use of communication technology to improve nurse-physician communication, teamwork, and care coordination during bedside rounds

Novel use of communication technology to improve nurse-physician communication, teamwork, and care coordination during bedside rounds*

Alexis Wickersham a, Krista Johnsonb,c, Aparna Kamathc,d and Peter J. Kabolib,c,e

aDepartment of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA; bIowa City VA Healthcare System, Iowa City, IA, USA; cDepartment of Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA; dDepartment of Medicine, Duke University School of Medicine, Durham, NC, USA; eComprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System and VA Quality Scholars Fellowship Program, Iowa City, IA, USA

ABSTRACT Background: Inter-professional bedside rounding has been used to reduce communication deficits and improve patient outcomes. Our objective was to evaluate nurse and physician participation in inter-professional bedside rounds and perceptions of communication, teamwork, and care coordination, through a quality improvement (QI) intervention. Method: A web-based survey was completed by attending and resident physicians and nurses working on the general medical wards of an academic-affiliated Veteran’s Health Administration Hospital (VHA). Responses were assessed using the chi-square statistic. Qualitative responses were grouped into themes for analysis to guide the intervention. A pre-existing electronic communication device was utilized in a novel way by resident physicians to facilitate nursing participation in bedside rounds. Perceptions of communication, teamwork, and care coordination between nurses and physicians prior to and after introduction of the electronic communication device were assessed. Direct observation was used to assess nursing presence during physician team rounds. Results: Following the intervention, both nurses and physicians agreed more nurses were alerted by physicians when rounds began and better communication between nurses and physicians occurred. However, technological barriers limited sustainability. Nursing presence on rounds increased from a baseline of 16.5% to 36% post-intervention. Conclusions: Implementation of a voice-activated, communication device on rounds facilitated improvement in perceptions of communication, teamwork, and care coordination, which may ultimately impact cultural change and patient outcomes.

KEYWORDS Teamwork; inter-professional communication; care coordination; technology; hospital medicine

Introduction

Creating a culture of safety is a cornerstone of the VHA [1] and prior work demonstrates that communication deficits are a leading cause of medical errors that can lead to patient harm [2]. There have been several studies aimed at improving inter-professional involve- ment in physician rounds, but despite these efforts, many barriers to bedside collaboration exist, including perceptions of teamwork and communication amongst nurses and physicians and time required to participate in inter-professional rounds [3–8].

Medical decision making and attending physician rounding practices at academic medical centers vary widely in structure, content, and degree of inter-pro- fessional staff involvement [9–11]. Stickrath, et al esti- mated that nursing communication on physician rounds occurs 12% of the time [11] while another study suggests that nursing presence during rounds is ‘largely a matter of chance’ [3].

Academic medical centers, and academic-affiliated VHA hospitals, typically have resident-based inpatient teams as, well as hospitalist-based teams, caring for patients on one or more medical wards. Facilitating inter-professional bedside rounds to include the phys- ician team and nursing staff has many challenges [7]. First, patients may be housed on multiple, geographi- cally dispersed units requiring the teams to walk con- siderable distances. Second, the precise timing of when rounds will occur on a particular patient is vari- able, making it difficult to have a set schedule of when the team will round. Other factors influencing rounding time include attending physician prefer- ence, day of the week, duty hour regulations, inten- sive care unit rounds, and on-call duties [11]. Finally, nurse staff ratios may require a single staff nurse to be responsible for up to five or more patients, result- ing in competing demands for nursing time during bedside rounds [12].

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CONTACT Alexis Wickersham alexis.wickersham@jefferson.edu Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, 833 Chestnut Street, Suite 701, Philadelphia, PA 19107 *This manuscript is not under review elsewhere and there is no prior publication of manuscript contents. The preliminary results of this manuscript were presented at the Society of General Internal Medicine National Meeting, Hollywood, Florida in May 2016. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

JOURNAL OF COMMUNICATION IN HEALTHCARE, 2018 VOL. 11, NO. 1, 56–61 https://doi.org/10.1080/17538068.2018.1431425

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Nurse, physician, and administrative champions demonstrated interest in a QI project to promote the VHA’s culture of safety. With the overall goal to improve nurse-physician communication, we aimed to evaluate nurse and physician perceptions of com- munication, teamwork, and care coordination prior to and after a QI intervention promoting nursing partici- pation during physician bedside rounds. A secondary objective was to increase nurse participation to 50% of physician-team bedside rounds, as way to promote inter-professional rounding culture.

Method

To determine the current perceptions of communi- cation practices between nurses and physicians, we developed an online Qualtrics® survey through litera- ture review of published surveys [5,6] and adapted questions to our specific aims. The survey was reviewed for content and face validity by several internal medi- cine residents, attending physicians, and nurses prior to initial surveying of participants. All nursing staff and physicians who worked on the general medicine inpatient units in the two months prior to our interven- tion start date were invited to complete the survey. The survey contained 25 questions which are listed in their entirety in Table 1.

Survey questions were divided into three domains: communication, teamwork, and care coordination with responses dichotomized from a 5-point Likert scale. For perception questions, Strongly Agree and Agree were dichotomized as favorable and Neither Agree nor Disagree, Disagree, and Strongly Disagree were dichotomized as not favorable. To access fre- quencies of perceived behaviors, Always and Often were combined as favorable and Sometimes, Rarely, and Never were combined as not favorable. Dichoto- mized survey responses pre- and post-intervention for nurses and physicians were assessed using the chi-square statistic. Qualitative survey responses were grouped into themes through informal word-repetition analysis and used as formative data to plan our intervention.

The Iowa City VHA Medical Center is an academic- affiliated hospital with three internal medicine resi- dent teams and one hospitalist-only team providing inpatient care to hospitalized medical patients admitted to one of three geographically separate inpatient medical wards. Each resident team is com- posed of two interns, a senior resident, and an attend- ing physician. For the intervention, senior residents on the three inpatient teams were given a Vocera® Badge, a pre-existing two-way communication device used at our institution primarily by non-phys- ician staff. The senior resident alerted each of the three nursing units when a physician team was round- ing on a specific patient. Residents were given

instruction on how to properly use the Vocera®, including scripted vernacular to be used to ensure patient privacy. Residents alerted the unit using the voice-activated device on the way to a patient’s bedside to serve as a ‘just-in-time’ communication that rounds were beginning on a specific patient. All nurses logged into the Vocera® system for a particular unit would receive the resident audio broadcast. The patient’s primary bedside nurse, if available, would join and participate in rounds. A charge or covering nurse was expected to join rounds in place of the primary nurse if unavailable. This cycle of alerting the unit for each patient to be rounded on was con- tinued for the duration of physician morning rounds. The Vocera® Badge was used on weekdays in the manner described above for a 2-month period.

We assessed nursing presence and participation during physician rounds through direct observation. An undergraduate work-study student, posing as a student gaining physician shadowing experience, observed and tracked the number of patients rounded on by the team and the percentage of time a nurse rounded at the bedside with the physician teams before and after the intervention. Observations occurred on 19 non-consecutive days prior to and fol- lowing the intervention’s start date based on the work-study student’s availability. On observation days, the student observed morning rounds from 9:00– 11:00 am, rotating amongst the three different resident teams. Observations on non-consecutive days allowed the student to observe rounding practices of different resident teams and attending physicians.

Two months following our intervention start date, we repeated our initial communication survey, inviting all nurses and the resident and attending physicians who had worked on the unit during the intervention period. Survey responses were dichotomized in the same manner as the pre-intervention responses then grouped into domains. We analyzed changes in per- ceptions amongst physicians and nurses pre- and post-intervention using SAS® statistical software version 9.2 (Cary, NC). We had full access to and take full responsibility for the integrity of the data.

The study was approved by the University of Iowa Institutional Review Board and the Iowa City VHA Healthcare System Research and Development Com- mittee, and was determined to be Human Subjects Research Determination Exempt (IRB #201507852). The main ethical issue of implementing our project centered primarily on privacy concerns. The Vocera® device that was utilized in our project was not compli- ant with Health Insurance Portability and Accountabil- ity Act (HIPAA) guidelines for patient privacy, thus no protected personal health information could be trans- mitted using this device. All users of the device were properly trained on device etiquette prior to the planned intervention.

JOURNAL OF COMMUNICATION IN HEALTHCARE 57

Results

The pre-intervention survey response rate for nurses and physicians (n = 60) was 53%; the response rate of the post-intervention survey was 54% (n = 57). Primary survey evaluation was by each group (phys- ician and nurses) from pre-intervention to post-inter- vention. The complete survey findings are in Table 1, with the following results highlighted.

For the communication domain, none of the respon- dents on the pre-intervention survey agreed that ‘nurses are alerted by physicians when rounds begin’. Following the intervention, 17.9% of nurses (P = 0.01) and 25% of physicians (P = 0.01) agreed ‘nurses are alerted by physicians when rounds begin’. Likewise, a significant improvement following the intervention occurred for both nurses (29.6%, P = 0.01) and phys- icians (48.1%, P = 0.01) who agreed that ‘communi- cation between nurses and physicians occurs during rounds’. Physicians perceive communication with

nurses to be more efficient (40.7%, P = 0.04) following the intervention. After the intervention, 44% of phys- icians (P = 0.05) agreed they know which nurse to contact regarding their patients.

Regarding perceptions of teamwork, nearly 15% of nurses (P = 0.02) following the intervention believe they are alerted by physicians when rounds are occurring on their patients. Similarly, though not statistically signifi- cant, nearly 30% of physicians (P = 0.08) following the intervention agree to alerting nurses when rounding on their patients. Following the intervention, physicians feel they ‘make an active effort to discuss care plans withnurses’ (55.6%,P = 0.03)and ‘nursinginputisencour- aged’ during rounds (74.1%,P = 0.04). Though notstatisti- cally significant, 15% of physicians (P = 0.06) and 19% of nurses (P = 0.2) agree bedside nurse-physician rounds are a part of the unit’s culture after the intervention.

In the domain of care coordination, 59.3% phys- icians (P = 0.03) agreed that ‘discharges occur

Table 1. Percent agreement amongst physicians and nurses with pre- and post-intervention survey questions.

Communication

% Physician Agree Pre- N = 42

% Physician Agree Post- N = 40

P value

% Nurse Agree Pre- N = 71

% Nurse Agree Post- N = 66

P value

Nurses often alerted by physicians when rounds begin 0 25.9 0.01 0 17.9 0.01 Communication between nurses and physicians occur during rounds

13.6 48.1 0.01 5.6ǂ 29.6ǂ 0.01

Communication between nurses and physicians is efficient

13.6 40.7 0.04 23.7 35.7 0.29

Providers know who to contact regarding their patients 18.2 44.4 0.05 47.4ǂ 63 0.21 Nurses alert physicians about patient care questions in a timely manner

54.6 74.1 0.15 92.11ǂ 75 0.06

Difficult for nurses to speak up if they perceive a problem with patient care

3.1 3.7 0.43 21.05 17.86 0.75

Feel comfortable communicating with nurse/physician regarding my patients

81.8 88.9 0.5 83.8 85.2 0.9

Teamwork Physicians alert nurse when rounds are occurring on their patients

9.1 29.6 0.08 0ǂ 14.8 0.02

Physicians make an active effort to discuss care plans with nurses

23.8 55.6 0.03 10.5 21.4ǂ 0.22

During Rounds, nursing input is encouraged 45.5 74.1 0.04 16.2ǂ 28.6ǂ 0.23 Nursing input about patient care is well received 90.9 100 0.11 31.6ǂ 39.3ǂ 0.52 Bedside nurse-physician rounds are part of the unit’s culture

0 14.8 0.06 7.9 19.2 0.2

Resident physician lack of comfort with nurse-physician encounters

28.6 7.4 0.05 5.2ǂ 11.5 0.36

Nurse lack of comfort with nurse-physician encounters 19.1 7.4 0.23 10.5 15.4 0.6 Attending physician lack of comfort with nurse- physician encounters

9.5 3.7 0.4 7.9 15.4 0.3

Appreciate the roles and contributions of other providers

95.5 88.5 0.38 86.5 92.6 0.4

Physicians and nurses work together as well- coordinated teams

22.7 48.2 0.07 37.8 44.4 0.6

Care Coordination Nurses aware of clinical issues needing to be addressed on their patients

36.4 13.1 0.01 52.6 46.4ǂ 0.62

Discharges occur promptly 27.3 59.3 0.03 16.2 14.8ǂ 0.9 There is clarity in patients’ daily care plans 40.9 66.7 0.07 8.11ǂ 24.43ǂ 0.12 Difficult to locate nurses on unit when rounds are occurring

68.2 45.2 0.1 26.3ǂ 30.7 0.7

Time required for bedside nurse-physician rounds is too cumbersome

31.8 18.5 0.3 18.4 19.2 0.9

Coordinating timing of rounds between physicians and nursing is difficult

81.8 77.8 0.7 65.8 66.7 0.9

Nurse-physician rounding at the bedside will improve patient safety

81.8 88.9 0.48 84.2 82.1 0.82

Nurse-physician rounding at the bedside will improve patient outcomes

86.4 85.2 0.91 84.2 78.6 0.56

ǂP-value <0.05 when comparing physician and nurse responses from pre- to post-intervention. 58 A. WICKERSHAM ET AL. promptly’ following the intervention. Following the intervention, 13% of physicians (P = 0.01) agree that ‘nurses are aware of clinical issues needing to be addressed on their patients’. We also evaluated differences between physicians and nurses both pre- and post-intervention to identify discordance in perceptions of the same questions. Differences that were statistically significant (P ≤ 0.05) are indicated by ǂ in Table 1. Of note, for the communi- cation domain, 55% of physicians felt they were alerted by nurses about patient care questions in a timely fashion, compared to 92% of nurses agreeing in the pre-intervention survey. In the teamwork domain, nearly all physicians agree that nursing input is well received in both pre- (91%) and post-intervention (100%) surveys, compared with nursing agreement of only 32% and 39%, respectively. Direct observation data of physician team rounds on non-consecutive sampling days showed that nurse- physician interactions during physician team rounds (N = 109) occurred on average 16.5% of the time prior to the intervention. After introduction of the Vocera®, nursing presence and participation in physician team rounds increased to an average of 36%. As seen in Figure 1, no nursing participation on rounds occurred on 4 of the 19 observation days. Discussion The objective of this QI project and subsequent evalu- ation was to assess the change in nurse and physician perceptions of communication, teamwork, and care coordination following an intervention designed to promote and increase nursing presence and partici- pation during physician team rounds through the novel use of a pre-existing communication device. Prior to our study, nursing input was not an integral aspect of physician medical decision making of patient care plans and nurse-physician bedside round- ing was not a part of the hospital culture. Although not all survey questions were statistically significant, most questions in each domain showed an improvement in nurse and physician perceptions. Following the intervention, communication between nurses and physicians increased during rounds and more physicians alerted nurses when rounds began. Though not statistically significant, improvements have also been made in the efficiency of communi- cation between nurses and physicians and knowing who to contact in regard to patient care questions. Similar responses pre- and post-intervention confirm that nurses and physicians feel comfortable communi- cating with one another, suggesting that this is likely not a barrier to communication. In the teamwork domain, although not all statisti- cally significant, 9 of 10 questions showed an improve- ment in physician responses, with 6 of 10 questions improving in nursing responses. Following the inter- vention, more nurses reported being alerted by phys- icians when rounds begin, but still feel their input is not well received. Despite this, most respondents agree they appreciate the roles and contributions of other providers. More physicians and nurses agree that nurse-physician bedside rounding is a part of a unit’s daily practice following the intervention. This increase, although modest, suggests that a cultural change may occur with continued work in breaking down barriers to communication on the wards, knowing that cultural change is difficult and takes sig- nificant time. Regarding coordination of care, physicians per- ceived that discharges occur more promptly following the intervention, which may be due to increased dis- cussion with the bedside nurse during rounds about discharge planning despite nursing perceptions that discharge time did not improve. Though not statisti- cally significant, nurses agree there is more clarity in a patient’s daily care plans following the intervention. An unexpected result in our study is that less physicians agreed that nurses are aware of clinical issues needing to be addressed on patients following the intervention. This possibly sheds light on physician assumptions that nurses are aware of patient care plans when they are not significantly involved in the rounding process. No other negative findings were reported following the implementation of the Vocera® for rounding purposes. The observation data was a random sampling of different physician teams, which allowed us a snapshot of the current rounding practices of the inpatient resi- dent teams. The data shows us there is high variability of rounding practices amongst physicians, both pre- and post-intervention. Some attending physicians pre- ferred to round on patients in team workrooms prior to seeing patients, limiting the potential for inter-pro- fessional interactions, while others would round in the hallway outside of patients’ rooms or at the patient’s bedside. This variability in rounding practices certainly contributes to the level of engagement with nursing staff. Our pre-intervention observation data confirms a previous study showing communication with nursing staff occurring infrequently during rounds [11]. Although not meeting our aim of 50% nursing participation on rounds, an increase to 36% nursing participation with introduction of the Vocera® on rounds suggests the tool was effective at facilitating nurse-physician rounds by providing a ‘just-in-time’ alert to nurses. The Vocera® device is still in use at our institution as a communication device, but its use for facilitating nurse-physician communication on rounds has fallen out of favor for reasons discussed below. Nurses are encouraged to join bedside rounds with teams when able and charge nurses participate in inter-professional team rounds with senior residents to share care plans and anticipated discharge needs. JOURNAL OF COMMUNICATION IN HEALTHCARE 59 Limitations Adaptation of the Vocera® to be used in the manner described in this study was technically challenging, likely contributing to limited sustainability. Prior to this QI project, the Vocera® device was used primarily by non-physician staff at our institution, thus nurses were largely familiar with the operational capacity of the device. Resident physicians rotating on the inpatient units were not familiar with how to use the Vocera® device. Residents required device training, instruction on project protocol, and frequent reinforcement to use the device on rounds. Resident motivation to routi- nely use the device was highly variable, and due to fre- quent resident turnover, it was difficult to teach senior residents how to operate the device on a continuous basis. Batteries were often not fully charged prior to rounds and obtaining a battery from a central charger was often inconvenient for residents. Vocera® ‘dead zones’ in wireless connectivity exist in areas throughout the hospital, which interrupted or delayed communi- cation in some instances. The Vocera® frequently misun- derstood user voice commands requiring users to repeat commands, leading to user frustration and decreased likelihood of using the device on a continu- ous basis. Likewise, there were instances where no nursing participation occurred despite proper resident physician use of the Vocera® on rounds, possibly dis- couraging residents from further use of the device. There are a number of limitations in our evaluation of this QI project. This study occurred at a single academic institution, thus our findings might not be generalizable to other institutions or specialties. We also had no formal qualitative evaluation, as this was not the focus of our study. We used our pre-intervention comments as formative data to guide our intervention. As with all technology, there are inherent limitations to the Vocera®. It is a useful tool and promising technology, but as other hospitals attempt to overcome communi- cation barriers, they should take these factors into account. Future research We hope to repeat our survey within the next year to determine if our continued efforts of improving nurse-physician communication during bedside rounds can shift our institution’s culture towards a more inter-professional, team-based care model. We aim to find innovative ways to improve nurse-physician communication regarding patient care and nursing participation in daily physician rounds. Conclusions Effective communication amongst healthcare providers is imperative to creating a culture of safety and improv- ing the care provided for patients. Communication, teamwork, and care coordination amongst providers are largely determined by an institution’s culture. Using a pre-existing electronic communication device to alert nursing staff immediately before rounding on patients increased nursing participation in bedside rounds and improved perceptions in communication, teamwork, and care coordination amongst nurses and physicians. More nurses were alerted to the beginning of rounds, increased communication with nurses occurred during physician rounds, and nursing input was encouraged in patient care plans with use of the Figure 1. Percent of nursing interactions during bedside physician team rounds on non-consecutive observation days, as tracked by a student observer. Nurse participation on rounds prior to the introduction of Vocera® was 16.5%, doubling to 36% following the introduction of the electronic communication device. 60 A. WICKERSHAM ET AL. Vocera® device for rounding. This study suggests imple- menting a new technology alone cannot change culture, but may have an impact on it, and with contin- ued work, perceptions amongst healthcare providers may continue to improve. Ethical approval This study was approved by the institutional review at Univer- sity of Iowa and the Iowa City VHA Healthcare System Research and Development Committee: IRB #201507852. Disclosure statement No potential conflict of interest was reported by the authors. Funding The author(s) did not receive funding for this study. Acknowledgements The work reported here was supported by the Department of Veterans Affairs, Veterans Health Administration, VA Chief Resident in Quality and Safety Fellowship Program, VA Quality Scholars Fellowship Program, and the Health Services Research and Development (HSR&D) Service through the Comprehensive Access and Delivery Research and Evaluation (CADRE) Center (REA 09-220). Notes on contributors Alexis Wickersham, MD is a Clinical Instructor and Hospitalist in the Department of Internal Medicine at the Sidney Kimmel Medial College at Thomas Jefferson University. Krista Johnson, MD is a Clinical Associate Professor of Internal Medicine at the University of Iowa Carver College of Medicine and Educational Director for Safety and Quality of the Internal Medicine Residency Program. Aparna Kamath, MBBS, MS is an Assistant Professor of Internal Medicine at the Duke University School of Medicine. Peter J. Kaboli, MD, MS is a Professor of Internal Medicine at the University of Iowa Carver College of Medicine and the Vice Chair of VA Affairs for the Department of Internal Medicine. ORCID Alexis Wickersham http://orcid.org/0000-0001-9981-2700 References [1] Weeks WB, Bagian JP. Developing a culture of safety in the Veterans Health Administration. Eff Clin Pract. 2000;3(6):270–276. [2] Commission TJ. Sentinel event statistics data: root causes by event type (2004–2014). [cited 2015 July] Available from: http://www.jointcommission.org/assets/ 1/18/Root_Causes_by_Event_Type_2004-2014.pdf [3] Amin Y, Grewcock D, Andrews S, et al. Why patients need leaders: introducing a ward safety checklist. J R Soc Med. 2012;105(9):377–383. [4] Carney BT, West P, Neily J, et al. Differences in nurse and surgeon perceptions of teamwork: implications for use of a briefing checklist in the OR. AORN J. 2010;91 (6):722–729. [5] Carney BT, West P, Neily JB, et al. Improving perceptions of teamwork climate with the Veterans Health Administration medical team training program. Am J Med Qual. 2011;26(6):480–484. [6] Gonzalo JD, Kuperman E, Lehman E, et al. Bedside inter- professional rounds: perceptions of benefits and bar- riers by internal medicine nursing staff, attending physicians, and housestaff physicians. J Hosp Med. 2014;9(10):646–651. [7] O’Leary KJ, Buck R, Fligiel HM, et al. Structured inter- disciplinary rounds in a medical teaching unit: improv- ing patient safety. Arch Intern Med. 2011;171(7):678– 684. [8] O’Mahony S, Mazur E, Charney P, et al. Use of multidis- ciplinary rounds to simultaneously improve quality outcomes, enhance resident education, and shorten length of stay. J Gen Intern Med. 2007;22(8):1073– 1079. [9] Wachter RM, Verghese A. The attending physician on the wards: finding a new homeostasis. JAMA. 2012;308 (10):977–978. [10] Najafi N, Monash B, Mourad M, et al. Improving attend- ing rounds: Qualitative reflections from multidisciplinary providers. Hosp Pract. 2015;43(3):186–190. [11] Stickrath C, Noble M, Prochazka A, et al. Attending rounds in the current era: what is and is not happening. JAMA Intern Med. 2013;173(12):1084–1089. [12] Clarke SP. Nurse staffing in acute care settings: research perspectives and practice implications. Jt Comm J Qual Patient Safety. 2007;33(11 Suppl):30–44. JOURNAL OF COMMUNICATION IN HEALTHCARE 61 http://orcid.org/0000-0001-9981-2700 http://www.jointcommission.org/assets/1/18/Root_Causes_by_Event_Type_2004-2014.pdf http://www.jointcommission.org/assets/1/18/Root_Causes_by_Event_Type_2004-2014.pdf Copyright of Journal of Communication in Healthcare is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. Abstract Introduction Method Results Discussion Limitations Future research Conclusions Ethical approval Disclosure statement Acknowledgements Notes on contributors ORCID References

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