Health plans guide enrollees’ access to specialty drugs through coverage policies. Practice guidelines recommend that the evidence supporting drug coverage policies should be comprehensive and routinely updated to reflect evidence-based medicine.To examine the frequency with which health plans update their coverage criteria and supporting evidence and to determine the pattern with which plans cited relevant literature in their coverage policies.Coverage policies from 17 large US commercial health plans were retrieved from the Tufts Medical Center Specialty Drug Evidence and Coverage database for August 2017 and August 2019. We identified drug-indication pairs  for which plans had issued coverage policies in August 2017 and August 2019. We examined the frequency with which plans reissued these policies  between these 2 time points and the frequency with which plans altered coverage criteria or updated the cited evidence. A random sample of 20 drug-indication pairs was chosen to determine the comprehensiveness of cited evidence from the Specialty Drug Evidence and Coverage database. For each pair, a systematic literature search was conducted to identify relevant clinical and economic studies. A comparison of the systematic literature search with the evidence cited in each drug-indication pair’s coverage policy was conducted to determine the comprehensive nature of each coverage policy’s evidence.We identified 4,597 instances of plans issuing a coverage policy for the same drug-indication pair in both August 2017 and August 2019. Of those 4,597 instances, plans reissued an updated coverage document in 4,468 (97%). Fifteen percent of reissued policies revised both their coverage criteria and the evidence cited, 2% only their coverage criteria, 69% only the cited evidence, and 14% made no change. A total of 2,760 literature documents were identified relevant to at least one of the 20 drug-indication pairs, of which at least one plan cited 146 of these documents at least once (5.3%). Plans cited health technology assessments, randomized controlled trials (RCTs), systematic reviews/meta-analyses, and clinical guidelines most comprehensively.Health plans reissued most of their specialty drug coverage policies over a 2-year period. When plans revised their drug coverage criteria, they also tended to revise the evidence cited in their coverage polices. Of all the evidence found in our systematic review, plans more comprehensively cite health technology assessments, RCTs, and systematic reviews/meta-analyses. Clinical and economic evidence should guide health plans’ drug coverage policies. We reviewed the citations of clinical and economic evidence plans included in their drug coverage policies between August 2017 and August 2019. When plans revised their drug coverage criteria, they also tended to update the cited evidence. This finding suggests, albeit indirectly, that clinical and economic evidence informs plans’ decisions, and that plans may adjust their drug coverage criteria in response to new evidence. Implications for managed care pharmacyPractice guidelines recommend that plans should routinely update the evidence they review in their drug coverage policies. Some plans updated the evidence in their coverage policies more often than others, which may suggest that some plans react to new evidence more quickly than others. The types of evidence plans cited in their coverage policies differed, which may indicate that plans vary in the evidence they rely on when formulating their drug coverage policies.5Clinical and economic evidence are key inputs for health plan drug coverage policies. Although it is unrealistic for coverage policies to cite all relevant evidence, Pharmacy and Therapeutics committee practice guidelines recommend that evidence reviews be comprehensive and routinely updated.6 and has characterized variation in the use of real-world evidence (RWE).8 But the literature has not systematically investigated how often plans materially update their coverage or the evidence they cite. Nor has it looked at how comprehensively plans cite relevant literature. This study addresses these gaps.Various studies have evaluated health plan evidence review practices. The literature has focused on the extent to which evidence cited varies across plansWe examined the following measures of change.First, we calculated the proportion of drug-indication pair coverage policies  each health plan reissued between August 2017 and August 2019. We considered a policy “reissued” if the plan issued a new coverage document, regardless of whether it altered coverage criteria or updated the cited evidence.Second, we examined how often these reissued policies included revised coverage criteria. Here, we noted how plans revised their coverage criteria, including changes to (1) patient subgroup ; (2) step therapy protocol ; (3) combination therapy (requirement for a drug to be used concomitantly with another medication); and (4) other.Third, we examined how often these reissued policies updated their cited evidence, eg, by adding or removing cited studies in these reissued policies.Finally, we reported how often reissued policies (1) revised both their coverage criteria and their cited evidence, (2) revised their coverage criteria but did not revise the cited evidence, (3) revised the cited evidence but did not revise their coverage criteria, and (4) revised neither their coverage criteria nor the cited evidence.We randomly selected 20 drug-indication pairs documented in the Tufts Medical Center Specialty Drug Evidence and Coverage  database. We excluded biosimilars because their evidence base differs markedly from the type of evidence cited for other specialty drugs.Supplementary Exhibit 1, available in online article) to identify all relevant publications, including randomized controlled trials (RCTs), RWE studies, other clinical studies , evidence syntheses , economic studies , technology assessments , and evidence-based treatment guidelines. Researchers screened the identified titles and abstracts to confirm publication relevance. When the title and abstract included insufficient information, we reviewed the publication’s full text. We excluded animal studies, editorials, non-systematic review articles, and clinical studies that did not report clinical safety or efficacy outcomes .For each of the 20 drug-indication pairs, we performed a systematic literature search of PubMed  approved within 5 years, between 5 and 10 years, and more than 10 years of the date of this analysis.10The SPEC database contains information on coverage of specialty drugs by 17 of the largest US commercial health plans, including details on (1) coverage restrictions and (2) the evidence cited to support these policies. This information comes from publicly available coverage policy documents. Additional detail on the SPEC database appears elsewhere.Supplementary Table 1). Of the reissued policies, 17% revised coverage criteria  and 84% revised the evidence cited . As detailed in We identified 4,597 coverage policies that plans made available in both August 2017 and August 2019, of which plans reissued 4,468 (97%), although this proportion varied across plans, ranging from 70% to 100% (Supplementary Table 2). The proportion of relevant documents cited once varied by document type , health plan , and drug-indication pair  ; for drugs approved from August 2009 to August 2014, plans cited clinical guidelines and evidence synthesis studies most comprehensively ; and for drugs approved before August 2009, plans cited health technology assessments most comprehensively (4%).Plans reissued the majority of their coverage policies during the 2-year study period and routinely updated the literature cited, suggesting that they do reevaluate evidence. Indeed, when plans revised their coverage criteria, they also tended to update the evidence cited in support of their decisions, thus suggesting, albeit indirectly, a relationship between coverage updates and evidence reviews.7 Further, some plans may tend to rely on syntheses of the available evidence , whereas other plans choose to rely on their own independent review of individual studies.6 It may also be that plans may have different committees that consider different types of evidence. For example, although a plan’s Pharmacy and Therapeutics committee may focus on clinical evidence, the same plan may reserve their consideration of economic evidence for their pricing/rebate committee.The frequency with which plans updated the evidence cited in support of their decisions varied across plans, a finding that could suggest that some plans react to new evidence of a therapy’s utility more quickly than others. It is perhaps unrealistic to expect plans to refer to all potentially relevant evidence. The fact that some plans refer to more evidence than others may reflect differences in thoroughness or differences in the type of evidence they find most helpful. For example, some plans cite RWE studies more than other plans.11 In contrast, plans cited only a fraction of the available evidence for etanercept for ankylosing spondylitis. The FDA approved etanercept for the treatment of ankylosing spondylitis in July 2003, and we identified 298 pertinent published studies.Another influential factor may be how long ago a drug received FDA approval and, hence, how large an evidence base it has. If the evidence base is relatively new and small, plans may cite a large proportion of it. After a drug has been available for a long time and has a large evidence base, the need to cite much of the literature declines. For example, policies most comprehensively cited the available evidence for eteplirsen, a drug indicated for Duchenne muscular dystrophy. The FDA approved eteplirsen in September 2016, and we identified only 9 pertinent published studies. Eleven plans cited the sole published RCT available for eteplirsen.Our study indicates that the evidence cited in coverage policies evolves over a product’s life cycle. Plans tended to cite RCTs and other clinical studies for recently approved products and cite clinical treatment guidelines and evidence syntheses for products on the market for longer.Our findings suggest that there may be a mismatch between the evidence developed by researchers and the evidence cited in coverage policies. For example, we found that plans cited only a very small percentage of the available RWE studies and economic evaluations in their coverage policies.12Greater transparency for health plan evidence requirements would incentivize the generation of evidence relevant to decision makers and increase the likelihood that it influences coverage decisions.Our study has the following limitations. First, an important limitation is that we rely on the evidence that health plans cite in their publicly available coverage policies. Plans may not fully report the evidence that they review in their publicly available coverage documents. The absence of a citation could indicate that health plan officials were unaware of the study or that they reviewed it but purposely omitted the citation. Second, our study may not be generalizable to other US commercial health plans or to public health care payers . Third, we did not account for the quality of the studies that plans reported reviewing. Nor did we investigate how newly cited studies affected plan decision making. Fourth, we did not account for plans’ varying sophistication with different types of evidence, eg, RWE studies and economic evidence. Finally, we relied only on the PubMed database to identify the relevant literature for each drug-indication pair.We found that large US commercial health plans reissued the majority of their specialty drug coverage policies over a 2-year period. When plans revised their drug coverage criteria, they also tended to revise the evidence cited in their coverage polices. Plans more comprehensively cited certain study types than others, with plans citing health technology assessments, RCTs, and systematic reviews/meta-analyses most comprehensively. Greater transparency for health plan evidence requirements would help ensure that generated evidence is relevant to decision makers.


Pityriasis rosea (PR) is a benign, self-limited skin disease characterized by the eruption of multiple erythematous plaques on the trunk and proximal extremities. The proposed etiology links the eruption to the reactivation of human herpesvirus (HHV) 6 and 7 in the skin . HHV-6 vA 2007 Cochrane review  and its P<.001) [Macrolide antibiotics are not recommended for the treatment of PR. Erythromycin was shown in a single clinical trial to significantly reduce the pruritus score compared to a placebo (P<.001) . HoweverP=.04) [P=.004) [P<.001) and resolution of pruritus (P=.02) compared to standard care alone [Acyclovir monotherapy may be useful for the treatment of PR. Compared to a placebo, participants on acyclovir experienced greater resolution of pruritus (P=.04) . Three t[P=.004) . Acyclovre alone .Using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework, there is moderate quality evidence to support the use of acyclovir monotherapy for the rash and pruritus of PR and low to moderate quality evidence for erythromycin to treat pruritus in PR. A range of acyclovir dosages has been used in studies with unclear evidence based on different regimens . AntivirIn general, the self-limited nature and overall low incidence of PR pose challenges to study designs. Additional high-quality studies are needed to determine if acyclovir or other antivirals are superior to supportive care.


Indeed, there might be endpoints, which are easier to reach, allow smaller sample sizes or shorter follow-up, and reflect some betterment in the clinical course. However, mortality is the most relevant endpoint and it is the ideal endpoint for a meta-analysis, as it is easy to measure and there is little variation in the way it is assessed. If a single intervention improves patient’s condition more than just providing easier handling, it should translate into a mortality benefit. This goal might be difficult to reach in a single study, but that is where strengths of meta-analyses come into play. By pooling the evidence, the results from small studies that each in itself have limited power can reach large impact.We completely agree that treating the underlying disease and its relevant mediators is the most important task in intensive care medicine. That is where cytokine adsorption could indeed have its place. Harmful cytokine release can efficiently be treated, and doing this properly should then translate into a survival benefit. The problem is that we were not yet successful in defining the ideal situation and timing for the intervention. No evidence could be generated for positive effects of the device and, therefore, we do indeed believe that it should not be used widespread, but rather investigated further in well-designed RCTs for certain medical conditions. The commenters mention differing time periods during ECMO therapy , and we We believe we have to decide what kind of medicine we want to practice: do we want to rely on personal experience, personal beliefs, or-at the best-logically sounding concepts and call it an “individualized approach” or do we want to rely on data. This means: do we want to base our medicine on eminence or evidence? We can only treat our patients individually, if proper data exist, which allows us to analyze the situation of each single patient in the context of therapeutic evidence. The fact that “patients are different” must not be used to whitewash therapy without evidence. Only proper data give us the knowledge and the justification to treat our patients individually.®, this does not mean that we should not use it. Nevertheless, we have the obligation to perform RCTs in properly selected patients, taking into account the natural course of the respective disease in order to give us enough evidence for the safe usage of the device to the benefit of our patients.In the case of Cytosorb


The smartphone has become an indispensable part of everyday life. It enables endless possibilities and offers persistent access to a multiplicity of entertainment, information, and social contacts. The development towards a greater use and a persistent presence of the smartphone does not only lead to advantages, but also raises potential for negative consequences and a negative influence on attention. In this research, the hypothesis of the mere smartphone presence leading to cognitive costs and a lower attention is being tested. The smartphone may use limited cognitive resources and consequently lead to a lower cognitive performance. To investigate this hypothesis, participants aged 20–34 perform a concentration and attention test in the presence and absence of a smartphone. The results of the conducted experiment imply that the mere presence of a smartphone results in lower cognitive performance, which supports the hypothesis of the smartphone presence using limited cognitive resources. The study as well as the subsequent results and the resulting practical implications are presented and discussed in this paper. The fact that smartphone usage is increasing is a result of the many advantages it offers. From unlimited communication options to unlimited access to knowledge, the smartphone enables endless possibilities. However, the societal shift towards a greater use of the smartphone raises potential for negative consequences.The smartphone represents a device that is becoming more and more widespread around the world. According to the Pew Research Center, in 2021 100% of Americans aged 18–29 owned a cellphone of some type, while 96% owned a smartphone2. The executive function, as part of a working memory model, was firstly mentioned by Baddeley (1974). In the context of this model, Baddeley proposes that cognitive resources are limited3.People are permanently surrounded by distractions, such as the smartphone. To suppress an impulse like “I want to play on my smartphone now!”, a higher instance must control this impulse to be able to perform. The ability to organize, plan, analyze, and compare past and present actions and to control impulses are described as executive functions5. The extent to which the cognitive processes are influenced by this is described in John Sweller’s Cognitive Load Theory (1988)6. In the Cognitive Load Theory (CLT), the load which arises, for example from new information, is described7.In accordance with Baddeley, other scientists assume as well that the working memory is limited in its processing capacity. This has been proven several times8. The extraneous load in a given situation can differ as well. The smartphone could therefore represent a load, namely in the form of an extraneous load.According to the CLT, different tasks may have different requirements as well as different levels of complexity. The intrinsic load of a task can thus be different. If the available working memory resources needed to process the intrinsic and extraneous load are exceeded, the cognitive system cannot process all the necessary information to some extent, which results in poorer cognitive abilities9. Another study shows that an involuntary attention system becomes active, which actively listens to the smartphone10. It was found that hearing one’s own name activates the same system as the ringing of one's own cell phone or smartphone. Distracting effects of the cell phone could also be shown for college students in the context of a lecture. It was shown that participants who kept their cell phones with them during a lecture performed worse and had a worse recall of the contents of the lecture than participants who did not have their cell phones with them11.Smartphones receive notifications, which can trigger noises (sounds) and vibrations. These notifications and potential sounds can be a distraction for humans. Studies show the significant distraction of smartphone notifications, even when participants do not respond to the messages12 that particularly focused on the smartphones influence on areas of attention, inhibition, and working memory, strong effects of the smartphone can be seen on precisely these areas. Many studies indicate that the smartphone has negative effects on sleep, stress, and academic performance. Liebherr et al. point to the fact that the smartphone has the potential to negatively affect human cognition. Besides being evident in the context of media multitasking, Liebherr et al. point out that the mere presence of the smartphone can already have effects on cognition12.According to a reviewSome of the research claims that even the mere presence or the availability of a smartphone, without having an interaction with it, may already be distracting. Although many of the following studies claim to examine the influence of the effect of the mere smartphone presence, it should be noted that most of these studies only examine the influence of smartphone availability. Smartphone availability describes the continuing ability to receive messages and notifications, while the mere smartphone presence describes a smartphone that is turned off, so that no messages and notifications can be received. In contradiction to that, more recent research does not support the hypothesis that the mere presence of a smartphone influences attention.13. A distracting effect of smartphone presence/availability could also be shown in social interactions. It was shown that the presence/availability of the smartphone forms an interference with the formation of relationships in people by inhibiting the development of interpersonal closeness and familiarity14.First, it was Thornton et al. who found a distracting effect of the smartphone by its mere presence. Students in presence of a turned-on smartphone performed poorly in neuropsychological tests compared to students that did the tasks without the presence of a smartphone15.Research also shows that the mere smartphone presence and the availability influences working memory capacity and fluid intelligence, which leads to lower attention. Ward et al. shows in a series of studies that smartphone availability depletes cognitive resources and that the consumption of cognitive resources is high even when subjects manage to continue to gather their attention, for example, when they are not looking at their smartphones. In addition to that, results indicate that only the location  of the smartphone affected the performance of the subjects. However, there was no effect of smartphone power (smartphone turned off vs. smartphone turned on) on the interference effect of smartphone presence16. Smartphone availability also influences students’ learning and memory. It was shown that subjects without smartphones had a higher recall accuracy compared to those with smartphones. In addition, it was highlighted that the presence/availability of a smartphone and many conscious thoughts of the smartphone impaired memory performance and information retrieval17.Negative effects on cognitive functions due to smartphone availability could also be examined by Ito and Kawahara. The results show that the group of subjects performing a visual-spatial task under smartphone presence takes longer on average to complete the task18.Canale et al. investigated whether individual differences in emotion-related impulsivity traits influenced the effect of smartphone availability on cognitive performance. Here, the effect of smartphone availability on cognition could only be detected when the smartphone was turned on. No effect was found when the smartphone was turned off. In both conditions, the smartphone was on the table and the smartphone that was turned on was muted. Therefore, Canale et al. suggest that attentional capacities and visual working memory capacities are associated with incoming messages, or the possibility of receiving them19.Liu et al. tested the relationship between the effect of the phone’s presence on attention and phone activeness, which is defined as the phone’s physical contact state (on desk or held in hand) and the phone’s power state . Therefore, Liu et al. used a dual-task paradigm, namely the “letter recognition task” and the “luminance-change detection task”. In this way, the influence of smartphone presence on basic perceptual processes was assessed, which builds the precondition for attentional performances. The results suggest that even a minimal awareness of the presence of a phone, including a switched-off smartphone, can cause a distraction13. Ito and Kawahara corroborate these findings16. Canale et al. found that the more demanding a task, the stronger the interference effects on the subjects' cognitive performance18.Recent research also suggests that the effect of smartphone presence or availability on attentional functioning is only present in high-level tasks and not in low-level attentional tasks. Low-level or basal attentional performance describe the ability to recognize and differentiate between stimuli, as well as to select these stimuli and show a reaction to these . High-level tasks involve meta-cognitive decisions, e.g. reacting on changing demands. Thornton et al. did a study with high attentionally demanding tasks and low attentionally demanding tasks. Here, the negative effect of smartphone availability on attentional processes was only found in the context of high-level tasks20.Schwaiger and Tahir tested the effect of smartphone presence on undergraduate students on several simple and complex attentional tasks as well as on a non-verbal reasoning task. Participants undertook these tests in 4 conditions . However, the authors do not define smartphone power (turned-on or turned-off). They found out that the presence had no impact on simple attentional tasks , as well as the smartphone presence had no influence on fluid intelligence. However, an effect while solving a more complex attentional task on students was shown: students experienced higher difficulty when their phone was present17, Internet use/attachment16 or excessive smartphone use18. Findings show that strong smartphone users or users that show a tendency to smartphone dependence are more likely to be affected by the effect of the smartphone availability on attentional processes or cognitive functions.Furthermore, research also states that the effect of smartphone presence and availability on cognition is moderated by several other constructs, such as smartphone dependence and addiction21.Contrary to that, more recent research does not clearly support that smartphone presence influences attention. For example, Hartmann et al. tested the effect of smartphone presence on different memory functions, namely short-term memory and prospective memory. No overall effect was found for smartphone presence on short-term and prospective memory performance. However, results show that for participants with low smartphone dependency, performance was better when the smartphone was absent than when the smartphone was present. These results show that the effect of smartphone presence that was shown for working memory cannot be generalized for other domains of memory capacity, such as short-term memory and prospective memory22.Ruiz Pardo and Minda did a replication of the study by Ward et al. (2017) and used the same tasks and conditions that Ward et al. used in their second experiment. Ruiz Pardo and Minda could not replicate the findings of Ward et al. and did not find differences between the different smartphone location conditions , neither on the o-span task, nor on the go/no-go task. Ruiz Pardo and Minda conclude that the presence of one’s phone may not be enough to affect cognitive performanceThe present research aims to contribute to the field of smartphone presence leading to lower cognitive functioning. In particular, it will be investigated whether the mere presence of the smartphone affects attention while the smartphone is turned off. This study is conducted to investigate whether the smartphone presence influences the attention of college students. There have been only few studies on the influence of the turned-off smartphone on attention, which is why this work can make an important contribution to the existing research. In addition to the recording of attention performance under the presence of a smartphone, the smartphone dependence of the subjects is also assessed. As smartphone dependence played a crucial role in other research and influenced the effects of the smartphone presence and availability on attention, it should also be considered here.The current state of research does not clearly show whether the mere presence of a smartphone influences attention. Many circumstances of this effect are still unclear, which is why this study is a contribution to the question of the smartphone being an influence on attention. Furthermore, recent studies, that proved an influence of the smartphone presence on attention, suggest that there is only an effect of smartphone presence and availability on cognitive functions in the context of high-level tasks. On the other hand, it is unclear whether basal skills are affected by the interference effects of smartphone presence. Therefore, the present study examines the possibility that smartphone presence may already have an effect on basal attentional processes. The concentration and attention test used represents a test that examines basal functions and attentional processes. The present paper can give more insights into the circumstances that lead to lower cognitive functioning while the smartphone is present.7. If attention is used because it is directed to the smartphone and cognitive resources are depleted, resources will be missing from it and performance to complete tasks will be negatively affected.It is hypothesized that the mere presence of the smartphone affects attention, which could lead to poorer cognitive performance. The allocation of attentional resources might be divided between the central task and the smartphone. As presented in the Cognitive Load Theory, the smartphone could represent an additional cognitive load in the form of an extraneous loadIn this experimental study, the assumption is tested whether the mere presence of the smartphone influences attention. College students perform an attention task in or out of smartphone presence. The experiment takes place in form of online video conferences. In addition to the assessment of attention, smartphone dependence is tested, for which the participants fill out a self-reporting questionnaire.Due to the COVID-19 pandemic and lockdown measures, the methods as well as the target group had to be adapted, which is why the study was conducted via videoconferences with college students.Mage = 27.29, SDage = 2.87). 21 results are from participants in the without smartphone condition, whereas 21 results are from participants in the group who performed the attention test in the presence of a smartphone. Participants were informed about the relevant procedure of the study. Informed consent was obtained from all the participants. Subjects’ participation in the study was voluntary and confidential, and participants obtained no compensation. The study was approved by the audit committee of the Faculty of Arts and Humanities of Paderborn University according to the guidelines of the DGPS (Deutsche Gesellschaft für Psychologie—German Society for Psychology). All methods used in the experiments performed during the present study were performed in accordance with the relevant guidelines and regulations of the research ethics committee of Paderborn University.A total of 49 students volunteered to participate in this study. The age ranges from 20 to 34 years. The study takes place in a total of 12 online videoconferences, of which 1–5 people participate in one session at the same time. Data is collected over a three-week period in February and March 2021. The conditions under which the attention test is administered are manipulated by randomly assigning participants to one of the conditions (with or without smartphone). Participants in the smartphone condition are asked to place their smartphone on their desk during the test. The smartphone is switched off and the screen of the smartphone is placed covered on the table, so that the screen is not visible. The other condition is the without smartphone condition, in which the participants switch off their smartphone and place it outside the room. Seven subjects are excluded from the study. Reasons included completing the test incorrectly, not having test materials that work or participants indicating that they had already known the attention test in advance, which would lead to biased results. Thus, the final sample consists of 42 participants 23. The d2-R is a strikethrough test in which objects and characters must be searched for that are located between similar objects and characters. The task is to mark the correct ones among many characters. The characters are the letters ‘d’ or ‘p’ and one to four marks, which can be below or above the letter. Participants had to cross out the ds with two marks. The d2-R test consists of a sheet on which are 789 characters. The total time to complete the test is 4 min and 40 s. The test consists of a total of 14 lines and participants have 20 s of processing time per line. If a participant completes the test without errors, 359 characters would be crossed out.Attention is assessed by using the 24. Differences in the ability to concentrate become apparent by the speed and accuracy with which large numbers of such non-demanding tasks can be completed continuously. The d2-R was chosen as the test for this study because it is one of the most widely used methods for measuring attention in German-speaking countries. It is a validated instrument and proven as reliable and dependable23.The d2-R can be seen as a test consisting of tasks that are cognitively not very demanding but can be completed quickly23. The AP score is a measure of processing speed that was adjusted for made errors. In addition to the attention performance score, the speed score, called PTO score (processed target objects) and the E% score are assessed. The standardized E% score indicates the accuracy of a test person in processing the d2-R23.The d2-R provides information about the processing speed, accuracy and attention performance of the test subjects. The attention performance score, referred to as the AP score, indicates a person's ability to focus their attention23.The speed, the accuracy as well as the attention performance are recorded by the number of processed target objects (i.e. crossed out target objects) as well as the errors made, i.e. crossing out distractors or not crossing out target objectsGerman short version of the smartphone addiction scale (d-KV-SSS). This scale was selected to prioritize instruments that have been validated25 and proven as a reliable and dependable instrument in a German speaking region 26. Montag (2018) adapted the original scale  by Kwon et al. (2015)25 via a traditional translation and back-translation procedure and developed the German short version of the Smartphone Addiction Scale (d-KV-SSS)26. Modifications of the d-KV-SSS were made in the present study to increase comprehensibility, as well as to make it more personal to the participants (see supplementary information for the questionnaire). For example, educational language words as well as sentence constructions were simplified and adapted.Smartphone dependence is assessed by using the 26. Cronbach’s Alpha was 0.78.The d-KV-SSS questionnaire can reveal a possible smartphone dependence as well as tendencies towards a smartphone dependence. The items used in the questionnaire can be answered using a six-point Likert scale. Participants can give answers ranging from "I do not agree at all" (1) to "I fully agree" (6). These responses to the 10 items are summed to obtain an overall score of smartphone dependence. The total score thus ranges from 10 to 60 points. Higher scores are associated with a stronger tendency towards smartphone dependenceThe experiment is conducted in form of digital video conferences via a video platform. In advance, participants receive detailed instructions on how to prepare for the test, which include a detailed description and a sketch of how they should position themselves and organize their surroundings during the test (see supplementary information for the handed-out instructions and the sketch). Participants are advised to sit at an empty desk with only a pen, their smartphone and the envelope sent to them, which contains the test materials. In addition, participants are told to eliminate all possible distractions. Furthermore, participants receive a note to also inform possible family members, roommates, etc. that they must not be disturbed during the experiment. It is emphasized as particularly important that all functions and notifications of the participants’ own laptop or computer, except for the function of the video call, are disabled. Participants receive a detailed list of what to switch off. This is to ensure that the laptop or computer serves only as a camera and audio source and is not a distraction.Besides the instructions, participants receive the d2-R test and the questionnaire d-KV-SSS by mail. Whether the instructions are implemented can be observed during the video call by the supervisor. If the instructions are not implemented correctly or sufficiently, participants will be informed by the supervisor. This ensures that the instructions are implemented correctly.The experiment is conducted in a session over a period of approximately 20 min. Since the study takes place via an online videoconference, participants are in their usual environment and a representative situation is given. The situation created in the experiment, in which the participants are at their desk, working on a task and having their smartphone next to them, resembles an everyday life situation and can be transferred to it.Before the testing, precise instructions are prepared. To keep confounding variables as low as possible, a video is sent to the participants in advance in which the experimenter gives instructions for the attention test (d2-R). Participants are advised to not watch the video until the beginning of the videoconference. The instructions in the video include a reminder of the instructions that should be carried out before the experiment and a brief description of the course of the test.In the further course of the conduction of the d2-R, the instructions are read aloud by the experimenter. The experimenter adheres to the exact, prepared wording to create the most equal conditions possible for all participants. When the conduction of the d2-R begins, the instructions given in the test manual of the d2-R are used.Besides the advantage of the video, that the instructions are the same for all participants, there is another positive aspect. The participants are instructed to download the video to their smartphone in advance. The video, which the subjects watch on their smartphones during the testing, ensures that all subjects own a smartphone. The subjects can be instructed immediately after watching the video to place their smartphone in a specific location without receiving a hint about the experimental manipulations as well as the hypotheses to conduct a blinded experiment. Participants are given the information that the general development of college students’ attention is examined.After the participants have watched the video, they are advised where to place their smartphone. Depending on the group they are assigned to, the smartphone is either placed on the table or taken to another room. Subsequently, the participants create an individual personal code to ensure that completed documents can be assigned to each other, but at the same time the results remain anonymous. Next, the d2-R is conducted. During the test conduction, after every 20 s, the experimenter gives the cue "Stop. Next line." until after 4 min and 40 s the cue "Stop. Put the pen aside." is given and the test is completed. After completing the d2-R, participants answer the d-KV-SSS to gather information about a possible tendency towards smartphone addiction.To test the hypothesis that subjects have lower attention performance when the smartphone is present, the d2-R concentration and attention test is conducted. The performance score of the d2-R represent the individual attention performance scores. The performance is evaluated for both conditions (with or without the smartphone). In addition, the German short version of the smartphone addiction scale is evaluated. Stronger and weaker tendencies towards smartphone addiction are examined. The results of the d2-R and the questionnaire are evaluated using SPSS Statistics for Mac. An effect could be shown.A one-factor ANOVA was used to examine the subjects’ attention performance in connection with a tendency towards smartphone addiction. The presence or absence of the smartphone is the independent variable, and the attention performance score is the dependent variable. Group comparisons were made using the ANOVA. Additionally, a covariance analysis was conducted to picture the potential moderating effect of the covariate “smartphone addiction”.For the hypothesis that people have lower attention performance when the smartphone is present, three one-tailed ANOVAs are performed with the presence or absence of the smartphone as the independent variable and one of the three given scores of the d2-R  as the dependent variable.To perform an ANOVA, the following necessary assumptions for the validity of the results of an ANOVA are checked: the normal distribution of the scores, the homogeneity of the variance and the independence of the samples. There was no normal distribution given for all values. As an ANOVA is a robust test, an ANOVA was chosen as the used test. We use an alpha level of 0.05 for all statistical tests.2 = 0.01), medium (η2 = 0.06), and large (η2 = 0.14) effects. For the classification of the effect size η2, reference values for classification according to Cohen27 are used.To test the hypothesis that there is a significant difference between the two groups, an ANOVA is performed with attention performance score (AP score) as the dependent variable and condition (with or without smartphone) as the independent variable. In addition, the effect sizes are given and are classified into small  = 6.168, p = 0.017, η2 = 0.134). The without smartphone group has significantly higher attention performance (M = 108.95) compared to the with smartphone group (M = 99.71). There is a tendency towards a large effect. In addition to the AP score as a dependent variable, the ANOVA is performed with the speed score (PTO score) as dependent variable and the condition (with or without smartphone) as independent variable. A significant effect is also found for this ANOVA  = 7.592, p = 0.009, η2 = 0.160). The significance of this ANOVA means that the subjects under the smartphone condition (M = 98.48) have a significantly lower work speed compared to the without smartphone condition (M = 108.57). A large effect is present here.The means of the AP, PTO and E% scores for the two conditions (with and without smartphone) are shown in Table F = 2.088, p = 0.156, η2 = 0.050). The result of this ANOVA is not significant, meaning that the subjects do not have significantly different scores in accuracy under the two conditions.To test the hypothesis that there is a difference between the without smartphone and with smartphone groups for accuracy , an ANOVA is performed with the E% score as the dependent variable and the condition (with or without smartphone) as the independent variable  and working speed (PTO scores) are significantly lower in the smartphone presence group compared to the smartphone absence group. Only accuracy (E% score) does not differ significantly.M = 29.47, SD = 8.38. The mean for the group of subjects in the with smartphone condition is M = 29.80, SD = 8.89. For the group in the without smartphone condition, the mean is M = 29.14, SD = 8.04. No significant mean difference is found, F = 0.065, p > 0.05.The mean for the d-KV-SSS for the entire group is M = 29.47 and thus forms the midfield. This shows that there are no strong, but also no low tendencies towards smartphone dependence.Thus, overall, no strong tendencies toward smartphone dependence can be found for the entire group of subjects. If the mean of the total group is considered, it is The possibility of smartphone dependence as a moderating variable is examined. For this purpose, covariance analysis is performed with the variable of smartphone presence or absence. This analysis shows no significant interaction of the variables. Thus, a moderation of the effect of the presence of the smartphone by the individual differences in the dependence on the own smartphone cannot be confirmed.28 and smartphones are permanent companions to people worldwide. As a result, they have the potential to significantly influence consumers.Students are increasingly using the smartphoneThrough the present paper, the possibility of a strong negative influence by the smartphone is investigated. Especially college students can be negatively influenced by the heavy use of the smartphone. The work presented here shows one consequence of the smartphone’s integration into the everyday life of students: the loss of attention. It provides evidence that even the mere presence of one’s smartphone consumes cognitive resources, without willingly shifting attention or actively using the smartphone. In the test situation, there was no visible interaction with the smartphone, as the smartphone was not looked at or picked up. This work was able to show in more detail to what extent attention performance is negatively affected: it was found that people show a slower work speed in the presence of a smartphone. New findings were obtained regarding the influence of smartphone presence on attention in the context of complex and non-complex tasks. Contrary to the previous state of research, a strong influence of smartphone presence was found in the context of tasks that require basal attentional processes, which is a new finding in this area. Since previous research cannot clearly show whether the mere presence of a smartphone influences attention, the results of this study represent a contribution to this and support the assumption that smartphone presence is a negative influence on attention.6. Thus, the limited resources must be divided. According to the Cognitive Load Theory, resources are consumed by different types and amounts of cognitive loads, which consequently leads to different cognitive performances7. The fact that attention was visible from the outside, but the subjects' performance was nevertheless lower in the presence of the smartphone, provides evidence of an invisible consumption of cognitive resources. According to Sweller’s categories for the classification of loads7, the smartphone presence can represent an extraneous load, as it is independent of the task and the content to be processed. The additional load represented by the smartphone consumes cognitive resources that are consequently no longer available to process further information. The additional load of the smartphone can thus be used to identify the reason for the negative influence of the smartphone on attention and consequently the lower performance under smartphone presence.The theoretical framework presented here proposes the consumption of cognitive resources as an explanation for the different performances. As the theoretical presentation of the executive functions show, the cognitive resources of humans are limited20. Additionally, Ito and Kawahara found that subjects show slower performance when a smartphone is available16. The present work can corroborate and extent the findings of Ito and Kawahara, as it could be shown that even the mere presence of the smartphone has the discovered effect of cognitive interference and lead to a slower work pace.Other studies have already shown that attention and performance decreases when a task is performed while the smartphone was available, which means that there was still the possibility to receive messages and notifications. The present study provides evidence that even the mere presence of one’s smartphone consumes cognitive resources, without any voluntary shift of attention or active use of the smartphone. The present findings are consistent with previous research findings that showed a reduction of attention and performance due to the presence/availability of the smartphone29.Moreover, Koessmeier and Büttner tested the mere presence effect of the smartphone while also tracking visual distraction that might be caused by smartphone presence. Participants wore mobile eye tracking glasses while performing cognitive tasks and reading tasks in smartphone presence and absence. Negative effects of smartphone presence on performance could not be replicated. During the task, participants almost never looked at their smartphone. Only during breaks and transitions between tasks, people drew their visual attention to their smartphones. Results show that the presence of the smartphone increased smartphone vigilance, however, this did not influence task performance. Koessmeier and Büttner conclude that people can regulate the visual attention that they pay to smartphones20. The results of our study are opposite to this. The d2-R represents a simple test with little complexity, where the subjects must discriminate simple visual stimuli and which consists of intellectually simple tasks23. Nevertheless, the presence of the smartphone had the effect of reducing attention performance. Moreover, a strong effect was shown, even in the context of a task that requires basal attentional processes. Thus, our study contributes to the previous findings regarding the effect in connection with tasks requiring basal or high-level attentional performance. It is shown that the smartphone presence has a negative effect on attention, even while solving non-complex tasks.The effect of smartphone presence and availability, i.e. the loss of attention, was only found for complex or high-level tasks in the prior body of research18. Results of Ward et al. (2017) and Thornton et al. show that a turned off smartphone influences attention13. Liu et al.19 also found a possible effect that having a turned-off smartphone present reduces attention. In our study, effects were found for a smartphone that was switched off. It could be shown that cognitive capacities are used by the mere presence of a smartphone even if there is no possibility to receive notifications. These results imply that the complete spatial separation from the own smartphone is a possibility to counteract a negative influence of the smartphone on the ability to focus attention. This also corresponds to the results of Ward et al., who stated as well that only the spatial separation counteracts a negative influence of the smartphone on attention15.A strong difference was found to Canale et al. who found in their studies that there was only an effect for the presence of the smartphone when it was switched on and not when it was switched off30. Thus, the study shows possible positive influences due to smartphone presence, which provides further indications for a positive handling of the smartphone: These results show that in certain contexts, the presence of a smartphone can have positive influences.In contrast to the negative effects presented here, positive effects are also possible due to smartphone presence. In another study, Liu et al. investigated whether the presence of a smartphone leads to higher levels of creativity. Previous research shows that environmental factors can change a state of attention into a diffused state, which fosters creativity. Results of Liu et al.’s study show that creativity increases when a smartphone is present, as workers' attentional state is affected by the presence of the smartphone. Due to the presence of the smartphone, workers are in a diffused state of attention, which leads to a better performance on a creativity task1, these findings are consistent with the overall prevalence. However, as previous research by Ward et al.15, Thornton et al.13, and Ito and Kawahara16 found an effect of smartphone dependence and personal relevance of the smartphone, this should be further investigated in future research.An influence of smartphone dependence on the effect of smartphone presence could neither be confirmed nor refuted here, as no strong smartphone dependence tendencies were present in the subjects. Given the recent increase in smartphone use, smartphone dependence was considered to be a relevant factor, and because smartphone dependence has played an important role in previous studies, this factor was controlled for. As smartphone addiction is not that common31. Thus, an influence on cognitive abilities can also be given by the laboratory situation compared to an everyday life situation, which is why keeping the participants in their natural environment is also an advantage given in this study. To counteract the different conditions that were given for the participants, exact instructions were prepared in advance and used while conducting the experiment. However, differences in instruction cannot be ruled out. Furthermore, participants in our study had their personal smartphones with them. Thus, each participant had a different smartphone, which also led to different conditions and the possibility of different influences on the participants. However, Ward et al. showed that the effect of smartphone presence on attention is mostly triggered by the personal smartphone, as the personal relevance of this device plays an important role15. As mentioned by Liu et al., the influence of cellphone ownership on the effect of smartphone presence was not examined enough in the currently existing research and should be further considered in future studies19.By conducting the attention and concentration tests via an online video platform, limitations for the given results should be considered. Limitations arise from the fact that the general test situation during the examination was no laboratory situation, which means that various influencing factors could be present. Possible external factors may have interfered with the participants attention. However, this limitation is also contrasted with the advantages of a situation in which the subjects are in their natural environment. Salvucci and Taatgen (2011) did a study on multitasking, in which they argue that a laboratory experiment cannot represent the true costs of multitasking, as experiments in the laboratory are not representative for multitasking situations in real life situationsLimitations also result from the sample of our study. First, with 42 test persons, only a relatively small sample was given. Second, the sample used in the present research was predominately White (93%), highly educated, and relatively young (20–34 years). Thus, it is not clear if the present results can be generalized to the broader population using a smartphone. To investigate the generalizability of the present findings, more studies on the effect of smartphone presence should be done, especially concerning a more diverse sample group.32. However, as results of this study show, placing the smartphone in another room is already sufficient to counteract the resource-consuming effect of the smartphone. This can be implemented by students in different contexts, for example while studying, to counteract the consumption of cognitive resources. In this way, better cognitive performance can be achieved by students.As our data suggests that the mere presence of the smartphone has a negative effect on attention, implications for the use of smartphones in students’ daily lives can be drawn. In general, students should be made aware of the fact that the presence of the smartphone negatively affects attention. This can be done, for example, at universities in form of posters. Based on that, students should change the way they use their smartphone: they should not carry it with them permanently, and students should make sure that they do not have their smartphones in their field of vision, especially while studying or attending a lecture or class. Furthermore, the general rules and limitations for smartphone use both at universities and in other learning contexts, such as schools, should be questioned based on the present findings. In addition, the question can be raised how much other objects of “mobile technology”, such as tablets, have the potential to negatively influence cognitive performance. In the course of digitalization, many efforts are being made to implement digital devices as much as possible in the classroom and everyday teaching, especially now in the context of the COVID-19 pandemicThe hypothesis that the mere presence of the smartphone influences attention without any interaction with it can thus be confirmed by this study. It could be shown that the presence of the smartphone results in lower attentional performance. In addition, with the help of this work, the type of influence on attention by the smartphone can be shown more specifically: the presence of the smartphone has a negative influence on the working speed and thus on cognitive performance and attention. Under the presence of the smartphone, individuals work slower.Taken together, most studies show an influence of a turned-on or available smartphone on attention in the context of high-level attentional tasks. This study shows an influence of the mere presence of the smartphone in the context of low-level attentional performance, which is a contribution to the previous body of research.The theoretical framework shows that the smartphone represents an additional cognitive load, whereby limited cognitive resources are consumed. As a result, cognitive performance is negatively affected. The results of this paper suggest that especially the speed of cognitive performance and processing is impaired. In addition, an important fact could be shown by this study: the smartphone presence influences attention even while solving tasks that require basal attentional processes.Based on these results, the everyday use of smartphones and the desire for a greater digitalization, and thus the increased implementation of digital devices in our daily lives, should be critically reflected. With this work, concrete possibilities for a positive handling of the smartphone can be given. It could be shown that it is not sufficient to cover the screen of the smartphone or to turn it off. However, placing the smartphone in a different room is sufficient to avoid the negative effects on attention performance. This is a simple and effective method to achieve this.As the results of this study show, the use and permanent presence of a smartphone imposes a great challenge on society. At the same time, current studies show that the smartphone and also the smartphone presence can have positive effects. For example, during the COVID-19 pandemic, the smartphone proved to be a particularly useful tool. All of this shows that in order to get the most out of a smartphone and make the best of its costs and benefits, a balanced and conscious use of the smartphone must be achieved.Thus, it can be shown that smartphone use should be critically scrutinized and should only be done in appropriate contexts. Students should avoid having their smartphone with them while attention is required. Based on this work, many other contexts can be explored in which the smartphone could be a negative influence on attention.The possibilities of the smartphone are enormous, however, this work shows that the advantages of the smartphone come with a strong negative disadvantage: high cognitive costs and strong losses of cognitive abilities.Supplementary Information.


Digital technology can have significant effects on language education. This effect makes the English language teachers teach the subjects better to the students and also improves the quality of teachers’ education.The purpose of this research is to evaluate the digital literacy of English language teachers and to investigate the difference between digital literacy and their gender, education level, and teaching experience. To conduct the study, the researcher invited 2,110 EFL teachers to fill out the Teachers’ Digital Literacy questionnaire. The researchers used SPPS and AMOS in analyzing the obtained data.The results of the study indicated that teachers’ contextual factors do not influence their digital literacy skills. In addition, the study showed that teachers’ attitudes toward technology, their skill to use technology, and their access to technology can significantly affect teachers’ digital literacy.Implications of the study are further discussed in this paper. Digital literacy can influence teachers’ performances and developments. Information and communication technologies have been effective in every aspect of life, and as a result, many changes have occurred in different ways of doing our regular work . It is nThe emergence of digital technology brought different types of literacy, including media literacy , computeHowever, digital technology has its limitations. For instance, digital spaces may be used more for entertainment and less for educational purposes . For insDespite the new and different types of digital technology, the movement from writing and speaking to digital style has led to essential changes in how teachers teach . LanguagMany factors affect the digital literacy of teachers, which can be mentioned as a willingness. They will have optimistic view of technology, knowledge of using technology, access to technology, and contextual factors. However, gender, teaching experience, and educational level are factors affecting the digital literacy of teachers. Reviewing the literature reveals that few studies had been conducted in evaluating the difference between digital literacy and contextual factors such as gender, education level, and teaching experience of English language teachers. As a result, the current research aim is to fill this research gap by proposing the following three questions:RQ1. What are Chinese EFL teachers’ perceptions of digital literacy?RQ2. Is there any significant association between EFL teachers’ demographic factors  and their differences in their technology literacy, their digital participation, engagement, and perceptions of technology integration?RQ3. Is there a significant association between EFL teachers’ demographic factors , technology literacy, and their perceptions of the barriers to technology integration ?In this section, digital literacy is discussed from different perspectives. First, the definitions of digital literacy are discussed. Then its importance is examined. Finally, the studies that have been done in this field in different environments are discussed.Digital literacy is the skills you need to live, learn, and work in a society where communication and access to information are through digital technologies like internet platforms, social media, and mobile devices . EducatiIn addition, the role of technology in the impact of language cannot be ignored. Researchers have given several definitions of digital literacy. Having digital literacy does not necessarily mean knowledge that can solve problems . The firOne of the main goals of education is to create correct and appropriate classroom changes . NaturalMany studies have confirmed this fact . For exaTo supplement new education abilities, a comprehensive framework for mechanical proficiency improvement is proposed. This is displayed in Attitude, access, and skill in using digital resources are influential factors that cover teachers’ digital literacy . The resFor example, Some other researchers have studied the digital literacy exercises of the students and their level of progress . The resThe relationship between identity and digital literacy has also been studied. Although researchers have examined emotional literacy, evaluative literacy, and other literacy, most of the studies have been on the use of technology in teaching and learning. For instance, The review of previous studies showed that although the role of digital technology, including using computers for teaching and learning, has been investigated, these studies have not investigated digital literacy, the use of digital technology, and environmental factors. Therefore, the present study aims to evaluate the level of digital literacy of English language teachers and the effect of individual characteristics such as gender, education level, and teaching experience on their digital literacy.Two thousand one hundred and ten EFL teachers participated in this survey research. Five hundred thirty-seven of the participants were male, making up 25.45 percent, and 1,573 were female, making up 74.55 percent. Their majors were English Language Teaching, English Translation, and English Literature. There are 1,315 participants majoring in English Language Teaching, making up 62.32 percent; 371 majors in English Translation who make up 10.57 percent, and 424 majors in English Literature make up 20.09 percent. Since the researchers tried to collect authoritative data, they distributed the questionnaire in any possible province. Through convenience sampling, the researchers distributed the questionnaire as much as possible. They taught English in 24 regions that were Beijing, Shaanxi, Guangdong, Guizhou, Anhui, Jiangsu, Gansu, Shandong, Hebei, Xinjiang, Fujian, Shanghai, Hubei, Sichuan, Zhejiang, Shanxi, Qinghai, Yunnan, Chongqing, Hunan, Heilongjiang, Ningxia, Tianjin, Jiangxi, Henan. There are 45 participants from Beijing, accounting for 2.132%; 11 participants from Guangdong who account for 0.521%; 10 participants from Guizhou who account for 0.474%; 14 participants from Anhui who account for 0.664%; 15 participants from Jiangsu who account for 0.711%; 25 participants from Gansu who account for 1.184%; 11 participants from Shandong who account for 0.521%; 5 participants from Hebei who account for 0.237%; 5 participants from Xinjiang who account for 0.237%; 3 participants from Fujian who account for 0.142%; 9 participants from Shanghai who accounting for 0.426%; 10 participants from Hubei who account for 0.474%; 7 participants from Sichuan who account for 0.332%; 30 participants from Zhejiang who account for 1.422%; 12 participants from Shanxi who account for 0.142%; 3 participants from Shaanxi who account for 0.474%; 10 participants from Qinghai who accounting for 0.426%; 9 participants from Yunnan who accounting for 0.043%; 2 participants from Chongqing who accounting for 0.095%; 5 participants from Hunan who accounting for 0.237%; 1 participants from Heilongjiang who account for 0.758%; 16 participants from Ningxia who account for 0.014%; 2 participants from Tianjin who accounting for 0.095%; 4 participants from Jiangxi who accounting for 0.2%; 1851 participants from Henan who account for 87.725%. The study adhered to primary research ethics. The participants had been informed that the information provided would be kept confidential and used only for research purposes. There was no prior association between the researcher, the participants, and no conflict of interest. The authenticity and reliability of the data collected has been checked carefully.r = 0.80). This questionnaire has six sections; the first section specifies the ethnographic information of the participants, the second section specifies the participants’ attitudes toward technology and their skill in conducting it in their classrooms, the third section specifies their participation in technology-based learning environments, the forth section specifies their engagement with technology in their learning contexts, the fifth section specifies their perceptions of technology use in their learning environments. The last section determines their attitudes toward the barrier to use technology in the language classroom and enhance teachers’ and learners’ digital literacy. This questionnaire measures four key concepts. The more items we include in the analysis, the higher Cronbach’s α will be, but such a higher alpha may not be able to reflect the real internal consistency of an instrument. To control this issue, the researchers reported the α of different constructs of the questionnaire, respectively, rather than regarding them as a whole. The results of the Cronbach Alpha Coefficient show a reliability of 0.75 (r = 0.75) for digital participation, 0.78 (r = 0.78) for attitudes, 0.83 (r = 0.83) for engagement, and 0.79 (r = 0.79) for perceptions.The Digital Literacy Questionnaire was the only instrument that was employed in this study. The first version of the questionnaire was developed from the answers of three experts in the field to the interview questions. The first version of the questionnaire had 101 questions. Three experts checked its face and content validity and delivered their comments. Based on the provided comments, the researchers revised the questionnaire. The revised version was subjected to exploratory and confirmatory factor analysis. The final version of the questionnaire with 52 questions was piloted by 50 participants from the same population. The results show a reliability of 0.8 . The researchers distributed the questionnaire among 2,500 EFL teachers. In this survey research, from 2,500 distributed questionnaires, 2,110 questionnaires were received. The overall unweighted response rate for this survey was 84 percent. Ensure about the understanding of the items, the researchers used the questionnaire in English and Chinese. The data collection procedure lasted six working days. The data was collected from 24 provinces of China that were Beijing, Shaanxi, Guangdong, Guizhou, Anhui, Jiangsu, Gansu, Shandong, Hebei, Xinjiang, Fujian, Shanghai, Hubei, Sichuan, Zhejiang, Shanxi, Qinghai, Yunnan, Chongqing, Hunan, Heilongjiang, Ningxia, Tianjin, Jiangxi, Henan. The collected data were entered into SPSS version 27 and AMOS version 24 for further analyses. The researchers used SEM analyses to answer the research questions.The researchers used descriptive analysis to find the answer to research question number one. In the following tables, the results of these analyses are presented.The results of The results of The results of The results of To answer the second and third research questions, the researchers used SPSS, version 27, and Amos version 24. The results of the analyses are presented in the following According to the software output, Chi-square = 14930.669, Degrees of freedom = 65, and Probability level = 0.000; Chi-square test is significant (Sig = 0.000 < 0.05), so it can be concluded that there is a significant difference in the frequency of variables. The values of the analyses are presented in the following tables.As the results of the However, the analyses showed a significant association between teachers’ digital literacy and their attitudes toward technology, participation in technology-based teaching activities, engagement in technology, and their perceptions of technology in their teaching contexts. In addition, the results show that EFL teachers believed that the major barriers in conducting technology-based language classrooms are teachers’ digital literacy and their access to technology in their teaching contexts.The results of This study investigated the digital literacy of English language teachers. In addition, the present study examines the relationship between digital literacy and gender, education level, and teaching experience of English language teachers. The obtained results indicate no significant association between environmental factors and the digital literacy of EFL teachers. It should also be noted that factors such as insufficient training of teachers, and lack of up-to-date textbooks can affect teachers’ digital literacy and put their teaching under the spotlight.Another finding of the current research was that there was no statistically significant difference between male and female teachers in digital literacy skills. This finding is somewhat consistent with the research findings of Another finding of the current research was that no significant statistical difference was found between teaching experience and digital literacy. Some studies indeed show conflicting results , but as Consistent with the literature, this research found that there was no statistically significant difference between the level of teachers’ education and their digital literacy . One of Although the results of this study showed no significant relationship between environmental factors such as age, gender, education, and their digital literacy, factors such as teachers’ attitudes, their skills in using technology, and their access to technology have a significant impact on their digital literacy. This important result can be rooted in access to digital resources and their use in society. More access to digital technology can increase the digital literacy of language teachers, and digital literacy can make language teachers more capable of teaching and optimal use of digital technology in the digital age in a way that facilitates the teaching process and as an available tool should be used for educational purposes. Therefore, the need to attract, empower, and retrain teachers before and during service should be given serious attention.The rapid growth of human knowledge resources and the emergence and expansion of information and communication technologies have made mankind today face unprecedented confusion in finding information sources. The only way to overcome this confusion and speed up finding the required information is to increase digital literacy skills. Digital literacy skills have been considered due to the expansion of communication networks and electronic resources and the selection of the best and most relevant source. A literate person in terms of information technology can use computers, application software, databases, and other technologies to perform various tasks related to his education, career, and personal affairs; Therefore, people who want to achieve information literacy must first acquire the relevant technological skills.According to the findings of this research, some practical suggestions can be made to the policy makers, planners and implementers of the education and training system:Measuring the level of computer literacy of teachers should be considered as a basis for their evaluation; By holding educational workshops and in-service training courses and by adding the topic of classroom management to the subject of teacher training centers and teacher training courses, actions should be taken to improve the behavior style of teachers in classroom management; special attention should be paid to new teachers, in terms of the need to understand digital literacy, receive sufficient training and feel responsible for their own education; in order to improve educational quality and coordinate with digitally literate teachers, students should also receive the necessary training for the optimal use of technology; the authors of textbooks should compile books with new content and materials to be in harmony with new environments, and policy makers should also try to make fundamental changes in English language education programs. Learning from the findings of this study, when planning or delivering technology-based learning environments, teachers need to first understand the students in terms of their level of digital literacy for learning. A good fit of digital literacy level to course expectations is necessary for successful technology-based learning. If some students have low digital literacy levels, additional exercises, and tutorials can be used to help these students improve their digital literacy capabilities. The participants in this study had different technology usage experiences. How familiar they were with technology could influence their views of its usefulness was in their teaching process. In addition, the participants were from different courses and provinces. The types and levels of digital literacy capabilities required could be diverse across subject matter areas. The study context was a local university that had adopted blended learning. Future studies can examine the original research model in different contexts, for instance, primary or secondary schools, professional courses, working adults, and full-time young students, etc. Future studies can consider new factors, investigate interactions among the factors, and introduce moderators. More studies are required to generalize the findings of the present study. Future studies can focus on the quality of teacher training courses and investigate their adequacy in longitudinal studies. Teachers’ beliefs in different contexts can be investigated in EFL contexts. Learners’ beliefs and their digital literacy can be scrutinized in future studies. Digital literacy abilities offer colossal advantages and benefits to the two teachers and students, nonetheless, without legitimate use and understanding, the use of digital apparatuses can become overpowering, or even perilous, particularly with regards to more youthful age gatherings. Youngsters right now live in a developing digital world that requires expanding capacities and abilities to utilize and adjust digital apparatuses. While there is understanding that another arrangement of abilities including innovations is imperative for the instructive improvement of students, there is little agreement about definitively what information and capacities are important for youngsters to be viewed as digitally educated. Future studies could investigate young learners’ understandings of digital literacy and the specific skills they require to cope with this new mode of instruction.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Jiaozuo Normal College Academic Ethics Committee. The patients/participants provided their written informed consent to participate in this study.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Debriefings give healthcare workers voice through the opportunity to discuss unanticipated or difficult events and recommend changes. The typical goal of routine debriefings has been to improve clinical outcomes by learning through discussion and reflection of events and then transferring that learning into clinical practice. However, little research has investigated the effects of debriefings on the emotional experiences and well-being of healthcare workers. There is some evidence that debriefings are a multi-faceted and cost-effective intervention for minimising negative health outcomes, but their use is inconsistent and they are infrequently adopted with the specific intention of giving healthcare workers a voice. The purpose of this systematic scoping review is therefore to assess the scope of existing evidence on debriefing practices for the well-being and emotional outcomes of healthcare workers.Following screening, 184 papers were synthesised through keyword mapping and exploratory trend identification.The body of evidence reviewed were clustered geographically, but diverse on many other criteria of interest including the types of evidence produced, debriefing models and practices, and outcomes captured.The current review provides a clear map of our existing understanding and highlights the need for more systematic, collaborative and rigorous bodies of evidence to determine the potential of debriefing to support the emotional outcomes of those working within healthcare.https://osf.io/za6rj. Employee voice is informal and discretionary communication by an employee, about work-related issues with the intent of bringing about improvement or change, to people who might be able to take appropriate action . In healThe idea of speaking up for safety as an extra-role behavior, like in debriefings, is not a new one. Hofmann et al.  conceptuThere has been wide proliferation of a number of different models and approaches to debriefing, with previous reviews reporting a diverse range of purposes, methodological variations and outcomes e.g. , 14]. Th. Th14)].First, models focused upon learning include the REFLECT , a scriSecond, models focused upon minimizing post-traumatic stress and other such mental health outcomes like depression include Critical Incident Debriefing , Psychological Debriefing and Trauma Risk Management (TRiM). These models can encapsulate quite a range of debriefing practices , and canResearch to date has suggested limited efficacy of the use of CISM as a debriefing intervention for the emotional responses of workers. Tuckey and Scott  found thPsychological Debriefing has been the subject of contentious debate, particularly surrounding the potential to cause harm to those engaging with it . This waTriM consists of peer support for those that have experienced a traumatic event. The role of debriefing has been suggested to be favorable compared to CISM approaches, as it does not require participants to talk through details of the event . FurtherWhile there have been many diverse bodies of evidence exploring these various practices, there have been a number of concerns raised. For example, some debriefing practices, like providing single sessions without follow-up, are concluded to be detrimental to healthcare workers’ wellbeing . ConsistDebriefing holds the potential to represent an accessible, flexible and low-cost intervention for a community of workers in desperate need for emotional support to complete demanding but vital work . Given tThe aim of this article is to map existing evidence on debriefing practices for the wellbeing and emotional outcomes of healthcare workers. We investigate: “How have the effects of debriefing practices on the wellbeing/emotional outcomes of healthcare workers been studied to-date?.” The current article represents a systematic scoping review to explore the state of current understanding with respect to diversity and efficacy of practices. In doing so, we aim to promote developments in understanding and practice for the debrief interventions available to improve the emotional wellbeing of healthcare staff (following both traumatic incidents and day-to-day practices) and to provide greater employee voice in healthcare.This project was preregistered on the Open Science Framework, November 22nd 2021Our full search criteria can be found in The online screening platform, Rayyan , was adoA central practice focus must be on debriefing, regardless of whether it is reported as an intervention, response to specific event, or daily practice. These can sometimes be referred to as briefings or huddles and are inclusive of day-to-day practices and one-off trauma-based interventions.A central sample or focus should be upon healthcare staff and/or healthcare profession. These should be interpreted broadly.The work should include a note of affective/emotional outcomes of debriefing. These should be interpreted broadly and can include mood, specific emotions and emotional states, coping, resilience, psychological health outcomes, wellbeing ratings and similar.n = 1,040) or TRE  to assess compliance with all three criteria. During this process, 193 papers were coded as ‘unsure’ and subsequently assessed by the core research team  who met online to discuss each case. From this, 151 were collaboratively agreed to be relevant when consistently erring on the side of inclusion. In total, 271 papers were considered to meet the three criteria.The title and abstract of each paper was assessed by RE (M = 24). At all review stages, raters were offered the opportunity to exclude themselves from rating the specific article if they had a conflict of interest or other such issue. All data were collected through Google Forms and all forms and data can be found on the OSF project page.All 271 papers were then subject to a full-text review by two members of the wider research team (see ‘Investigation’ in n = 4) and full-text accessibility (n = 30). Of the 30, 19 were inaccessible journal articles, 3 were book chapters and 8 were doctoral theses. The majority of these (18/30) were published before 2015, when research attention in the field increased Type of study Sample size Population type/specialism (e.g. Paramedics)Regularity of event (e.g. trauma or routine)Whether real-world or simulation settingSpecific wellbeing outcome (e.g. PANAS score)Type of Debriefing model Support provided To provide an indication of inter-rater agreement, two of the nine criteria were evaluated for similarity between coders. As many of the criteria were recorded as open responses, we present agreement on the forced-choice ‘type of study’ and ‘regularity of event’ responses. These were chosen on the basis of qualitative feedback from coders as to the easiest and most complex coding decisions, respectively, thereby providing an indicative range of agreement for the study. Where more than 2 coders evaluated a paper, we compared agreement between the first two chronologically. For both questions, the coders could provide a free-entry ‘other’ response and as such these were interpreted by TRE on a case-by-case basis as similar  or contradictory (“Specific Incident” with “Routine”). Of 238 judgement pairs, there were 23 disagreements (~10%) on study design, most commonly due to the ‘Case Study’ category overlapping with other options , and 48 disagreements (~20%) on regularity where most were direct contradictions.M = 59). The analyses reported in this manuscript use this final third review as the primary data source.For each paper, the two independent ratings of each manuscript were shared with a member of the core research team who reviewed the responses alongside the original manuscript. They were then asked to provide the most accurate judgement possible based upon the information they had. They were free to decide in favor of one review, to combine responses, or to make a different judgement as they saw fit. Each team member recorded between 42 and 69 manuscripts (n = 24). A healthcare population (n = 16) and emotion outcome (n = 18) were also absent in a number of manuscripts. Five manuscripts were excluded on the basis of more than one criteria.Of the 237 papers, 53 were excluded upon this third review, most commonly due to not meeting the debriefing focus criteria , Australia (n = 29), the UK (n = 26) and Canada (n = 21). The places of publication were more widely distributed, with 140 publication destinations identified. The journals identified mostly featured one or two publications, with the exceptions of Clinical Simulation in Nursing (n = 7), Nurse Education in Practice (n = 6), Journal of Clinical Nursing (n = 5), Prehospital & Disaster Medicine (n = 5), Emergency Medicine Australasia (n = 4), Emergency Medicine Journal (n = 3) and the International Journal of Environmental Research and Public Health (n = 3). Co-authorship mapping was also conducted but indicated negligible collaboration between researchers in the field.Second, we identified the locations and journals which have more commonly disseminated such works. Twenty-one locations were represented, yet work was predominantly conducted within the US (n = 119), but also included editorial/opinion papers (n = 27), reviews (n = 23), case studies (n = 14) and a study protocol (n = 1). Research typically focused upon debriefing following real-world events (n = 159), although there was an emerging body of work using simulation (n = 22) and three papers had elements of both simulation and real-world settings.Third, with respect to design, the works featured were predominantly empirical (n = 112) represented between 3 and 3,822 participants (M = 141.63). Three papers had more than 1,000 participants, and after excluding these papers the mean sample size decreased meaningfully . The sample size distribution is heavily positively skewed  was from a qualitative study  and sample . The method of normalization was association strength. Following an iterative and exploratory clustering process, the minimum cluster size was set to 12 and in total, 4 clusters were produced with 1731 links. This mapping, as seen in We explored the mapping of keywords and explored any meaningful groups or subgroups of literature using VOSviewer . A co-ocFinally, we explored trends within the literature based upon the various extraction criteria to identify areas of strength from which practice recommendations could be made more confidently, and highlight areas of potential development.n = 93) and working in emergencies , with many works discussing specific populations, e.g. doctors (n = 17) and students (n = 34), and some covering a range of disciplines or population types (n = 25).When discussing the purpose of the debrief, 102 papers captured debriefing in response to a specific incident or event, while 77 considered routine debriefing, and 5 papers captured elements of both. Populations discussed commonly focused upon nursing (n = 91). Using internal staff  or the involvement of the researcher/educator (n = 18) was much more common than external facilitation (n = 7). Nineteen studies made reference to facilitators but were ambiguous as to their role.With respect to models or approaches to debriefing, 65 papers stated no clear strategy, 28 noted critical incident stress debriefing, 13 noted critical incident stress management and 89 noted a diverse range of strategies including ‘hot’ debriefing, peer/group support, huddles, Schwartz rounds and bespoke models, tools and approaches. With respect to facilitation, nearly half of the studies did not report the individual responsible for the debrief (n = 42), post-traumatic stress disorder symptomatology (n = 36), wellbeing (n = 25), burnout (n = 21), and coping (n = 15). Other popular outcomes included specific emotional experiences like grief and anxiety, and more general terms including resilience, moral distress, compassion fatigue and emotional support.Whether perceived or measured, a diverse range of emotional outcomes were claimed from debriefing, most commonly including stress  were conducted to identify whether certain combinations of the coded features occurred more frequently, thereby representing trends within the literature. For example, relative to real-world work, simulation studies were less common in Australia (1/29) and the UK (0/26), compared to South Korea (4/5), Canada (3/21) and US (6/67). The majority of these exploratory analyses were non-significant and/or based upon insufficient numbers and were therefore mostly inconclusive. Together with the analyses presented above, the results are indicative of sporadic research attention.Following a rigorous review process, we coded 184 relevant academic sources of evidence considering the role of debriefing on the wellbeing and emotional outcomes of healthcare staff. Little of the work provided empirical evidence of how to negotiate employee voice for the employee’s affective benefit. We can conclude that the body of evidence is clustered geographically, but diverse on many other criteria of interest including the types of evidence produced, debriefing models and practices and outcomes captured. This diversity, likely manifesting the desire for novelty in research, should be considered problematic for building incremental understanding and convincing bodies of evidence from which practice can be informed. Efforts to evaluate local practice were common, but with limited efforts to incrementally build understanding and draw a consensus (e.g. in specific debriefing practices or measurement of outcomes), there are many barriers to confidence in subsequent conclusions.Given the importance of healthcare workers and their voice, the state of current evidence is concerning and at risk of being considered too disparate for informing practice. The majority of studies in the field have been published since 2015 and while there does appear to be a dramatic increase in research published on this theme, this trend loosely maps onto the observed increase in research outputs in most healthcare and psychology domains over this same time period  and is iThe sporadic nature of the literature identified makes it clear that there are not standardized approaches, tools or practices to impact and assess the wellbeing and emotional outcomes of healthcare workers’ debriefs. This conclusion is similar to that previously noted by Richins et al. . While mad-hoc and required subjective decision-making that may compromise the representation of the evidence sources. We encourage researchers interested in conducting further reviews of the field to focus on specific debriefing practices or outcomes, using the current review resources for search validation, and to expand their review scope to consider the full range of grey literature and non-academic sources that could inform practice.Any further conclusions drawn from this work should be made in context of our scope and limitations. For example, our review was conducted using Western databases and consisted of studies adopting the English language. We also deviated from our preregistration to provide a clearer statement on the current state of academic understanding, at the cost of omitting a number of crucial non-academic evidence sources like professional practice guidelines. We therefore conclude our findings represent only part of a much wider body of evidence in the field. There are plenty of highly informative expert and experience-based evidence sources in this field . FurtherThe current review excluded a large number of sources based upon their inaccessibility to the research team. As we are a relatively privileged group, holding institutional subscriptions and access to a number of additional approaches to read otherwise inaccessible work, this should be considered highly problematic. Furthermore, we saw little evidence of transparency, with few papers sharing detailed information on debriefing, only one paper representing a preregistration and little-to-no data sharing. We believe this is reflective of the wider body of evidence, and we encourage researchers in this domain to prioritize accessibility and transparency through open scholarship practices like preprinting, open materials and data and sample size planning.Finally, the current review did not evaluate the evidence for the efficacy of debriefing. Recommendations for practice should only be made upon the basis of a critical evaluation of all existing evidence sources, and this was not possible from the current review. When coding the work, a number of claims for both positive and negative outcomes were identified, and the debriefing practices, size of effects and outcomes captured tended to be highly diverse. For example, differences in the valence of outcomes were anecdotally observed between routine debriefing and strategies for managing traumatic experiences. Having coded much of the academic literature, we hope the resources and work produced here provides a springboard to complete this important work evaluating debriefing efficacy, and other such works considering important factors like profession or debriefing model. Furthermore, given the extent of case studies, editorial/opinion claims and generally low sample sizes identified, we hope this evidence review will place great emphasis upon reviewing evidence quality. To contribute toward these goals in advancing evidence and practice, subsequent work in this field should avoid making strong claims about debriefing efficacy and prioritize generating quality evidence with transparency trails to facilitate effective evaluation and synthesis.The emotional wellbeing of healthcare staff has been neglected and under-acknowledged, leading to substantive numbers of staff experiencing moral injury, stress and burnout . DebriefTE, RE, CB, GF, and SW: conceptualization and methodology. TE and RE: software, analysis, visualization, and project administration. TE, RE, CB, and GF: validation. AC, BH, BM, EH, FQ, GB, GW, HE, JC, JM, JS, KJ, LS, LJ, MC, MD, MM, PC, PG, WM, and YY: investigation. TE: data processing and supervision. CB, EH, GF, and TE: writing–original draft. AC, BH, BM, CB, DM, EH, FQ, GB, GF, GW, HE, JC, JM, JS, KJ, LJ, LS, MC, MD, MM, PC, PG, RE, SW, TE, WM, and YY: writing–review and editing. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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