High-altitude hypoxia exposure inhibits erythrophagocytosis by inducing macrophage ferroptosis in the spleen.

High-altitude polycythemia (HAPC) affects individuals living at high altitudes, characterized by increased red blood cells (RBCs) production in response to hypoxic conditions. The exact mechanisms behind HAPC are not fully understood. We utilized a mouse model exposed to hypobaric hypoxia (HH), replicating the environmental conditions experienced at 6000 m above sea level, coupled with in vitro analysis of primary splenic macrophages under 1% O2 to investigate these mechanisms. Our findings indicate that HH significantly boosts erythropoiesis, leading to erythrocytosis and splenic changes, including initial contraction to splenomegaly over 14 days. A notable decrease in red pulp macrophages (RPMs) in the spleen, essential for RBCs processing, was observed, correlating with increased iron release and signs of ferroptosis. Prolonged exposure to hypoxia further exacerbated these effects, mirrored in human peripheral blood mononuclear cells. Single-cell sequencing showed a marked reduction in macrophage populations, affecting the spleen's ability to clear RBCs and contributing to splenomegaly. Our findings suggest splenic ferroptosis contributes to decreased RPMs, affecting erythrophagocytosis and potentially fostering continuous RBCs production in HAPC. These insights could guide the development of targeted therapies for HAPC, emphasizing the importance of splenic macrophages in disease pathology.

The Impact of Income Inequality on Health Levels: Empirical Evidence from China:2002-2016.

Income inequality had been one of the important manifestations of social inequality, which can affect the health level by affecting savings, health care and living standards. Existing researches about the relationship between income inequality and health ignored the comprehensive characteristic of health concept, and did not consider the intrinsic relationship between health and income inequality. This paper attempts to re-shed light on the relationship. Firstly, this paper constructs a new health level evaluation system from three aspects: health basis, health environment and behavior, and health security. By means of the combination evaluation method, the health levels can be obtained. Then, considering the interaction between health and income inequality, a simultaneous equation group model is constructed to empirically test the relationship between income inequality and health levels in China. The results reveal that health level is negatively correlated with income inequality. Reducing income inequality plays an important role in improving health levels in China.

Hypobaric hypoxia induces iron mobilization from liver and spleen and increases serum iron via activation of ghrelin/GHSR1a/MAPK signalling pathway in mice.

Hypobaric hypoxia (HH) exposure affects appetite and serum iron levels in both humans and animals. Thus, whether appetite-regulating ghrelin is involved in iron regulation under HH needs to be elucidated. In vivo, C57BL/6J mice were placed in a hypobaric chamber to establish a 6000-m-high altitude exposure animal model. In vitro, mouse primary hepatocytes and peritoneal macrophages were exposed to hypoxia (1% O2) to examine the effects of ghrelin on iron-regulating proteins. HH obviously reduced the body weight of mice and significantly increased the levels of erythrocytes, and also significantly enhanced the levels of serum iron and plasma ghrelin. However, iron content in the liver and spleen was decreased, while ferroportin (Fpn) expression was increased. Moreover, ghrelin significantly induced Fpn and pERK expression in both hepatocytes and macrophages under hypoxia, which were reversed by pretreatment with growth hormone secretagogue receptor 1a (GHSR1a) antagonist or pERK inhibitor. Our findings indicated that HH leads to decreased appetite and insufficient dietary intake, which may negatively regulate the levels of ghrelin. Furthermore, GHSR1a/ERK signalling pathway is further activated to upregulate the expression of Fpn, and then promoting iron mobilization both in the liver/hepatocytes and spleen/macrophages in mice. Thus, these results revealed that ghrelin may be a potential iron regulatory hormone, and raised the possibility of ghrelin as a promising therapeutic target against iron disorders under HH.

The relationship between the local environment, N-type, spin state and catalytic functionality of carbon-hosted FeII/III-N4 for the conversion of CO2 to CO.

Iron and nitrogen codoped carbon (Fe-N-C) materials are promising alternatives to precious metal catalysts for the carbon dioxide electrochemical reduction reaction (CO2RR); however, the influence of the oxidation state, spin state, N-type and local environment of Fe-N on its catalytic activity remains poorly understood. In this study, we employed density functional theory (DFT) calculations to evaluate the catalytic activity of the pyridine-type FeIII/IIN4 motifs at the armchair and zigzag edges, the activity of the pyrrole-type FeIII/IIN4 sites in the bulk plane of carbon-based materials for the two-electron CO2RR by analyzing the stability of initial reactants, free-energy evolutions and energy barriers for the possible elementary reactions in the different spin states. The Fe ions in the armchair-edge pyridine-type FeN4 are mainly in the +2 oxidation state, and use the high spin state in the spin uncoupling manner to achieve the most efficient CO2-COOH-CO conversion. In contrast, the zigzag-edge pyridine-type FeIIN4 employs the medium spin state in the spin uncoupling manner to achieve the highest catalytic activity in the two-electron CO2RR. However, the Fe ions in the pyrrole-type bulk-hosted FeN4 mainly remain in the +3 valence state during the conversion process of CO2 to CO and utilize the medium spin state with spin coupling to obtain the highest catalytic activity. The corresponding kinetic analyses show that the armchair-edge pyridine-type FeIIN4 catalyst exhibited the best catalytic performance among the three cases. Consequently, these findings present significant insights into the design of Fe single-atom catalysts for enhancing CO2RR catalytic activity by producing more armchair-edge pyridine-type FeN4 sites, which may be constructed by introducing micropores in the carbon materials.

Impact of Two-Way FDI on China's Environmental Quality: The Perspective of Environmentally Cleaner Production and End Treatment.

While the rapid development of two-way foreign direct investment (FDI) has boosted China's economic growth, its impact on environmental quality is uncertain. Based on provincial panel data from China covering the period from 2002 to 2020, this paper proposes an environmental quality assessment index system for China from two aspects: environmentally cleaner production and environmental end treatment. The comprehensive environmental quality index (EQI), environmentally cleaner production index (EPI), and environmental end treatment index (ETI) were all measured, with the geographic information system tool and Dagum Gini coefficient used to analyse the indicators' differences using a system-generalised method-of-moments (SYS-GMM) estimation to study the impact of two-way FDI on environmental quality in various regions across China. The results demonstrate that during the sample period, inward FDI positively impacted environmental quality and cleaner production but had a negative impact on environmental end treatment. Outward FDI significantly promoted EQI, EPI, and ETI, and the interaction between inward FDI and outward FDI positively impacted environmental quality and environmentally cleaner production, while it negatively impacted environmental end treatment. This indicates that under two-way FDI, China's relationship with environmental quality has gradually evolved from 'pollution first and then treatment' to 'green development of cleaner production'.

Temporal and spatial evolution and influencing factors of urban ecological total factor productivity in the Yellow River basin under strong sustainable development.

A growing consensus worldwide has indicated the need to protect the ecological environment and achieve sustainable development. Ensuring ecological protection and high-quality development of the Yellow River basin have become China's major national strategy. We reviewed extant literature, summarised government reports and guidance documents on the Yellow River basin, and proposed introducing a strong sustainable development theory into the study of total factor productivity (TFP). The spatial-temporal evolution and influencing factors of urban ecological TFP in the Yellow River basin are of great practical significance. We proposed a new ecological TFP indicator: the modified input-oriented Luenberger productivity indicator (MIL). Using panel data from 78 cities in the Yellow River basin during 2003-2019, we measured the urban ecological TFP. We adopted the geographic information system tool and kernel density estimation to analyse the temporal and spatial evolution of the indicator, as well as its spatial effects and influencing factors, using the global Moran's I index and dynamic spatial Durbin model (SDM). Our results show that, during the sample period, our indicator increased in cities in the region with an average annual growth rate of 0.627%, driven by technological progress. The average annual growth rate in urban areas showed a decreasing distribution of 'downstream-midstream-upstream'. Fiscal decentralisation (FD), industrial structure (IND), financial development (FIN), urbanisation level (URB) and research and development (RD) investment improved growth rates in this and the adjacent regions through direct and indirect effects. However, environmental regulation (ER), opening level (OPEN) of cities and population density (POP) were obstacles to TFP growth.

The regional difference, dynamic evolution, and multidimensional inequality of China's ecological environment quality from the concept of ecological resilience.

Based on the concept of ecological resilience, this paper systematically constructs an evaluation system of ecological environment quality and dynamically measures the ecological environment quality (EQI) and its dimensional oriented indices: environmental pollution production (PPI), environmental pollution management (PMI), and ecological environment restoration (ERI). Then, the dynamic evolution of EQI, PPI, PMI, and ERI could be analyzed by the kernel density estimation and Markov chain, and the multidimensional inequality and its sources of ecological environment quality are studied by Maasoumi index. The main conclusions are as follows: China's EQI shows a tendency of slow growth despite swings. In terms of dimensional-oriented indices, PPI exhibits a slow decreasing trend, and PMI and ERI exhibit an ongoing upward trend. There are showing signs of sustained improvement of EQI across regions, especially in the southwest and northwest. Meanwhile, EQI has the evolutionary characteristics of increasing internal regional synergy and inter-regional differentiation effects. The multidimensional inequality of EQI shows a downward trend first and then an upward trend, and its contribution decreases in turn with "PPI-ERI-PMI." There are obvious differences in the multidimensional inequality of EQI across regions. The intra-regional inequality is absolutely dominant. The marginal contribution of this paper is to construct an evaluation framework of ecological environment quality based on the concept of ecological resilience and to conduct empirical research on China's ecological environment quality, so as to further explain the spatial distribution, evolutionary path, and formation mechanism of China's ecological environment quality.

Discovery of orally active 1,4,5,6,8-pentaazaacenaphthylens as novel, selective, and potent covalent BTK inhibitors for the treatment of rheumatoid arthritis.

Bruton's tyrosine kinase (BTK) plays a crucial role in adaptive and immune responses by modulating B-cell, Fc, toll-like, and chemokine receptor signaling pathways. BTK inhibition is a promising therapeutic approach for the treatment of inflammatory and autoimmune diseases. The development of novel, highly selective, and less toxic BTK inhibitors may be beneficial for the treatment of autoimmune diseases with unmet medical needs. In this study, structure-based drug design was used to discover a series of novel, potent, and selective covalent BTK inhibitors with a 1,4,5,6,8-pentaazaacenaphthylen scaffold. Among them, compound 36R exhibited high kinase selectivity, long target occupancy time, appropriate pharmacokinetic properties, and dose-dependent efficacy in a rat model of collagen-induced arthritis. Therefore, 36R is a novel BTK inhibitor requiring further development for the treatment of autoimmune diseases.

Ferrostatin-1 Ameliorates Liver Dysfunction via Reducing Iron in Thioacetamide-induced Acute Liver Injury in Mice.

Background and Aims: Hepatic iron overload always leads to oxidative stress, which has been found to be involved in the progression of liver disease. However, whether iron disorder is involved in acute liver disease and the further molecular mechanisms remain unclear. Methods: A mice model of acute liver injury (ALI) was established via intraperitoneal injection of thioacetamide (TAA) (250 mg/kg/day) for 3 consecutive days. Ferrostatin-1 (Fer-1) was administered intraperitoneally (2.5 µM/kg/day) starting 3 days before TAA treatment. Deferoxamine (DFO) was intraperitoneally injected (200 mg/kg/day) with TAA treatment for 3 days. We further observed the effect of Fer-1 on TAA model with high-iron diet feeding. ALI was confirmed using histological examination and liver function activity. Moreover, expressions of iron metabolism and ferroptosis proteins were measured by Western blot analysis. Results: The study revealed that the iron accumulation and ferroptosis contributed to TAA-induced ALI pathogenesis. TAA induced prominent inflammation and vacuolar degeneration in the liver as well as liver dysfunction. In addition, protein expression of the cystine/glutamate antiporter SLC7A11 (xCT) and glutathione peroxidase 4 (GPX4) was significantly decreased in the liver, while transferrin receptor 1 (TfR1), ferroportin (Fpn) and light chain of ferritin (Ft-L) expression levels were increased after TAA exposure. As the same efficiency as DFO, pre-administration of Fer-1 significantly decreased TAA-induced alterations in the plasma ALT, AST and LDH levels compared with the TAA group. Moreover, both Fer-1 and DFO suppressed TfR1, Fpn and Ft-L protein expression and decreased iron accumulation, but did not affect xCT or GPX4 expression in the liver. Both Fer-1and DFO prevented hepatic ferroptosis by reducing the iron content in the liver. Furthermore, Fer-1 also reduced iron and reversed liver dysfunction under iron overload conditions. Conclusion: These findings indicate a role of TAA-induced iron accumulation and ferroptosis in the pathogenesis of ALI model. The effect of Fer-1 was consistent with that of DFO, which prevented hepatic ferroptosis by reducing the iron content in the liver. Thus, Fer-1 might be a useful reagent to reverse liver dysfunction and decreasing the iron content of the liver may be a potential therapeutic strategy for ALI.

Spatio-temporal evolution of ecological environment quality in China from a concept of strong sustainability.

Based on the concept of strong sustainability, this paper builds a dynamic evaluation system on ecological environment quality from the concepts of ecological environment pollution and ecological environment management and puts forward the evaluation indexes including ecological environment pollution index (EPI), ecological environment management index (EMI), and ecological environment quality index (EQI). On this basis, kernel density estimation, Markov chain, Theil index, and dynamic SDM are used to reveal and explain the spatio-temporal evolution of ecological environment quality in China. The results were as follows. Overall, the EPI is decreasing while EMI and EQI are on the rise. In the long run, there is low possibility of upward and cross-level transition for EPI and EQI. The differences of EPI, EMI, and EQI are mainly caused by the regional differences. The regional differences have been reflected in the value of EPI, EMI, and EQI. It has been shown that the internal regional differences are continuously narrowing and the inter-regional differences are expanding. The convergence speeds of EPI, EMI, and EQI are 13.77%, 23.80%, and 9.69%, respectively. In the regional convergence test, different regions have shown different convergence speeds.

Short-run forecast and reduction mechanism of CO2 emissions: a Chinese province-level study.

Rational prediction of future CO2 at the regional level is essential to the carbon emission reduction targets in China. The primary aim of this study is to examine the applicability of an up-to-date forecast algorithm, namely dynamic mode decomposition (DMD), in provincial CO2 emission prediction. The testing results validate the accuracy and application value of the DMD short-run forecast, which may provide method reference for relevant policy formulation and research areas. Moreover, the 2020 provincial economic situation and CO2 emissions in China are projected via DMD. On this basis, the unqualified provinces regarding CO2 emission reduction are identified considering the relative standard and absolute standard, and the corresponding mitigation paths are proposed through decoupling analysis and shadow price calculation. The results indicate that the unqualified provinces include Heilongjiang, Gansu, Shanxi, Hebei, Liaoning, Jilin, Shaanxi, and Inner Mongolia. The open-emission-reduction mechanism should be adopted in the first five provinces; the conservative one should be applied in the other provinces. Graphical abstract.

Allocation of carbon emission allowance based on DLA-GA model: a case study in China.

To achieve China's determined contributions by 2030 and establish nationwide carbon emission trading system (ETS) which main participants are sectors, appropriated carbon emission allowance (CEA) allocation among sectors is crucial. In CEA distribution, fairness is primary; and sectoral efficiency is another significant factor. Nevertheless, considering fairness and efficiency while covering various sectors is a challengeable issue. Hence, combined with a new tow-objective data envelopment analysis (DEA) model and genetic algorithm (GA), a novel allocation framework is proposed, i.e., dual level allocation scheme incorporated with GA (DLA-GA). On the basis of evaluating the CO2 emission performance of various sectors in China, the corresponding allocation steps are put forward. Through the value convergence and value repetition tests, the stability and feasibility of DLA-GA are justified. Then, the results of the DLA-GA and grandfathering principle are compared. The research shows that: (1) under the same constraint conditions, the emission right of CO2 is allocated with DLA-GA, which leads to lower cost and higher overall sectoral performance; (2) through utilizing the En-Lorenz and En-Gini coefficients, it has found that higher allocation equity among sectors emerges via DLA-GA;(3) the key reduction sectors have been revealed through emission value estimation. This work may contribute to enrich the methodologies in CEA allocation at different dimensions, and provide some references for policymaker regarding the achievement of 2030 carbon reduction target.

[Legal Risk Management in Nursing Practice: The Importance of Duty of Care].

The steady and continued rise in medical-related disputes and lawsuits is one indicator of the myriad risks and challenges faced in today's nursing practice. When nurses become defendants, the lengthy litigation process and pressures that ensue greatly impact their professional and personal lives. Nursing practice dispute categories marked by particularly high severity and frequency over the past ten years include: (1) Failure to operate according to standard procedures, (2) Insufficient nursing sensitivity and negligent care, (3) Failure to communicate and deal with issues promptly and appropriately, (4) Beyond the scope of nursing practice, and (5) Falsification or alteration of nursing records. In this paper, the important duties of care in four major nursing practices are first summarized based on the relevant legal risks. Next, based on this, risk management procedures are prioritized, evidence-oriented nursing routine standards are set, and systematic analysis and management are conducted. In addition, to strengthen the legal awareness of nurses, nursing staffs, supervisors, and institutions must all understand clearly the three types of civil and criminal legal liabilities and their respective administrative responsibilities. Nurses should proactively work to handle the related legal risks and avoid the unpleasant consequences of civil liability in the realms of compensation, criminal punishment for negligent injury and homicide, and administrative disciplinary action.

[Reflections on the Nursing Work Environment in Light of the Experience With COVID-19].

Labor issues related to the nursing profession have been gaining prominence in Taiwan as well as overseas. In 2016, the United Nations highlighted the importance of societies investing sufficient funds in their professional nurses to support and promote public health, gender equality, and economic growth. Good-quality care requires that nurses have good physical and mental health, while creating and maintaining a friendly nursing work environment rely on cooperation among the government, labor unions, and hospitals. Over the past decade, the Taiwan government has increasingly promoted relevant regulations and established a friendly platform to allow nursing staffs to identify problems and report labor rights violations. In addition, nurses have formed unions to defend and advocate for their professional rights. After the outbreak of COVID-19 in late 2019, the Department of Nursing and Health Care of the Ministry of Health and Welfare actively proposed policies related to creating and maintaining good nursing work environments. The Taiwan Nursing and Medical Industries Union took a supervisory role in this process, providing feedback on policies from the perspective of Taiwan's professional nurses and arguing for the reasonable and fair subsidization of epidemic prevention facilities, implementation of mask and protective equipment, nursing labor rights, and social respect for the nursing profession. Much work still needs to be done to improve the domestic working environment for nursing staffs, including improving and expanding education, normalizing and effectively utilizing nursing staff feedback and whistleblowing information, promoting information transparency, and implementing better policies. We hope that a friendlier nursing work environment will attract many more outstanding young persons to pursue a career in nursing.

[Exploring the Stress, Psychological Distress, and Stress-relief Strategies of Taiwan Nursing Staffs Facing the Global Outbreak of COVID-19].

BACKGROUND: The global outbreak of coronavirus disease (COVID-19) began in December 2019. The high levels of stress experienced by nurses during this pandemic may have immediate and long-term effects on their mental health. PURPOSE: To explore the stress and psychological problems of nurses during this pandemic and to identify strategies used by these nurses to relieve stress. METHODS: A cross-sectional online survey was conducted that included a basic information datasheet, stress of nursing staff during COVID-19 outbreak scale, psychological distress scale, and stress relief methods survey form. Convenience sampling was used and a total of 469 practicing nurses participated in this study. RESULTS: Most of the participants expressed concerns about living problems (72.7%). On the stress questionnaire, the facets of "burden of taking care of patients" and "worries about social isolation" earned the first and second highest scores, respectively. In terms of items, "worrying about infecting family members and friends" and "worrying about being separated from family after being infected" earned the two highest scores (2.35 ± 0.79 and 2.17 ± 0.92, respectively). Scores for psychological distress averaged 5.49 ± 3.83, with stress anxiety (1.32 ± 0.84) earning the highest mean subscale score followed by distress and irritability (1.17 ± 0.92) and depression (1.12 ± 0.94). Nearly two-thirds (61.8%) of the participants earned psychological and emotional distress scores within the 'normal' range, and 3.4% earned scores indicating severe distress. "Receiving education and training" was the most common method used by the participants to relieve stress (2.27 ± 0.51). CONCLUSIONS: The following six strategies are proposed based on the above findings: (1) Caring: provide psychological assessment and care; (2) Supporting: create a friendly team atmosphere and provide support; (3) Inquiring: recruit volunteers with relevant experience; (4) Informing: provide timely, open, and transparent epidemic-prevention information; (5) Equipping: provide complete and appropriate epidemic-prevention education and training; (6) Assisting: establish a strategy for family support and caring to reduce the stress and worries of nurses.

[Infection Control: The Roles and Functions of Nurses Working at the International Medical Center].

Travelers are known to convey infectious diseases across international borders. After its experience with SARS, Taiwan established a comprehensive mechanism at its border to prevent the entry of infectious diseases. However, people with chronic infectious diseases, carriers with no symptoms, and those likely to be infected are not easy to identify during border screenings. Therefore, Taiwan must implement internal disease-containment measures in addition to stopping infectious disease at its borders. With increasing numbers of patients coming to Taiwan for medical examinations, medical aesthetic treatments, and medical treatments and care, the risk of acute, chronic, and contagious diseases originating from non-residents must be considered and addressed. This article was developed to discuss the role and importance of nurses in preventing transnational infectious diseases from the perspective of international medical care. In addition to showing rich nursing experience, sensitivity, and conducting the management and communication of international cases, it is also necessary to make good use of information tools for remote screening care. Taking the period of the COVID-19 outbreak as an example, several procedures have been conducted. First, online detailed history of infectious diseases and nursing evaluations are conducted before admission. Second, preparation and movement notifications are given before admission. Third, online health education and follow-up care as well as cross-unit communication and coordination are implemented. International medical nurses directly affect the quality and effectiveness of international medical treatment. As Taiwan builds up its brand as an international medical caring destination, nursing professionals should help further this trend and announce to the world: Taiwan can help! Nursing can help!

Measurement and space-time evolution of health level under constraint of environmental pollution, China: 2002-2016.

China's massive energy consumption and low energy efficiency have caused severe environmental pollution and posed great threat to the national health level. The general occurrence of health complications caused by cumulative environmental pollution in China is on the rise. This paper attempts to shed light on the evolutionary trajectory of health level in China under the constraint of environmental pollution. Firstly, on the basis of environmental pressure and environmental elasticity, an evaluation system of environmental pollution is constructed, and China's environmental pollution level is obtained with combination evaluation method. An evaluation system for measuring health level is proposed based on three dimensions of health, namely health foundation, health behavior and environment, and health protection. To avoid possible bias caused by neglecting environmental pollution in estimating health level and emphasize the health depletion by environmental pollution, this paper adopts pollution levels to correct health levels. Finally, an analysis is made concerning the temporal and spatial evolution characteristics of health level on the basis on the Theil index and spatial distribution map. The results reveal three facts: (1) Environmental pollution level in China is lowering with improvement in environmental quality; (2) The overall health level in China is rising, but the local health level is deteriorating; and (3) The spatial distribution of the health level is characterized by unbalance. From the perspective of difference, intra-regional difference is greater than inter-regional difference. The health level difference between the provinces in the same region is the main contribution to the overall difference. In terms of spatial distribution, the lower health level is mainly concentrated in the north, while the higher health level is found in the southern provinces and parts of the western provinces.

[A Challenge for Home-Based Hospice Care: Good Death at Home].

Taiwan is expected to become a "super-aged" nation in 2065. Modern medical advancements, while extending the average human lifespan, has led to higher incidence of patient suffering and greater medical expenses due to chronic disease and terminal illnesses. As the concept and services of hospice and palliative care have become increasingly accepted by the public, the issue of final care for a good death has become a priority concern for both patients and their families. Experiencing a good death at home is a common last wish for terminal patients. However, guidelines for good death at home are still unavailable in Taiwan. The promotion of this concept thus remains a challenge with many limitations. This article aims to explore: (1) the importance of hospice care; (2) the selection of a proper location for good death; (3) the requirements for nursing education in the care of dying patients; and (4) the challenges and strategies of a good death at home, including "the family dimension-connections with the family members" and "the education dimension-promotion of home-based dying in nursing education". The goal is to help terminal patients experience a good death at home, to assist family members embrace the good death of their loved ones, and, eventually, to facilitate peaceful and successful home-based dying for both the patient and their family members.

[Mutual Support Beyond Suffering and Mortality-Spiritual Care for Families of Terminal Cancer Patients].

With the progression of cancer and the approach of death in terminal cancer patients, the suffering of the family members of patients increases drastically, often leading into a difficult spiritual journey. The needs for spiritual care in this population generally consist of: 1. Empathy: Bearing the psychological stress due to the sharing of physical pain with the patients; 2. Powerlessness: Regretting not having the power to turn the tide; 3. Loneliness: Becoming exhausted due to facing heavy physical workloads alone; 4. Break down: Feeling hopeless in the face of the myriad challenges of care; 5. Despair: Feeling perplexed by the prospects of a desperate future; 6. Sorrow: Feeling bitter due to the realization that the disease is incurable and to being reluctant to acknowledge the parting. The spiritual needs of family members may be met by evaluating the needs for and resistance to spiritual care, followed by the use of religious and non-religious companions and the application of listening and empathy approaches in order to elicit positive thoughts and the values of love, forgiveness, and reconciliation. In strengthening their personal beliefs, family members may find connectedness with god, humanity, and objects; may see hope in life; and may find the meaning of suffering in order to further seek and find inner peace, accomplish themselves, and eventually achieve spiritual sublimation.

Building a bridge for nursing education and clinical care in Taiwan--using action research and Confucian tradition to close the gap.

BACKGROUND: Nursing workplaces in Taiwan are unable to retain talent. An examination of this problem has revealed that the causes of this phenomenon are that nursing education fails to cultivate the skills that meet workplace requirements and that there are gap between nursing education and clinical practice. OBJECTIVES: This paper is an action research that aims is to design educational programs that can close the gap between nursing education and clinical practice in Taiwan. DESIGN: In this action research project, 4 action cycles were used to design educational programs including concept mapping and focused discussion strategies. SETTINGS: Participants were invited to join the research in three teaching hospitals and one university. PARTICIPANTS: Two groups of participants, student nurses (SN) and nursing staff personnel (NS), were sampled and invited to participate in the research. METHODS: Participant observation, focus groups, and qualitative interviews were used to collect data. Qualitative data were not only profiled by content analysis, but they were also compared continuously between the two groups as well as between the 4 cycles. RESULTS: The qualitative data collected for the 135 participants were analysed. The themes of an effective nursing program were summarized. CONCLUSIONS: Many fundamental values of traditional Chinese education have gradually faded due to the Westernization of education. In this study, we discovered that Western educational models may play a critical role in improving traditionally taught nursing education programs.