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BACKGROUND: The hard clam (Mercenaria mercenaria), a marine bivalve distributed along the U.S. eastern seaboard, supports a significant shellfish industry. Overharvest in the 1970s and 1980s led to a reduction in landings. While the transition of industry from wild harvest to aquaculture since that time has enhanced production, it has also exacerbated challenges such as disease outbreaks. In this study, we developed and validated a 66K SNP array designed to advance genetic studies and improve breeding programs in the hard clam, focusing particularly on the development of markers that could be useful in understanding disease resistance and environmental adaptability. RESULTS: Whole-genome resequencing of 84 individual clam samples and 277 pooled clam libraries yielded over 305 million SNPs, which were filtered down to a set of 370,456 SNPs that were used as input for the design of a 66K SNP array. This medium-density array features 66,543 probes targeting coding and non-coding regions, including 70 mitochondrial SNPs, to capture the extensive genetic diversity within the species. The SNPs were distributed evenly throughout the clam genome, with an average interval of 25,641 bp between SNPs. The array incorporates markers for detecting the clam pathogen Mucochytrium quahogii (formerly QPX), enhancing its utility in disease management. Performance evaluation on 1,904 samples demonstrated a 72.7% pass rate with stringent quality control. Concordance testing affirmed the array's repeatability, with an average agreement of allele calls of 99.64% across multiple tissue types, highlighting its reliability. The tissue-specific analysis demonstrated that some tissue types yield better genotyping results than others. Importantly, the array, including its embedded mitochondrial markers, effectively elucidated complex genetic relationships across different clam groups, both wild populations and aquacultured stocks, showcasing its utility for detailed population genetics studies. CONCLUSIONS: The 66K SNP array is a powerful and robust genotyping tool that offers unprecedented insights into the species' genomic architecture and population dynamics and that can greatly facilitate hard clam selective breeding. It represents an important resource that has the potential to transform clam aquaculture, thereby promoting industry sustainability and ecological and economic resilience.

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Aquaculture is growing rapidly worldwide, and sustainability is dependent on an understanding of current genetic variation and levels of connectivity among populations. Genetic data are essential to mitigate the genetic and ecological impacts of aquaculture on wild populations and guard against unintended human-induced loss of intraspecific diversity in aquacultured lines. Impacts of disregarding genetics can include loss of diversity within and between populations and disruption of local adaptation patterns, which can lead to a decrease in fitness. The northern hard clam, Mercenaria mercenaria (Linnaeus, 1758), is an economically valuable aquaculture species along the North American Atlantic and Gulf coasts. Hard clams have a pelagic larval phase that allows for dispersal, but the level of genetic connectivity among geographic areas is not well understood. To better inform the establishment of site-appropriate aquaculture brood stocks, this study used DArTseq™ genotyping by sequencing to characterize the genetic stock structure of wild clams sampled along the east coast of North America and document genetic diversity within populations. Samples were collected from 15 locations from Prince Edward Island, Canada, to South Carolina, USA. Stringent data filtering resulted in 4960 single nucleotide polymorphisms from 448 individuals. Five genetic breaks separating six genetically distinct populations were identified: Canada, Maine, Massachusetts, Mid-Atlantic, Chesapeake Bay, and the Carolinas (F ST 0.003-0.046; p < 0.0001). This is the first study to assess population genetic structure of this economically important hard clam along a large portion of its native range with high-resolution genomic markers, enabling identification of previously unrecognized population structure. Results of this study not only broaden insight into the factors shaping the current distribution of M. mercenaria but also reveal the genetic population dynamics of a species with a long pelagic larval dispersal period along the North American Atlantic and Gulf coasts.

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The notothenioid family Bathydraconidae is a poorly understood family of fishes endemic to the Southern Ocean. There is especially little information on Akarotaxis nudiceps, one of the deepest-dwelling and least fecund bathydraconid species. Using genetic and morphological data, we document and describe the larval stages of this unique species, offer a novel characteristic to distinguish it from the morphologically similar bathydraconid Prionodraco evansii and use the sampling locations to infer a possible spawning area of A. nudiceps along the western Antarctic Peninsula. These results provide important baseline information for locating, identifying and studying the biology of A. nudiceps, an important component of the Southern Ocean ecosystem.

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Globally, tunas are among the most valuable fish stocks, but are also inherently difficult to monitor and assess. Samples of larvae of Western Atlantic bluefin tuna Thunnus thynnus (Linnaeus, 1758) from standardized annual surveys in the northern Gulf of Mexico provide a potential source of "offspring" for close-kin mark-recapture (CKMR) estimates of abundance. However, the spatial patchiness and highly skewed numbers of larvae per tow suggest sampled larvae may come from a small number of parents, compromising the precision of CKMR. We used high throughput genomic profiling to study sibship within and among larval tows from the 2016 standardized Gulf-wide survey compared to targeted sampling carried out in 2017. Full- and half-siblings were found within both years, with 12% of 156 samples in 2016 and 56% of 317 samples in 2017 having at least one sibling. There were also two pairs of cross cohort half-siblings. Targeted sampling increased the number of larvae collected per sampling event but resulted in a higher proportion of siblings. The combined effective sample size across both years was about 75% of the nominal size, indicating that Gulf of Mexico larval collections could be a suitable source of juveniles for CKMR in Western Atlantic bluefin tuna.

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Resilience to climate change depends on a species' adaptive potential and phenotypic plasticity. The latter can enhance survival of individual organisms during short periods of extreme environmental perturbations, allowing genetic adaptation to take place over generations. Along the U.S. East Coast, estuarine-dependent spotted seatrout (Cynoscion nebulosus) populations span a steep temperature gradient that provides an ideal opportunity to explore the molecular basis of phenotypic plasticity. Genetically distinct spotted seatrout sampled from a northern and a southern population were exposed to acute cold and heat stress (5 biological replicates in each treatment and control group), and their transcriptomic responses were compared using RNA-sequencing (RNA-seq). The southern population showed a larger transcriptomic response to acute cold stress, whereas the northern population showed a larger transcriptomic response to acute heat stress compared with their respective population controls. Shared transcripts showing significant differences in expression levels were predominantly enriched in pathways that included metabolism, transcriptional regulation, and immune response. In response to heat stress, only the northern population significantly upregulated genes in the apoptosis pathway, which could suggest greater vulnerability to future heat waves in this population as compared to the southern population. Genes showing population-specific patterns of expression, including hpt, acot, hspa5, and hsc71, are candidates for future studies aiming to monitor intraspecific differences in temperature stress responses in spotted seatrout. Our findings contribute to the current understanding of phenotypic plasticity and provide a basis for predicting the response of a eurythermal fish species to future extreme temperatures.

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Genomic methodologies offer unprecedented opportunities for statistically robust studies of species broadly distributed in environments conducive to high gene flow, providing valuable information for wildlife conservation and management. Here, we sequence restriction site-associated DNA to characterize genome-wide single nucleotide polymorphisms (SNPs) in a broadly distributed and highly migratory large pelagic fish, striped marlin (Kajikia audax). Assessment of over 4,000 SNPs resolved spatiotemporal patterns of genetic connectivity throughout the species range in the Pacific and, for the first time, Indian oceans. Individual-based cluster analyses identified six genetically distinct populations corresponding with the western Indian, eastern Indian, western South Pacific, and eastern central Pacific oceans, as well as two populations in the North Pacific Ocean (F ST = 0.0137-0.0819). F ST outlier analyses identified a subset of SNPs (n = 59) putatively under the influence of natural selection and capable of resolving populations separated by comparatively high degrees of genetic differentiation. Temporal collections available for some regions demonstrated the stability of allele frequencies over three to five generations of striped marlin. Relative migration rates reflected lower levels of genetic connectivity between Indian Ocean populations (m R ≤ 0.37) compared with most populations in the Pacific Ocean (m R ≥ 0.57) and highlight the importance of the western South Pacific in facilitating gene flow between ocean basins. Collectively, our results provide novel insights into rangewide population structure for striped marlin and highlight substantial inconsistencies between genetically distinct populations and stocks currently recognized for fisheries management. More broadly, we demonstrate that species capable of long-distance dispersal in environments lacking obvious physical barriers to movement can display substantial population subdivision that persists over multiple generations and that may be facilitated by both neutral and adaptive processes. Importantly, surveys of genome-wide markers enable inference of population-level relationships using sample sizes practical for large pelagic fishes of conservation concern.

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We studied the effects of metabolic cold adaptation (MCA) in two populations of a eurythermal species, spotted seatrout (Cynoscion nebulosus) along the U.S. East Coast. Fish were captured from their natural environment and acclimated at control temperatures 15 °C or 20 °C. Their oxygen consumption rates, a proxy for metabolic rates, were measured using intermittent flow respirometry during acute temperature decrease or increase (2.5 °C per hour). Mass-specific standard metabolic rates (SMR) were higher in fish from the northern population across an ecologically relevant temperature gradient (5 °C to 30 °C). SMR were up to 37% higher in the northern population at 25 °C and maximum metabolic rates (MMR) were up to 20% higher at 20 °C. We found evidence of active metabolic compensation in the southern population from 5 °C to 15 °C (Q10 < 2), but not in the northern population. Taken together, our results indicate differences in metabolic plasticity between the northern and southern populations of spotted seatrout and provide a mechanistic basis for predicting population-specific responses to climate change.

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The life-history characteristics of blueline tilefish make them particularly vulnerable to overfishing. Although North Carolina, U.S.A. was previously considered to be the northern extent of the range of C. microps, concentrations have recently been discovered in Virginia and Maryland, with reports as far north as Montauk, New York. Attempts to manage the fishery have been hampered by a lack of information about whether the U.S. East Coast includes multiple stocks. To assess the appropriateness of alternate management options, we used 25 variable microsatellite loci and sequencing of the mitochondrial (mt)DNA control region (CR) to evaluate the genetic structure of 490 C. microps sampled from across the U.S. East Coast range. Pairwise comparisons of genetic differentiation among collection locations based on both nuclear microsatellite and mtCR sequence data were all low and non significant. No significant autocorrelation was observed across multiple distance classes, consistent with widespread dispersal., Although the assumed sedentary nature of adult C. microps suggests population structuring, the genetic data were consistent with the presence of sufficient gene flow to prevent the accumulation of significant genetic differences and supports management of C. microps as a single stock along the U.S. East Coast.

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Highly migratory, cosmopolitan oceanic sharks often exhibit complex movement patterns influenced by ontogeny, reproduction, and feeding. These elusive species are particularly challenging to population genetic studies, as representative samples suitable for inferring genetic structure are difficult to obtain. Our study provides insights into the genetic population structure one of the most abundant and wide-ranging oceanic shark species, the blue shark Prionace glauca, by sampling the least mobile component of the populations, i.e., young-of-year and small juveniles (<2 year; N = 348 individuals), at three reported nursery areas, namely, western Iberia, Azores, and South Africa. Samples were collected in two different time periods (2002-2008 and 2012-2015) and were screened at 12 nuclear microsatellites and at a 899-bp fragment of the mitochondrial control region. Our results show temporally stable genetic homogeneity among the three Atlantic nurseries at both nuclear and mitochondrial markers, suggesting basin-wide panmixia. In addition, comparison of mtDNA CR sequences from Atlantic and Indo-Pacific locations also indicated genetic homogeneity and unrestricted female-mediated gene flow between ocean basins. These results are discussed in light of the species' life history and ecology, but suggest that blue shark populations may be connected by gene flow at the global scale. The implications of the present findings to the management of this important fisheries resource are also discussed.

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AIMS AND OBJECTIVES: To evaluate the implementation of the Champions for Skin Integrity model on facilitating uptake of evidence-based wound management and improving skin integrity in residents of aged care facilities. BACKGROUND: The incidence of skin tears, pressure injuries and leg ulcers increases with age, and such wounds can be a serious issue in aged care facilities. Older adults are not only at higher risk for wounds related to chronic disease but also injuries related to falls and manual handling requirements. DESIGN: A longitudinal, pre-post design. METHODS: The Champions for Skin Integrity model was developed using evidence-based strategies for transfer of evidence into practice. Data were collected before and six months after implementation of the model. Data on wound management and skin integrity were obtained from two random samples of residents (n = 200 pre; n = 201 post) from seven aged care facilities. A staff survey was also undertaken (n = 126 pre; n = 143 post) of experience, knowledge and evidence-based wound management. Descriptive statistics were calculated for all variables. Where relevant, chi-square for independence or t-tests were used to identify differences between the pre-/postdata. RESULTS: There was a significant decrease in the number of residents with a wound of any type (54% pre vs 43% post, χ2 4·2, p = 0·041), as well as a significant reduction in specific wound types, for example pressure injuries (24% pre vs 10% post, χ2 14·1, p < 0·001), following implementation of the model. An increase in implementation of evidence-based wound management and prevention strategies was observed in the postimplementation sample in comparison with the preimplementation sample. This included use of limb protectors and/or protective clothing 6% pre vs 20% post (χ2 17·0, p < 0·001) and use of an emollient or soap alternative for bathing residents (50% pre vs 74% post, χ2 13·9, p = 0·001). CONCLUSIONS: Implementation of the model in this sample fostered an increase in implementation of evidence-based wound management and prevention strategies, which was associated with a decrease in the prevalence and severity of wounds. RELEVANCE TO CLINICAL PRACTICE: This study suggests the Champions for Skin Integrity model has the potential to improve uptake of evidence-based wound management and improve skin integrity for older adults.

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Little is known about self-management among people with Type 2 diabetes living in mainland China. Understanding the experiences of this target population is needed to provide socioculturally relevant education to effectively promote self-management. The aim of this study was to explore perceived barriers and facilitators to diabetes self-management for both older community dwellers and health professionals in China. Four focus groups, two for older people with diabetes and two for health professionals, were conducted. All participants were purposively sampled from two communities in Shanghai, China. Six barriers were identified: overdependence on but dislike of western medicine, family role expectations, cuisine culture, lack of trustworthy information sources, deficits in communication between clients and health professionals, and restriction of reimbursement regulations. Facilitators included family and peer support, good relationships with health professionals, simple and practical instruction and a favourable community environment. The findings provide valuable information for diabetes self-management intervention development in China, and have implications for programmes tailored to populations in similar sociocultural circumstances.

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AIM: A protocol for a new peer-led self-management programme for community-dwelling older people with diabetes in Shanghai, China. BACKGROUND: The increasing prevalence of type 2 diabetes poses major public health challenges. Appropriate education programmes could help people with diabetes to achieve self-management and better health outcomes. Providing education programmes to the fast growing number of people with diabetes present a real challenge to Chinese healthcare system, which is strained for personnel and funding shortages. Empirical literature and expert opinions suggest that peer education programmes are promising. DESIGN: Quasi-experimental. METHODS: This study is a non-equivalent control group design (protocol approved in January, 2008). A total of 190 people, with 95 participants in each group, will be recruited from two different, but similar, communities. The programme, based on Social Cognitive Theory, will consist of basic diabetes instruction and social support and self-efficacy enhancing group activities. Basic diabetes instruction sessions will be delivered by health professionals, whereas social support and self-efficacy enhancing group activities will be led by peer leaders. Outcome variables include: self-efficacy, social support, self-management behaviours, depressive status, quality of life and healthcare utilization, which will be measured at baseline, 4 and 12 weeks. DISCUSSION: This theory-based programme tailored to Chinese patients has potential for improving diabetes self-management and subsequent health outcomes. In addition, the delivery mode, through involvement of peer leaders and existing community networks, is especially promising considering healthcare resource shortage in China.

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This article documents the addition of 473 microsatellite marker loci and 71 pairs of single-nucleotide polymorphism (SNP) sequencing primers to the Molecular Ecology Resources Database. Loci were developed for the following species: Barteria fistulosa, Bombus morio, Galaxias platei, Hematodinium perezi, Macrocentrus cingulum Brischke (a.k.a. M. abdominalis Fab., M. grandii Goidanich or M. gifuensis Ashmead), Micropogonias furnieri, Nerita melanotragus, Nilaparvata lugens Stål, Sciaenops ocellatus, Scomber scombrus, Spodoptera frugiperda and Turdus lherminieri. These loci were cross-tested on the following species: Barteria dewevrei, Barteria nigritana, Barteria solida, Cynoscion acoupa, Cynoscion jamaicensis, Cynoscion leiarchus, Cynoscion nebulosus, Cynoscion striatus, Cynoscion virescens, Macrodon ancylodon, Menticirrhus americanus, Nilaparvata muiri and Umbrina canosai. This article also documents the addition of 116 sequencing primer pairs for Dicentrarchus labrax.

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Multiple paternity (MP) has been shown to be widespread in elasmobranch fishes although its prevalence and the number of sires per litter vary considerably among species. In the squaloid shark Squalus acanthias, MP has been reported, but whether it is a common feature of the species' reproductive strategy is unknown. In this study, we determined the frequency of MP in 29 litters of S. acanthias sampled from the lower Chesapeake Bay and coastal Virginia waters, using 7 highly polymorphic nuclear DNA microsatellite loci. Only 5 litters (17% of the total) were genetically polyandrous, with at least 2 sires per litter. Litter size increased with female size but was similar between polyandrous and monandrous females.

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The sandbar shark, Carcharhinus plumbeus, is a large, cosmopolitan, coastal species. Females are thought to show philopatry to nursery grounds while males potentially migrate long distances, creating an opportunity for male-mediated gene flow that may lead to discordance in patterns revealed by mitochondrial DNA (mtDNA) and nuclear markers. While this dynamic has been investigated in elasmobranchs over small spatial scales, it has not been examined at a global level. We examined patterns of historical phylogeography and contemporary gene flow by genotyping 329 individuals from nine locations throughout the species' range at eight nuclear microsatellite markers and sequencing the complete mtDNA control region. Pairwise comparisons often resulted in fixation indices and divergence estimates of greater magnitude using mtDNA sequence data than microsatellite data. In addition, multiple methods of estimation suggested fewer populations based on microsatellite loci than on mtDNA sequence data. Coalescent analyses suggest divergence and restricted migration among Hawaii, Taiwan, eastern and western Australia using mtDNA sequence data and no divergence and high migration rates, between Taiwan and both Australian sites using microsatellite data. Evidence of secondary contact was detected between several localities and appears to be discreet in time rather than continuous. Collectively, these data suggest complex spatial/temporal relationships between shark populations that may feature pulses of female dispersal and more continuous male-mediated gene flow.

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OBJECTIVE: To examine the psychometric properties of a Chinese version of the Problem Areas In Diabetes (PAID-C) scale. RESEARCH DESIGN AND METHODS: The reliability and validity of the PAID-C were evaluated in a convenience sample of 205 outpatients with type 2 diabetes. Confirmatory factor analysis, Bland-Altman analysis, and Spearman's correlations facilitated the psychometric evaluation. RESULTS: Confirmatory factor analysis confirmed a one-factor structure of the PAID-C (chi(2)/df ratio = 1.894, goodness-of-fit index = 0.901, comparative fit index = 0.905, root mean square error of approximation = 0.066). The PAID-C was associated with A1C (r(s) = 0.15; P < 0.05) and diabetes self-care behaviors in general diet (r(s) = -0.17; P < 0.05) and exercise (r(s) = -0.17; P < 0.05). The 4-week test-retest reliability demonstrated satisfactory stability (r(s) = 0.83; P < 0.01). CONCLUSIONS: The PAID-C is a reliable and valid measure to determine diabetes-related emotional distress in Chinese people with type 2 diabetes.

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BACKGROUND: Factors that individually influence blood sugar control, health-related quality of life, and diabetes self-care behaviors have been widely investigated; however, most previous diabetes studies have not tested an integrated association between a series of factors and multiple health outcomes. OBJECTIVES: The purposes of this study are to identify risk factors and protective factors and to examine the impact of risk factors and protective factors on adaptive outcomes in people with type 2 diabetes. DESIGN: A descriptive correlational design was used to examine a theoretical model of risk factors, protective factors, and adaptive outcomes. SETTINGS: This study was conducted at the endocrine outpatient departments of three hospitals in Taiwan. PARTICIPANTS: A convenience sample of 334 adults with type 2 diabetes aged 40 and over. METHODS: Data were collected by a self-reported questionnaire and physiological examination. Using the structural equation modeling technique, measurement and structural regression models were tested. RESULTS: Age and life events reflected the construct of risk factors. The construct of protective factors was explained by diabetes symptoms, coping strategy, and social support. The construct of adaptive outcomes comprised HbA1c, health-related quality of life, and self-care behaviors. Protective factors had a significant direct effect on adaptive outcomes (beta=0.68, p<0.001); however, risk factors did not predict adaptive outcomes (beta=-0.48, p=0.118). CONCLUSIONS: Identifying and managing risk factors and protective factors are an integral part of diabetes care. This theoretical model provides a better understanding of how risk factors and protective factors work together to influence multiple adaptive outcomes in people living with type 2 diabetes.

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PURPOSE: To evaluate the psychometric properties of a Chinese version of the Diabetes Coping Measure scale (DCM-C). METHODS: A self-administered questionnaire was completed by 205 people with type 2 diabetes from the endocrine outpatient departments of three hospitals in Taiwan. Confirmatory factor analysis, criterion validity, and internal consistency reliability were conducted to evaluate the psychometric properties of the DCM-C. FINDINGS: Confirmatory factor analysis confirmed a four-factor structure (chi(2)/df ratio = 1.351, good of fit index (GFI) = .904, comparitive fit index (CFI) = .902, root mean square error of approximation (RMSEA) = .041). The DCM-C was significantly associated with hemoglobin A1c and diabetes self-care behaviors. Internal consistency reliability of the total DCM-C scale was .74. Cronbach's alpha coefficients for each subscale of the DCM-C ranged from .37 (tackling spirit) to .66 (diabetes integration). CONCLUSIONS: The DCM-C demonstrated satisfactory reliability and validity to determine the use of diabetes coping strategies. The tackling spirit dimension needs further refinement when applying this scale to Chinese populations with diabetes. CLINICAL RELEVANCE: Healthcare providers who treat Chinese people with diabetes can use the DCM-C to implement an early determination of diabetes coping strategies.

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BACKGROUND/PURPOSE: The purpose of this study was to test the psychometric properties of the Perceived Therapeutic Efficacy Scale (PTES) for type 2 diabetes with a Taiwanese sample. The mortality rate and health care cost of diabetes have dramatically increased in Taiwan, with many people with diabetes lacking the ability to control their disease appropriately. Addressing this problem requires enhancing self-efficacy towards self-management. Thus, there is a particular need for research into developing a diabetes-specific self-efficacy measurement instrument in Taiwan. METHODS: This study was undertaken in two stages. Stage 1 consisted of forward and back translation of the PTES into Chinese and examination of content validity. Stage 2 established the validity and reliability of the Chinese version of PTES (C-PTES). A total of 230 people with type 2 diabetes aged 30 years or more from a diabetes outpatient clinic and taking oral medicine were recruited for psychometric testing. RESULTS: Significant criterion-related validity was demonstrated between the C-PTES and the Summary of Diabetes Self-Care Activities scores (r=0.32; p<0.01). Convergent validity was confirmed as the C-PTES converged well with the General Self-Efficacy Scale in measuring self-efficacy (r=0.42; p<0.01); construct validity using factor analysis composed a single subscale. Internal consistency showed Cronbach's alpha was 0.95 and the test-retest reliability (Pearson's correction) was 0.79 (p<0.01) and a Bland-Altman plot showed that 97% of the subjects were within two standard deviations of the mean. CONCLUSION: The results of reliability and validity strengthen confidence in using the C-PTES. The C-PTES requires future studies to confirm the psychometric properties.

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AIM: This study aimed to gain in-depth understanding of the actual hospital and home experience of patients with diabetes and a critical cardiac event to assist in developing a pertinent diabetes self-management programme. BACKGROUND: Type 2 diabetes can lead to cardiac complications requiring critical nursing care. Patients with diabetes and a history of cardiac disease are at greater risk of a further cardiac event. Greater self-efficacy or confidence in regulating diabetes and reducing the risk of a further cardiac event can be achieved through self-management programmes. However, the start of such a programme within the critical care environment presents challenges to critical care staff. It is important to understand patients' experiences and needs to improve quality of care. DESIGN: An interpretive approach comprising open-ended interviews was used to collect data from patients with type 2 diabetes experiencing a cardiac event who had a coronary care unit admission in 2002-2003. FINDINGS: The findings revealed that patients with diabetes who had a critical cardiac event experienced considerable feelings of hopelessness and fatigue. Patients also had concerns in the areas of self-confidence and confidence in health professionals. Patients indicated that greater self-confidence and confidence in health professionals would help their ability to manage their daily lives. CONCLUSION: This paper provides in-depth understanding of the perspectives of patients with type 2 diabetes who have also been hospitalized for a critical cardiac event. This study concluded that further research is needed to fully explore whether enhancing self-confidence for these patients will lead to improved diabetes management, reduced negative feelings and more positive health outcomes. RELEVANCE TO CLINICAL PRACTICE: The themes identified in this study provide direction and strategies for nursing staff to improve patients' confidence levels and reduce their feelings of hopelessness and fatigue.

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