a patient's condition and help nursing staff obtain real-time information about changes in the patient's condition, especially potential risk events, which can prevent medical risks caused by untimely and incorrect observation and treatment, thereby shortening the patient's hospital stay and improving the operational efficiency of medical resources. At the same time, due to its simplicity, easy access to information, low operating cost of its system, and not being limited by the hardware and equipment conditions of the hospital, the application of the corrected MEWS score does not require additional costs, and the informationized condition warning monitoring program based on the corrected MEWS also provides a graded monitoring program for the condition monitoring of patients after general anesthesia, ensuring that patients receive proper monitoring and treatment and avoiding unplanned transfers to the ICU. This will ensure that patients are properly monitored and treated, avoid unplanned transfers to ICU, further save medical resources, reduce patients' medical costs, and improve the rational allocation and effective utilization of medical resources. In this study, the number of cases transferred to ICU in the experimental group was less than that in the control group, but the difference was not statistically significant (P < 0.05) and nurses' own satisfaction with nursing work (P < 0.05). Nursing records and condition observation are the focus of nurses' work, and improving the quality of nursing record writing is important for improving the quality of care and the level of patient safety. Writing nursing records correctly and without errors usually takes a lot of nurses' time, and errors in writing nursing records may even cause medical disputes. At present, with the clinical workload, the relative shortage of nurses, and the increase of new nurses, the level of nursing documentation writing ability varies, and the nursing documentation records lack objectivity, continuity, and completeness. The informationized early warning and monitoring program based on corrected MEWS scores provides clear pathway and standardized management of nurses' condition observation and assessment, recording frequency, and content and relies on the computer to automatically calculate corrected MEWS scores, timely reminding nurses to assess patients' conditions, ensuring complete and continuous nursing assessment and recording, effectively reducing the incidence of nursing document recording defects, and standardizing nursing. This has effectively reduced the incidence of defects in nursing documentation and standardized nursing documentation.The application of the informatization system can improve the quality and efficiency of nurses' nursing documentation writing, effectively standardize nurses' behavior, reduce nurses' labor intensity, and improve the level of nursing documentation writing. The results of this study showed that the information-based early warning monitoring program based on the correction of MEWS can effectively improve the standardization rate of nursing records written by nurses (In this paper, the nursing model used in the clinic is no longer just disease-centered, and the holistic nursing model guided by the concept of the new biological, psychological, and social medical model is applied in clinical care. In order to meet the increasing nursing needs of patients, nurses should carefully complete patient-centered holistic nursing care, paying attention to meeting both the physical and psychological nursing needs of patients and giving full play to the role of psychological nursing to keep patients in the best physical and mental state so that their resistance to disease can be improved. In this study, patients in the control group only received conventional nursing interventions, while patients in the observation group received humanistic nursing. The degree of nursing satisfaction of patients with the observation group was significantly higher than that of the control group. In conclusion, the implementation of humanistic nursing can meet the nursing needs of endocrine patients, and while giving full play to the nursing-assisted treatment, it can also better improve patients' compliance and satisfaction with nursing care, which is worth applying and promoting in the nursing care of endocrine patients.


An unresolved issue in social perception concerns the effect of perceived ethnicity on speech processing. Bias-based accounts assume conscious misunderstanding of native speech in the case of a speaker classification as nonnative, resulting in negative ratings and poorer comprehension. In contrast, exemplar models of socially indexed speech perception suggest that such negative effects arise only when a contextual cue to the social identity is misleading, i.e. when ethnicity and speech clash with listeners’ expectations. To address these accounts, and to assess ethnicity effects across different age groups, three non-university populations (N = 172) were primed with photographs of Asian and white European women and asked to repeat and rate utterances spoken in three accents , all embedded in background noise. In line with exemplar models, repetition accuracy increased when the expected and perceived speech matched, but the effect was limited to the foreign accent, and—at the group level—to teens and older adults. In contrast, Asian speakers received the most negative accent ratings across all accents, consistent with a bias-based view, but group distinctions again came into play here, with the effect most pronounced in older adults, and limited to standard German for teens. Importantly, the effects varied across ages, with younger adults showing no effects of ethnicity in either task. The findings suggest that theoretical contradictions are a consequence of methodological choices, which reflect distinct aspects of social information processing. Social information and categorization thus shapes how listeners perceive speech. Effects of social information on speech processing may also arise when participants are merely told what the background of a speaker is. Believing that a speaker is from Detroit or Canada . This was followed by the foreign accent . The group of younger adults performed best across all speech contexts , followed by the teens . Repetition performance across all speech contexts was lower in the first half of the experiment than the grand mean , suggesting that listeners adapted to the talkers, i.e. repetition performance increased during the course of the experiment.Importantly, while no main effect of Face emerged , there was an interaction between accent and face, confirming changes in speech intelligibility (i.e. successful sentence repetition) across speech contexts as a function of perceived ethnicity. The effect was most pronounced in the foreign accent, with increased intelligibility in the Asian guise compared to the white European guise , as predicted by exemplar-based accounts. There was also a significant interaction with group, showing that the effect of face was more pronounced in the group of teens compared to the other two groups . Perceived ethnicity did not lead to enhanced intelligibility in the regional accent or in the standard accent in the first half of the experiment, but there was a significant interaction with experimental half in the regional context . This interaction suggests an intelligibility enhancement for the white European guise compared to the Asian guise in the second part of the experiment.To further investigate significant interactions, pairwise contrasts were extracted from the model to assess relationships between speech intelligibility and the fixed factors. The results, presented in 2 = 0.62). The model revealed a main effect of Face, such that across all speech contexts, the accent ratings were higher, i.e. more negative, for the Asian ethnicity when compared with the grand mean , in line with bias-based accounts. There was also a main effect of Accent, with foreign-accented speech being the most negatively rated , followed by the regional accent . There was no main effect of Group, but Group interacted with Accent and Face. Compared to the other groups, younger adults’ ratings of the foreign accent were more negative than for the other two accents , and the difference in ratings between the Asian and the white European ethnicity was smaller for the group of younger adults compared to the other two groups . This shows that the negative effect of the Asian ethnicity on ratings was least pronounced in the group of younger adults. None of the other interactions reached significance.Participants’ accentedness ratings in each age group and accent are given in The overall pattern of results supports previous suggestions in the literature. In line with bias-based accounts, the same acoustic signal was evaluated as more accented in the context of Asian women than white European women. However, differences between groups and across speech contexts emerged. To evaluate the outcome within each group and speech context, pairwise contrasts were extracted from the model. As can be seen in This study examined the hypothesized causal link between perceived ethnic similarity and social expectations in speech evaluation and comprehension, by comparing results from an implicit and an explicit task across three speech contexts and three age groups. There are two major conclusions to be drawn: first, both experimental methods showed partially successful integration of social information, but the consequences for speech processing and evaluation diverged. Sentence repetition performance as a function of perceived ethnicity squares best with socially indexed exemplar-based theories, but this holds largely for the foreign-accented context ,10,17,30Across all speech contexts and groups, the same acoustic signal was rated as more accented when presented alongside with photographs of women of Asian ethnicity than when presented alongside with photographs of white European women. This result lends credibility to bias-based accounts and reverse-linguistic stereotyping ,65, accoWhy might older adults’ accentedness ratings differ from those of teens and younger adults? Naturally, the interpretation of the task as well as the familiarity with rating tasks might differ between participants and result in large variation. In addition, inhibitory skill is one possible factor hypothesized to give rise to differences in stereotypes across the life span . As inhiAn alternative explanation is that life-long experiences with certain speakers and their language use shape distributional knowledge ,31,33,37The majority of previous studies reported negative ratings for standard speech with faces perceived as foreign  resulted in intra- and intergroup variation in language attitudes . Once foA clearly different pattern of results emerged for the sentence-repetition task. Repetition performance with foreign-accented speech increased in the context of the Asian ethnicity compared to the white European ethnicity, albeit only in the group of teens, and marginally in the group of older adults. In contrast, the regional accent was more intelligible  when it was associated with a photograph of a white European woman compared to a photograph of an Asian woman, but this effect was relatively small, and the marginal effects were limited to the second half of the experiment for the groups of teens and older adults. While this result goes in the predicted direction of socially indexed exemplar-based accounts, the effect is clearly malleable and somewhat ephemeral. The effects may also be explained by other accounts, such as the rational expectation-based account  or by thAn interesting aspect of the regional condition is its relatively low intelligibility; and the questionnaire results confirmed the difficulties associated with its identification as a regional dialect of German. Several participants assumed that they were listening to nonnative speech. For trials associated with white European women, the geographic origin of a talker speaking a regional dialect of German was less likely to be assessed as German, Swiss or Austrian than when speaking Standard German . Similarly, for trials associated with Asian women, a talker of a regional dialect of German was less likely to be assessed as German, Swiss or Austrian than when speaking Standard German . As a consequence, listeners might have needed more time to adjust to the regional speech and to update probabilistic cues and expectations accordingly. This flexible categorization of speech from nonnative to native and the resulting adjustment of expectations within the course of an experiment represent an interesting future testbed for the effects of ethnicity on speech adaptation.No effect of ethnicity on intelligibility of the standard accent emerged (note that accent ratings showed a reliable ethnicity effect in this condition), in contrast to reports from previous studies . This isIt is also possible that ethnicity effects in standard speech are mitigated when native and nonnative talkers are presented in a mixed fashion, and might appear more clearly in study designs that are limited to one speech context (as in ) or to bNote that the present study also employs slightly different measures in the sentence-repetition task for teens than for younger and older adults . This age-related adjustment to the design was made after the data collection with teens was completed. It is possible that the modality of the task could have influenced the overall effect size, because transcriptions are cognitively demanding and need more time than auditory repetition, which allows more time for the possible activation of attitudes and stereotypes. Interestingly, the main results are very similar across groups—for all groups, the intelligibility of the standard accent is better than that of the foreign accent, with both more intelligible than the regional accent. The main difference between the processing and the rating task with respect to the perceived ethnicity also remains the same, irrespective of the task modality. It would be of use for future methodological studies directly to assess the effect size of ethnicity in transcription tasks compared to oral response tasks.Despite descriptive similarities with respect to the ethnicity effects on the sentence-repetition performance across the three age groups, clear differences emerged regarding the habituation effect and the size of ethnicity effects. Age-dependent reliance on visual cues underscores diverging demands posed by the listening task, with different consequences for social cues integration across different age groups. There are at least three possible factors contributing to this variability, which need further examination in future studies: experience, cognitive and perceptual demands, and study design (as discussed above). Prior research has demonstrated a disadvantage for visual and auditory speech processing with increasing age.  suggest substitute for a theoretical attribute, but of devising a model structure to relate an observable to a theoretical attribute". Measurement is essentially continuous with theory construction; it is therefore important to understand how theoretical attributes (e.g. perceived ethnicity) relate to observations (e.g. as measured by sentence repetition or by accent ratings). The present work contributes to this debate by providing a methodological perspective on ethnicity effects in diverse speech contexts, across three age groups. The malleability of ethnicity effects for both measures shows the importance of substantial scrutiny of the methodological disparities used to support different theoretical accounts, and clarifies the need for further research to address the stability of social effects across intersecting categories, diverse contexts and age groups , the, the36])see also ,13,66).In summary, the results show that social and linguistic information interact across age groups in more complex ways than previously thought, underscoring the importance of diverse methodological approaches in diverse populations and speech contexts. Even though listeners might benefit from socio-indexical inferences during speech comprehension, successful comprehension is not limited to such inferences, and faces do not always speak volumes. Whether benefits or biases of social inferences for speech processing occur depends on the context in which the social information occurs, how it is perceived and interpreted by individual listeners, and how the experimenter assesses them.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.


The Future of Family Medicine Report calls for a fundamental redesign of the American family physician workplace. At the same time, academic family practices are under economic pressure. Most family medicine departments do not have self-supporting practices, but seek support from specialty colleagues or hospital practice plans. Alternative models for academic family practices that are economically viable and consistent with the principles of family medicine are needed. This article presents several "experiments" to address these challenges.The basis of comparison is a traditional academic family medicine center. Apart of the faculty practice plan, our center consistently operated at a deficit despite high productivity. A number of different practice types and alternative models of service delivery were therefore developed and tested. They ranged from a multi-specialty office arrangement, to a community clinic operated as part of a federally-qualified health center, to a team of providers based in and providing care for residents of an elderly public housing project. Financial comparisons using consistent accounting across models are provided.Academic family practices can, at least in some settings, operate without subsidy while providing continuity of care to a broad segment of the community. The prerequisites are that the clinicians must see patients efficiently, and be able to bill appropriately for their payer mix.Experimenting within academic practice structure and organization is worthwhile, and can result in economically viable alternatives to traditional models. The Future of Family Medicine Report  calls foMost departments have given up hope of operating self-sustaining practices, and seek support from their specialty colleagues in return for referrals and revenue generated by ancillary services. Such relationships are possible, as each dollar of revenue generated in the family practice can be linked to $8 of revenue within a health system . Still, Alternative models of operating academic family practices that do not require practice plan subsidies would be highly beneficial, especially if they were consistent with the goals and principles of family medicine. This article presents a series of alternative clinical office programs created by one family medicine department to address these challenges. The programs use a consistent accounting system, which allows for comparison across programs.The basis for comparison for the experiments is the traditional academic family medicine practice at Duke University, staffed primarily by family physician faculty, family medicine residents, physician assistants and nurse practitioners. It had been operating under the auspices of the faculty practice plan, common to all departments in the School of Medicine, which provides highly efficient billing and collection services. However, as with most academic family practices , the cenThe continuing deficits caused considerable attention to be focused on operating efficiencies, including patient flow, staffing ratios, and payer mix. Practice efficiencies eventually exceeded Medical Group Management Association (MGMA) private practice norms for work units per clinician full-time equivalent, and below median staffing. However, over a period of more than 10 years, the practice was never able to entirely cover its cost of operation.A financial statement from the best performing year in that decade is shown in Table Since 1998, the department has undertaken a number of "experiments" with different practice types and alternative models of service delivery. The intent of these was to develop practices that met the needs of the surrounding community, and could be financially sustainable.The first experiment was modest – to join in the academic health center's expansion efforts and establish a suburban family practice in a multi-specialty office , 40% said they would have gone to the emergency room if the clinic were not available. Emergency department diversion for uninsured patients represents a significant cost savings for the health system. As the clinic continues to grow, and establishes its patient panel, improved (though still deficit) operations are forecast for its third year.A third initiative was the establishment of clinics in 3 elementary public schools and a public high school in Durham. These clinics reach children and adolescents that are rarely seen in the traditional office. Each clinic is operated in donated space within the school with no overhead costs assessed to the department. The high school clinic is staffed by a nurse practitioner (NP) and a full-time nurse; the elementary school clinics are each staffed by a half-time NP and a receptionist whose time is donated by the school district. All clinics are supervised by off-site faculty physicians and all provide limited, elective learner participation. A financial summary of the high school clinic , and home health costs increased .Finally, the core teaching family practice was moved out of the faculty practice plan in 2002 and is now operating as a hospital-based facility  and nurse practitioners (NPs), with physician support for the more complicated patients, provide excellent care at a cost per visit lower than that of a physician working alone. While it is not clear what the optimal mix is of physicians to midlevel providers, our experience has been that the financial performance of the team increases with the number of PAs and NPs, but that the need for interaction and supervision will restrict a single physician from working with more than 2–4 midlevel providers. It has not yet been possible to test the model beyond a configuration of two midlevel providers per one physician, however, due to a shortage of qualified PAs and NPs.Family medicine departments in the United States face many challenges. Even when run efficiently, academic family practices can be financial burdens. But not all have to lose money – academic family practices can, at least in some settings, operate without subsidy. The prerequisites are that the practices must see patients efficiently, and be able to bill appropriately for their payer mix. Family practices can also help patients by offering accessible and affordable community-based alternatives. By creatively weaving together community resources to provide much-needed services to our underserved patients, family medicine departments can incorporate many of the elements called for in the Future of Family Medicine Report, and can demonstrate to skeptical learners and faculty that innovation in care delivery is possible.The author(s) declare that they have no competing interests.JM conceived of the study, and its design and drafted parts of the manuscript. TØ and VK participated in the design of the study, drafted parts of the manuscript and edited the mansucript. KK, KY, SY and MG helped in drafting and editing of the manuscript. JM, KK and SY oversaw data collection and management. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


School Health Index, a self-assessment and planning tool that addresses nutrition and physical activity.As school-based efforts increase to address the epidemic of childhood obesity, a priority for health professionals and educators will be to identify effective tools appropriate for use in schools to help guide health promotion programs and policies. This article describes the results of a qualitative research study examining school staff and community members' experiences working with the Centers for Disease Control and Prevention's School Health Index to develop nutrition and physical activity initiatives for students. Interviews were conducted twice: once after a school had completed the School Health Index and once approximately 1 year later. Transcript data from interviews with 34 participants were analyzed using thematic analysis.In-depth interviews were carried out with faculty, staff, and community collaborators in nine public schools that were using the School Health Index. Unlike staff in schools working on their own, school staff working with outside facilitators described completing the School Health Index in a collaborative way, creating action plans, and working as a team to implement health promotion initiatives. In addition, the involvement of an outside facilitator supported schools in undertaking more complex tasks with a greater degree of collaboration across the school and local communities in order to achieve goals.Findings indicated that school experiences differed markedly depending on whether they received help from an outside facilitator to work with the School Health Index and influence the organizational strategies they use to implement health promotion initiatives.Outside facilitators may significantly enhance schools' efforts to work with the  School Health Index: A Self-Assessment and Planning Guide (SHI) in 2000  and then again approximately 1 year later (Time 2). Interviews lasted an average of 45 minutes and were audiotaped and transcribed. Informed consent was obtained from participants before interviews. Participants were offered an incentive of $25 value. The Harvard School of Public Health institutional review board approved this study.Two semistructured interview guides were developed for the study. Interview questions at Time 1 elicited information about how the decision was made to work with the SHI, experience with the SHI manual, strategies used to complete the assessment, the role of the SHI coordinator and, if applicable, the role of a facilitator from outside the school, the types of health-promoting initiatives identified by the group as priorities, and the organizational strategies used to implement these initiatives. Questions at Time 2 explored the ways that members of the team worked together during the school year subsequent to completing the SHI self-assessment, the roles of the SHI coordinator and outside facilitator, the types of initiatives pursued since Time 1, and the organizational strategies used to carry out these initiatives.Research staff analyzed transcripts of interviews using the thematic analysis technique ,12 in whIn total, 52 interviews were conducted with 34 participants . Twenty-four interviews were with the LF group, 11 with the MF group, and 17 with the HF group. Approximately half of the interviews were conducted at Time 1 and half at Time 2. Study participants included school district staff, community agency staff, principals, school nurses, cafeteria managers, physical education (PE) teachers, classroom teachers, and one student. Schools participating in the study were ethnically and economically diverse. In three of the LF schools, approximately 85% of students were eligible for free or reduced-price lunches, and in the fourth school, 25% were eligible; in the MF schools, approximately 40% of students were eligible for free or reduced-price lunches; and in both HF schools, approximately 85% of students were eligible for free or reduced-price lunches.There were important differences by facilitation level in how well school teams followed CDC instructions for completing the SHI. In the LF schools, staff tended not to follow the instructions provided in the SHI manual. One school in the LF group distributed the SHI to staff and had them fill it out individually like a survey rather than complete it as a team. In another school, the SHI coordinator discussed the SHI with staff members individually, tabulated results, and came up with an average score. When asked about the SHI team structure, one participant from an LF school said, "Well, quite frankly, until today, I didn't quite realize we were part of the team." In contrast, MF and HF schools more consistently followed the instructions and worked as a team to complete the SHI, involving people from across the school community and, to some degree, the local community. They discussed the SHI during group meetings, then followed up with additional meetings to develop goals and action plans. In the MF and HF groups, decisions were made through consensus on scoring the SHI assessment and on goals and action plans.The MF group completed all of the SHI modules in one long meeting led by an outside facilitator, and then the team continued to meet monthly without the facilitator to discuss the team's action plan. Two staff members took on the role of team leaders and coordinated the monthly meetings and activities. The outside facilitator for the MF group, who worked on the district level, did not attend monthly team meetings but did provide guidance and technical assistance to the team as it worked on its action items. The two schools in the HF group completed three modules of the SHI at a series of monthly meetings led by the outside facilitator, and then the teams continued to meet monthly with the facilitator to work on their action plans.Members of the MF and HF groups perceived the facilitator as having a motivating presence in meetings, describing that they felt the facilitator kept the team focused, helped it achieve consensus on decisions, and guided it in following through with identified action items. A staff member in the HF group commented on how the team's experience might have been different had they not had a facilitator: "I think it probably would have been much more frustrating to try to get some policies or just get some consensus. I think it would have been more difficult. She [the facilitator] kind of keeps us on track."Participants from all three groups perceived that support from the school administration was essential. They described the following ways that they felt school administrators could support the efforts of health promotion teams: 1) ensure that staff have protected time to meet as a team; 2) participate in the team's meetings; and 3) authorize implementation of action plans. Before starting the SHI self-assessment, teams in both the MF and HF groups garnered support from the school administrators. In the MF group, the principal of the middle school participated in the team meetings. In the HF group, before initiating work on the SHI, the facilitator met with the school principals and staff and obtained a letter of support from the superintendent and agreement from the principals to allow the team to implement its recommendations. The facilitator from the HF group commented, "You absolutely need the approval, the blessing, of the principal to make this work." In three of the four LF schools, full support from the school principal was not obtained before embarking on the SHI self-assessment; the principals did not participate in team meetings nor did they agree to implement recommendations from the team.At Time 2, participants in all three groups spoke positively about the SHI and felt they became more aware of the importance of nutrition and physical activity while also noting that pressure from standardized testing and limited resources and staff time were obstacles to their efforts. The three groups diverged, however, during the school year (after completing the SHI) in the way that they described organizational strategies they used and the types of initiatives they pursued.During the follow-up year, the three groups differed in their reliance on teams and teamwork. In two LF schools, staff occasionally met in pairs or small groups to discuss the SHI results and the schools' health promotion needs, but none of the four LF schools held regular team meetings. In addition, LF schools did not develop and document action plans or work as a team toward defined goals for health promotion. In the MF group, participants met monthly without the facilitator, created an action plan, and worked toward goals. Two staff members continued in the role of team leader, and the outside facilitator provided guidance and technical assistance as needed. In the HF schools, the teams continued to meet monthly with the outside facilitator. Using what they described as consensus decision making, they identified goals and an action plan, focusing on a few priority issues, and worked as a team toward implementing those changes. A participant from a community agency in the HF group commented:School Health Index is a tool that's appropriate for a school that has a team in place, ready to begin and do some formal assessment and develop a formal action plan to improve the nutrition and physical activity environment in the school. I think that if you walk into any school cold, . . . you're going to meet with some resistance.I think the The kinds of activities and goals emerging from schools in each of the facilitation levels appeared to differ in two potentially important ways: task complexity and degree of collaboration used to achieve goals. Participants in LF schools described a variety of changes achieved by Time 2, most of which involved effort by one or two people. Changes mentioned included assigning a substitute teacher to teach PE classes that the regular PE teacher could not fit into her schedule, ordering exercise videotapes for PE classes and classroom resources on nutrition and physical activity, and allowing students access to the gym before and after school. With her school district facing drastic budget cuts, one PE teacher in the LF group considered the fact that PE classes had not been completely eliminated from the curriculum to be a positive result of their having completed the SHI assessment, which she believed had sensitized administrators to the need for PE. She also intimated that she doubted policy improvement in PE could be expected in her school:There was more of a push for more activity. We need more. [But] the schedule in and of itself cannot be changed. . . . Only the eighth graders get physical education two times a week. Everybody else gets it once a week. That's how the schedule allows it.In the MF group, activities achieved by the team in the year following completion of the SHI required substantial changes in school food service operations, including reducing the frequency that french fries were served, rearranging the lunch line so students passed by vegetables first, installing milk machines, and substituting baked for fried foods. In addition, the MF group planned and implemented a student health fair and staff wellness day and established a subsidized health club membership for staff. By the time of the second wave of interviews, however, several changes instituted by the school district, including the departure of a key advocate in the administration of the SHI team's work, had recently occurred. Members of the MF group felt these changes led the team to become less active. A staff member from the MF group explained:I think I would call this [second] year more maintenance. We have not stopped doing what we've been doing. We just haven't done probably as much. Maybe the momentum has slowed slightly. We still feel very strongly about it. We still would like to make changes. . . .In the HF group, the two schools' teams shared the same outside facilitator and began working on initiatives in similar ways. However, in one of the HF schools, near the end of the year, the district slated the school for closure, so the team stopped working on the planned changes. The other HF school differed from all the other schools in the study in that its team decided to focus on a single health issue that team members considered both important for student health and realistic for the team to address within the school year, given limited resources and time. In this school, the team chose to promote student hand washing before meals and snacks. Ensuring that students can wash their hands before meals and snacks is included as a recommendation in the school environment module of the SHI. Coordinating hand washing by hundreds of students every day required significant planning and collaboration across different sectors of the school community. The team planned this new initiative, gained approval of the school superintendent, developed an evaluation plan, acquired and installed hand-sanitizer dispensers, trained teachers on the new policy, and implemented the policy schoolwide to ensure that students washed their hands before eating snacks and meals. A participant from the school observed, "The fact that the team worked as a team and included everybody else, I think really helped move this thing along quickly."Participants in all three groups described insufficient funding for staff, sale of nonnutritious snack food to fund operating costs for school food services, and lack of physical activity space and equipment as barriers to health-promoting change. School staff from all three groups also reported that health programs and policies were at times seen by administrators as conflicting with student academic achievement. One teacher from an LF school described state and federal programs that she felt presented obstacles to health promotion efforts: "Well, unfortunately . . . right now their priority is the [state standardized testing] and the No Child Will Be Left Behind. . . and unfortunately, maybe as a result, other issues are left behind."Participants in the MF and HF groups described three central roles played by outside facilitators:1. Administration buy-in: Facilitators helped garner support from the administration before the SHI assessment was begun. They secured commitment from the administration to allow the team to meet regularly and to implement initiatives decided upon by the team.2. Team structure: Facilitators guided schools toward using a team structure, as recommended by CDC, to complete the SHI assessment and implement initiatives. Facilitators supported team structure by ensuring that 1) key stakeholders from across the school community and, to some degree, the local community were included on the team; 2) team meetings were held regularly for continued contact and communication among team members; and 3) team meetings were facilitated with an emphasis on consensus building and management of group tensions and conflict.3. Team sustainability: Facilitators helped teams become sustainable by maintaining team motivation and team cohesion through coaching and focus on feasible tasks to foster a sense of concrete gains and accomplishments.One participant from a community agency in the HF group emphasized the importance of the facilitator:School Health Index.Everybody in the school has a job to do, and this is in addition to their job. And having a facilitator who can lead — well, not necessarily lead, but help them lead, that can spot some of the stumbling blocks and help them get over those stumbling blocks faster, quicker, more efficiently and move towards completing action steps — is invaluable to the success of this project, to implementing the She saw the SHI as an important tool but not sufficient to effect change in schools: "A tool alone is not effective," she explained. "It's got to go in there with an advocate, with somebody to help it, help implement that tool."Across the nation, public schools are grappling with budget cuts, increasing demands on teachers' time, and political pressures to improve student performance on standardized tests. The schools in our study were no different. Despite the economic and academic pressures faced by all the schools in our study, school staff members working with the SHI with the help of outside facilitators, unlike those carrying out the work on their own, described completing SHI assessments in a collaborative way, creating action plans that involved complex tasks and required collaboration across multiple arenas of the school, and working consistently as a team during the school year to implement health promotion initiatives. The involvement of an outside facilitator appeared to be linked with meaningful differences in the strategies used by teams to work with the SHI and to implement initiatives.Staten et al recently reported results of a study of the SHI implemented in 13 public schools in Arizona, where the vast majority of students were Latino and from low-income households  development of action plans, including strategies for continuing to build political support for initiatives within the school community; 2) task complexity; and 3) degree of collaboration across the school community. Although our findings are suggestive, our model is preliminary, and continued research is needed to further characterize facilitator roles and organizational strategies used in schools working on health promotion initiatives.There were several limitations to our study. The majority of the schools were in New England, with just three in the Midwest; schools in other regions may have different experiences. In addition, our study relied on self-reported data and did not include a supplemental objective data source, which may have led us to overlook some important aspects of the schools' experiences.Based on our findings, we can make several recommendations for schools planning to use the SHI as a tool to guide their health promotion work. Before beginning the SHI self-assessment, it is important for schools to garner support from school administrators, perhaps even in writing. This buy-in should include a commitment to allow protected time for the team to complete the SHI and work on initiatives and commitment to implement team recommendations. Working with an already-established team may enhance this work. The team may benefit from including representatives from several different arenas of the school and local communities. A facilitator from outside the school, perhaps from the school district or a community agency, who has a commitment to work with the team for an extended period may be important, perhaps even essential, for some schools. Together, the facilitator and team need to anticipate and plan for likely obstacles.The federal Child Nutrition and WIC Reauthorization Act of 2004 included a new requirement that all school districts participating in the U.S. Department of Agriculture subsidized meals program must establish a school wellness policy for improving student nutrition and physical activity by the beginning of the 2006–2007 school year . This ne