Qualitative Descriptive Study Research Articles

Nurses' adherence to ethical principles - A qualitative study.

Nursing is regulated by a set of professional standards. Whilst many forms of ethics apply to nursing, the biomedical ethical framework is common, involving autonomy, beneficence, non-maleficence and justice. In healthcare, nurses often encounter ethical dilemmas that require them to navigate conflicting ethical principles. However, how nurses adhere to these principles in such situations is unclear. To explore how registered nurses adhere to ethical principles when dealing with ethical dilemmas at work. A qualitative descriptive study design. Between August and December 2023, 21 registered nurses were recruited from a teaching hospital through purposive sampling. Data were collected through semi-structured in-person interviews or online video conferencing. Braun and Clarke's thematic analysis approach was employed to analyse the data. Interview participation was voluntary. Written consent was obtained before participation. Participants' real identities were replaced with pseudonyms. This study was approved by the SingHealth Centralised Institutional Review Board. The data analysis developed four major themes and 15 subthemes. The four major themes are "Addressing the dilemma," "Contemplating the principles and consequences," "Coordinating for well-informed, ethical decision," and "Self-reflecting and finding consolation." This study explains how nurses navigate and uphold ethical principles when caring for patients to the best of their ability. Fully adhering to ethical principles can be challenging for caring for actively dying patients. Further research can expound on nurses' experiences and adherence to ethical principles in complex clinical cases.

Experiences of Second-Grade Primary School Children and Their Teachers in a Mind-Body Activity Program: A Descriptive Qualitative Study.

This study explored the experiences of second-grade children and their teachers who participated in a mind-body program to understand its impact on their development. A qualitative descriptive study was conducted. Student data were collected through seven focus groups, and semi-structured interviews were conducted with tutors in December 2021. Data analysis was performed following COREQ guidelines. Three themes were generated: (1) competitiveness and restlessness in children: something needs to be done; (2) seeds sown and fruits harvested; and (3) it is necessary to advance from the occasional to the structural. Participants reported positive changes in areas of their development such as self-regulation, relaxation, attention capacity, and stress reduction. Improvements in interpersonal relationships and social skills were also observed. These improvements in emotional well-being and social skills highlight the importance of this type of intervention in the school environment.

Health care providers' perceptions of family participation in essential care in the intensive care unit: A qualitative study.

Family participation in essential care may benefit patients and relatives. To examine the needs, perceptions and preferences of health care providers about family participation in essential care in the adult intensive care unit. A qualitative descriptive study using inductive thematic analysis. Three focus group interviews with a total of 30 intensive care unit health care providers, consisting of 20 critical care nurses, one nursing assistant, five physicians, three physical therapists and one speech therapist working in three Dutch intensive care units. One overarching theme, balancing interests, and four main themes emerged: looking after the patient's interests, taking the relatives' perspective into account, looking after interests of intensive care unit health care providers and conditions for family participation. The first theme, looking after the patient's interests, included three sub-themes: insecurity about patient's wishes and needs, patient safety concerns and potential benefits for the patient. The second theme, taking the relatives' perspective into account, was also characterized by three sub-themes: concerns about the relatives' possible burden, potential benefits for the relative and the relationship between patient and relative. The third theme, looking after interests of intensive care unit health care providers, included three sub-themes: attitude towards family participation in essential care, differing perceptions of essential care and concerns about intensive care unit health care provider's burden. The last theme, conditions for family participation, included two sub-themes: establishing a relationship and considering family participation in essential care as a process. Health care providers' perceptions and preferences regarding family participation in essential care in the intensive care unit are summarized in the overarching theme balancing interests. This overarching theme also reflects the needs and perceptions of patients and relatives. These findings may support critical care nurses and other health care providers when encouraging family participation in essential care.

An Exploration of the Knowledge and Current Practices of Frontline Workers Regarding Elder Abuse.

Annually, approximately 16% of adults aged 60 and older are victims of abuse in community settings. A critical first step toward effectively intervening and reducing the prevalence of elder abuse is to better understand the current state of knowledge, beliefs, and practices. This qualitative descriptive study explored the perceptions of US frontline community workers regarding elder abuse through focus groups and interviews conducted in the spring and summer of 2021. Participants represented various aging and victim services (n = 9), healthcare (n = 7), and law enforcement (n = 8). Thematic data analysis led to the emergence of three major themes in our data: societal influence, individual circumstances, and nature of abuse. Our findings point out several directions in which researchers and policymakers can begin moving the field forward. These include the need to focus on prevention strategies as well as the need to reduce ageist beliefs and attitudes.

Nursing Home Palliative Care Referral Process, Barriers, and Proposed Solutions: A Qualitative Study.

Despite evidence that specialized care for seriously ill nursing home (NH) residents is needed, barriers to accessing palliative care (PC) remain. A significant issue is the complexity of the referral process that inhibits timely and equitable access to care. This qualitative descriptive study explored the PC referral process in NHs. Using rapid qualitative analysis with semi-structured interview data from NH staff, primary care, and specialty PC providers (N = 17) in six states, this study outlines a multistep referral process along with barriers and proposed solutions. Key recommendations include comprehensive PC education program development, implementation of an evidence-based PC screening tool, and the holistic integration of PC services in NHs.

The Entrepreneurial Impact of the European Directive on Corporate Sustainability Due Diligence

The European Commission’s Directive on Corporate Sustainability Due Diligence, adopted in 2022 and approved in 2024, mandates that companies identify, prevent, and mitigate hostile human rights and environmental impacts across their operations and supply chains, integrating sustainability into corporate governance. This article examines the directive’s influence on European entrepreneurial activity, ecosystems, and innovation using a qualitative descriptive literature analysis, comparative frameworks, impact assessments, policy recommendations, and case studies. Findings suggest that while the directive imposes compliance challenges and costs, particularly for startups and small and medium-sized enterprises, it offers significant long-term benefits, such as improved risk management, enhanced reputation, and market differentiation. The directive promotes accountability and ethical practices, harmonizing due diligence across the EU and fostering a culture of sustainability. It concludes that companies addressing these impacts can gain a competitive edge and attract sustainability-focused investors, necessitating support mechanisms for startups and small and medium-sized enterprises to mitigate burdens and encourage compliance.

"It Isn't What I Had to Do, It's What I Get to Do": The Experiences of Black Family Caregivers Managing Dementia.

Black family caregivers of persons with dementia experience high levels of stress that can negatively affect caregiver health outcomes and reduce caregiving capacity. However, Black caregivers tend to report low levels depressive symptoms or other negative health effects. This qualitative descriptive study aimed to identify factors that contribute to resilience among Black family caregivers. Using the rigorous and accelerated data reduction (RADaR) technique to complete thematic analysis, a team of five coders examined transcript data from three focus groups of Black current and former family caregivers (n = 17) of persons with dementia. We identified three primary factors that contributed to caregiver resilience including access to supportive environments, adaptability, and planning skills. Caregiver resistance to reporting depressive symptoms may be attributed to the strong Black woman schema. Findings from this study may be used to develop future culturally responsive interventions that support caregivers and promote family health.

Contribution of Children's Literature in the Formation of Character of Elementary School Children

This study aims to describe the contribution of children's literature in character education and the selection of children's literature according to the developmental stage of elementary school children. This study is a qualitative-descriptive study of the library research type. Data collection techniques are by searching for sources and constructing from books on children's literature and accredited journals, then analyzing critically and in-depth. Based on the results of data analysis, it can be explained that the contribution of children's literature to the emotional aspect is obtained from demonstrations of life as demonstrated by the characters in the story so that children will learn how to manage their emotions so as not to harm themselves and others. In the intellectual aspect, children's literature contains sequencing and plot logic to support children's use of their minds to think, understand and criticize the stories they get. In the aspect of imagination, literature in its stories can attract the child's entire self. With this, the child gains an extraordinary experience that is significantly correlated with creativity and will provoke the growth and development of creativity. In the social aspect, children's literature demonstrates character interactions so that it supports children in maximizing their development in their proximal development zone. In addition, from an educational aspect, children's literature is connected to aspects of exploration and discovery, language, beauty, multicultural insight, and children's reading habits that influence reading habits and literacy culture, which are very necessary in facing the progress of science and technology in this era.

Working with Joanne Elphinston Movement Systems® - physiotherapists’ experiences in primary health care. A focus group study

Background JEMS® (Joanne Elphinston Movement Systems) described as a systematic, holistic approach to analyze and create sound foundations for movement, is increasing in popularity among physiotherapists. The aim of this study was to investigate and capture the experiences and narratives of physiotherapists (PTs) using JEMS® for rehabilitation with patients in primary healthcare. Materials and methods In this qualitative description study, we invited 13 PTs to focus group discussions (FGD). Four groups were conducted, three FGD at different locations in Region Västra Götaland, Sweden, and one FGD using Skype. The groups met on one occasion. The FGD method has a qualitative semi-structured research design based on a social constructivist tradition of research. Data were analyzed using the Kreuger method, considering the content of the discussion in a collective understanding of the subject and the interaction taking place among participants. Results Three themes were identified: how the PTs describe their practical and emotional experiences, and how JEMS® has changed their clinical work. Most clearly emerged subjects considering the interaction and communication with the patient, about finding a structure in clinical practice and about the development the informants experience in their role as a physiotherapist and as an individual. Conclusions The FGD was chosen to capture the variety and width of experiences of the PTs using JEMS®. The opportunity for learning and reflecting in the FGDs was appreciated by the PTs. The interaction between the patient and the PT was described as fundamental in establishing foundations for movement. Opportunities to meet and treat patients regardless of functional limitations elaborated and were in that way applicable in primary healthcare where patients seek a physiotherapist for a variety of reasons.

Service-policy gaps in the settlement journey of Arabic-speaking immigrant newcomer and refugee older adults in Edmonton, Canada.

Immigrant newcomers and refugees (INRs) are two migrant categories that experience consistent systemic barriers to settlement and integration in Canada as older adults. This paper explores the challenges experienced by Arabic-speaking INR older adults in Edmonton, Canada, during settlement and discusses policy and service implications. A qualitative description study using community-based participatory research principles was implemented to evaluate and support digital literacy in Arabic-speaking INR older adults. We included men and women aged 55 and older who identified as immigrants or refugees and spoke Arabic. Experiences of settlement challenges were consistently identified during data collection and engagement of INR older adult participants. A thematic sub-analysis of interviews with (10 individuals and one couple) of participants' narratives was completed in 2022 and was used to identify themes related to settlement barriers for this population. Two main themes were identified: (1) Limited English skills and digital literacy gaps create service barriers for INR older adults, and (2) Gaps in services and policies as basic needs remain unmet. We describe key challenges experienced by INR older adults, such as language barriers, precarious finances, poor access to health care services and lack of transportation and employment opportunities, which hinder successful integration into the new society. This study showcases the ongoing challenges with early settlement and integration that continue despite Canada's well-developed immigration settlement landscape. INR older adults often remain invisible in policy, and understanding their experiences is a first step to addressing their needs for resources that support healthy aging in the post-migration context.

Student perspectives on student-led family medicine clinics in Qatar: a descriptive qualitative study

BackgroundStudent-led clinic is an educational-professional training environment where students are leading the care of patients under the supervision of licensed health care professionals. This study aims to explore medical students’ experiences in leading family medicine clinics in Qatar.MethodsThe study used a qualitative descriptive method. To collect the data, the researchers have used semi-structured interviews. To recruit students, a convenience sampling strategy was used by sending a call to participate to all students who completed the rotation and met the inclusion criteria. An inductive thematic analysis was employed to data analysis.ResultsTen students participated in the study. Data analysis revealed six themes. These are: Student led clinic as transitional and transformative stage, Challenges faced by students, coping strategies, protective factors, implications of the experience and students’ reflections for future rotations. The study revealed that students experienced a mixture of anxiety and excitement during the transition to leading clinics. Challenges included patient-related challenges such as language barriers, challenges related to personal skills such as time and knowledge, and institutional challenges that included limited supervisor availability and balancing academic responsibilities with clinic duties. Coping strategies included continuous knowledge revision, seeking advice from colleagues, and employing creative tools to overcome language barriers.ConclusionLeading family medicine clinics has an impact on students such as enhancing their time management, diagnostic abilities, communication skills, and confidence. Support from supervisors, team members, patients, and colleagues play a crucial role in students’ experiences. This transitional experience supports the shift from self-perception as students perceiving themselves as physicians.

“Do I feel safe here?” Organisational climate and mental health peer worker experience

BackgroundIn Australia, lived experience peer support workforces are expanding making it one of the fastest growing emerging disciplines in transdisciplinary mental health settings. This article provides insight for organisations on the contextual realities peer workers face, increases understanding of peer support services to improve service delivery environments and contributes to mental health systems reform. This study aimed to qualitatively explore peer support workers experience integrating into and working within transdisciplinary mental health service teams.MethodSemi-structured interviews were undertaken with 18 peer support workers currently working in mental health services in Australia. The research was a qualitative descriptive study design. All data collected were analysed utilising thematic analysis.ResultsPeer workers found their experience in the workplace was influenced by their colleagues and the organisation’s understanding of the peer role. Factors relating to organisational culture and climate were a central theme throughout discussions noting that a negative climate was perceived as harmful to peer workers. Themes established through results include (1) the role of leadership, (2) attitudes and behaviours of colleagues, (3) provision of psychologically safe environments, (4) the organisations messaging and use of language and (5) organisational structures and policy.ConclusionThis study contributes to evidence for the impact of organisational culture on integrating and supporting peer support workers in mental health service delivery. This study provides insights into peer worker experiences integrating into transdisciplinary teams, confirming findings established in previous studies, highlighting a lack of movement or change in workplace culture to support peer worker integration into mental healthcare settings.

Whether and What to Tell: A Qualitative Study of HIV Disclosure Among Heterosexually Married Men Who Have Sex with Men in China

In China, HIV transmission increasingly affected men who have sex with men (MSM) and those in heterosexual marriages. This study addressed a critical gap in understanding HIV and sexual orientation disclosure within conventional heterosexual marriages, framed within a family-oriented cultural context. Heterosexually married MSM living with HIV (HIV+ MMSM) faced complex identity dynamics and interactions between “gay circles” and marital life. Such disclosure was fraught with potential repercussions, including accusations of “marriage fraud”, HIV-related stigma, and divorce. This descriptive qualitative study, conducted in 2022, aimed to explore the common factors influencing HIV status disclosure to wives among Chinese HIV+ MMSM. Sixteen semi-structured interviews were conducted to analyze the factors related to the disclosure process model. Four key themes emerged: (a) concern for wives’ well-being, (b) perceived marriage strength, (c) the degree of social support they had, and (d) a desire to maintain their status in a heterosexual society. The decision to (non)disclose was shaped by both approach-focused and avoidant-focused goals related to these four themes. The findings underscored the need for culturally sensitive strategies that balance family dynamics, stigma reduction, and HIV care management, emphasizing tailored approaches to effectively support this population.

Nursing home leader response during COVID-19: a qualitative descriptive study about use of external resources during the pandemic

BackgroundUS nursing homes were ground zero for COVID-19 and nursing home leaders faced multiple challenges to keep residents and staff safe. Understanding the leader’s role and their use of external resources to rapidly respond to the pandemic is important to better prepare for the next infectious disease outbreak emergency. The purpose of this study is to describe Missouri nursing home leaders’ use of external resources to manage challenges encountered during the pandemic.MethodsThis qualitative descriptive study uses data from semi-structured interviews conducted with leaders from 24 Midwestern nursing homes between March 2022 and March 2023. Interviews were transcribed verbatim and analyzed using Dedoose software. Directed content analysis, guided by Donabedian’s Structure, Process, Outcome framework, was used for analysis. Interviews were conducted as part of a larger mixed-methods study focused on developing knowledge and recommendations to improve US nursing homes’ capacity to respond to infectious disease outbreaks.ResultsForty-three interviews were conducted across the 24 homes. Participants included administrators (n = 24), nurse leaders (n = 19), and infection preventionists (n = 16). Six sub-categories of external resources/support were used by leaders to manage challenges during the pandemic:1) corporate support and communications, 2) statewide resources, 3) community-based resources, 4) health care coalitions focused on emergency response planning, 5) existing affiliations with local organizations i.e., hospitals, and 6) community members and families. Corporate support was a primary resource; however, it was limited to chain-based homes. Leaders from standalone homes seemed most reliant on statewide agencies, existing affiliations, and other community-based resources due to their lack of corporate connections. Health care coalitions were few, but when available, helped nursing homes prepare for the pandemic onset. Family and community members were vital despite being off-site from nursing homes at the pandemic onset.ConclusionLeaders played a pivotal role in accessing and using external resources to manage challenges during the pandemic. Statewide and community-based agencies and existing affiliations were particularly critical for standalone homes who otherwise had little to no means of support. Federal, state and local agencies must consider opportunities to build multi-agency regional collaborations, local health care coalitions and community-based partnerships that include nursing homes as member. Finally, community members and family were important in providing support, thus closing visitation is a double-edged sword that needs careful, future consideration.

Views from midwives and perinatal nurses on barriers and facilitators in responding to perinatal intimate partner violence in Japan: baseline interview before intervention

BackgroundMidwives and perinatal nurses play a crucial role in responding to intimate partner violence (IPV) against pregnant women; however, these roles are often not performed adequately. This study aimed to identify provider-related, healthcare system, and social barriers and facilitators to IPV response from the perspective of midwives and perinatal nurses.MethodsThis qualitative descriptive study used semi-structured interviews with five midwives and a nurse from perinatal care facilities in Tokyo, Japan. A framework approach was employed to analyze the interview transcripts.ResultsBarriers included inadequate knowledge about IPV and reluctance to provide support by healthcare providers. Barriers in the healthcare system included the absence of structural infrastructure for IPV response. This involved the lack of screening tool adoption, the partner’s presence during interviews, and time constraints. Additionally, there was insufficient systematic and collaborative coordination within and outside the team. Another barrier was the lack of in-service training to develop IPV-related knowledge and skills. Finally, there was uncertainty about how the support at healthcare facilities impacts women’s lives. Further barriers in the social system included the absence of additional reimbursement for IPV response. There was also a lack of a comprehensive approach to IPV that provides for the rehabilitation of perpetrators and care for the children of victims and a culture that discourages separation from the perpetrator. Conversely, facilitators included healthcare providers recognizing the perinatal period as an opportunity to address IPV. They also acknowledged IPV as a prevalent issue, practiced conscious self-care, and systematically collaborated within the healthcare team.ConclusionThis study emphasized the need for routine IPV screening in perinatal care and the importance of team-based educational interventions for healthcare providers to facilitate implementation.

Exploring Physicians' Perceptions of Digital Health's Impact on the Patient-Physician Relationship in the Primary Health Care Setting: Qualitative Descriptive Study.

Digital health has become essential for effective clinical practice. However, the successful adoption of digital health is dependent on the strength of the patient-physician relationship. The patient-physician relationship shapes the quality of care and impacts health care outcomes, especially in primary care. However, the impact of the increasing use of digital health on the patient-physician relationship is uncertain. This study aims to explore the types of digital health primary care physicians use and understand their impact on the patient-physician relationship from their perspective. This exploratory qualitative descriptive study used individual in-depth interviews guided by a semistructured topic guide. We purposively sampled physicians from 6 general primary care clinics in Singapore and used thematic analysis to identify emergent themes. We conducted 12 interviews. We found that primary care physicians in Singapore had minimal exposure to digital health beyond the scope of institutional implementation. The three key themes that emerged were as follows: (1) evolving roles of both physicians and patients; (2) impact on trust, knowledge acquisition, and longitudinal care; and (3) adoption and use factors of digital health impacting patient-physician relationships. The adoption and use factors comprised "social and personal," "technical and material," and "organization and policy" factors. The study identified that, while primary care physicians held mostly positive views on adopting digital health in improving the patient-physician relationship, they were concerned that digital health might erode trust, hinder proper knowledge acquisition, and reduce humanistic interaction. These concerns called for a nuanced approach to ensure that digital health would not compromise the patient-physician relationship. This could be achieved by ensuring that physicians possess the necessary skills, knowledge, and positive attitude, while health care organizations would provide robust IT capabilities and support. We recommend that education be refined and government policies on digital health adoption and use be revised to align with the goal of strengthening the patient-physician relationship.

Analysis of English Learning Strategies Performed by Successful EFL Learners in Non-English Department

The objectives of this research were to know and describe English learning strategies that are used by successful EFL learners in non-English departments at the University of Mataram and the factors driving them. This is a descriptive qualitative study using purposive sampling. The samples were 5 Engineering students and 5 Economics students with TOEFL scores of 457 to 560. The data was collected through the Strategy Inventory for Language Learning (SILL) questionnaire version 7.0 and semi-interview. The result of the study reveals that successful EFL learners in Engineering and Economics implement all learning strategies at two different levels. The learners use compensation, metacognitive, and cognitive strategies at a high level, then memory, social, and affective strategies at a medium level. This research found that each learning strategy that the learners performed is intertwined. The naturalistic factors that contribute to driving the appropriation and implementation of those strategies are their English proficiency, learning style, and motivation. While there is no significant influence from gender identity found in this research.

Are we preparing healthy & responsible adolescents? Exploratory qualitative study to understand the health and social issues of adolescent living in Karachi, Pakistan.

This study aimed to understand the lives of adolescents living in squatter settlements of Karachi, Pakistan regarding their assigned roles and responsibilities, health and social issues, their decision-making process, and mechanism and channels of information. An exploratory descriptive qualitative study design was employed. Purposive sampling techniques were used to carry out Focus Group Discussions (FGDs) with adolescents (n = 10, Participants = 190), adolescents' parents (n = 10, Participants = 180), and In-Depth Interviews of with key adolescent stakeholders (n = 20). Adolescent stakeholder mapping was conducted for enrolling participants. The data were analysed thematically using deductive and inductive approaches. Based on gender norms parents assign specific roles and responsibilities to adolescent girls and boys. Due to societal norms, communication gap exists between adolescents and their parents. The most popular information channels are social media platforms and friends. Adolescents reported being subjected to a variety of physical, sexual, mental, social, and environmental pressures. Lack of guidance from parents, inadequate knowledge and skills to deal with physical, sexual, mental, social and environmental hazards, and misuse of social media lead to risky decisions, injuries, and social instability. This study underlines the urgent need for targeted interventions for addressing gender issues and improving adolescents' decision-making and life skills. We recommend Behavior Change Communication interventions to dismantle gender stereotypes and support a balanced domestic environment for children's education and well-being, awareness raising among parents, teachers, and healthcare providers about adolescent risks emphasizing their role in youth guidance, and advocacy for youth-led forums to co-create educational content engaging parents, educators, and health professionals focusing on life skills. These strategies would turn demographic transitions into productive dividends.

Leadership Behaviors That Impact Nurse Faculty Job Satisfaction: A Qualitative Descriptive Study.

The aim of the study was to identify specific actionable behaviors academic nurse leaders can implement to improve nurse faculty job satisfaction. The nurse faculty shortage is a persistent and worsening problem, with job dissatisfaction a significant contributor in the United States. However, little is known about actionable behaviors academic nurse leaders can do to improve nurse faculty job satisfaction. Qualitative semistructured interviews were conducted with 15 nurse faculty. Inductive thematic analysis was used to analyze and interpret the interviews. Four themes emerged about academic nurse leader behavior: 1) build relationships with leaders and faculty, 2) create an environment where autonomy is valued, 3) facilitate faculty growth and development, and 4) serve as a role model. Effective leadership contributes to nurse faculty job satisfaction. Academic nurse leaders need to be aware of their influential behaviors and intentionally contribute to creating a workplace environment that promotes nurse faculty job satisfaction.

Management of a Dual Low Sodium and Diabetic Diet by Patient-Caregiver Dyads: A Qualitative Descriptive Study.

The purpose of the study was to explore factors surrounding management of simultaneous dietary recommendations for heart failure and type 2 diabetes among patient-caregiver dyads. Qualitative description was used to explore dyad experiences managing a dual diet. Semi-structured interviews were conducted with patients with a concurrent diagnosis of type 2 diabetes and heart failure and their family caregiver. Each 60-minute interview was conducted virtually. Interviews were audio recorded and transcribed verbatim. Thematic analysis was conducted with coding used for themes at dyadic-and individual levels. Twelve patient-caregiver dyads (N = 24) were interviewed. The mean age was 57 years (±15 years). Most participants were white (75%); patients were predominantly male, and caregivers were predominantly female (83.3% for both). Dyadic-level themes that emerged included factors that influence simultaneous management of dual diet recommendations. Themes included shared barriers, facilitators, motivators, and strategies for dual diet management. Individual-level themes discussed by patients were barriers and motivators to dual diet management, and caregivers discussed barriers to supporting dual diet management. Findings from the study highlight that patients and caregivers often work together and share similar barriers, facilitators, motivators, and strategies for adhering to a dual diet. The results provide insight into chronic disease management at the family level and can guide health care providers' efforts to promote family involvement with dietary recommendations for patients with multiple comorbidities.