Resilience for working in Ontario home and community care: registered practical nurses need the support of themselves, family and clients, and employers.
Care partner
Client
Community
Grounded theory
Home care
Registered Practical Nurses
Resilience
Journal
BMC health services research
ISSN: 1472-6963
Titre abrégé: BMC Health Serv Res
Pays: England
ID NLM: 101088677
Informations de publication
Date de publication:
01 Oct 2024
01 Oct 2024
Historique:
received:
31
05
2024
accepted:
23
09
2024
medline:
1
10
2024
pubmed:
1
10
2024
entrez:
30
9
2024
Statut:
epublish
Résumé
The context of practice is often not explicit in the discourse around the personal and professional resilience of nurses. The unique factors related to providing nursing care in home and community care may provide novel insight into the resilience of this health workforce. Therefore, this research addressed how nurses build and maintain resilience working in the home and community care sector. A qualitative study was conducted between November 2022 to August 2023 using 36 in-depth interviews (29 registered practical nurses [RPNs], five supervisors of RPNs, two family/care partners (FCPs) of clients receiving home and community care services). Analysis was consistent with a grounded theory approach including coding and comparative methods. The factors of personal and professional resilience were not distinct but rather mixed together in the experience of nurses having resilience working in the home and community care sector. The process of building and maintaining resilience as home and community care nurses was informed by three categories: (1) The conditions of working in HCC; (2) The rapport RPNs held with FCPs; and (3) The nurses' ability for supporting the 'self'. Multiple components to inform these categories were identified and illustrated by the words of the nurse participants. The process of building and maintaining resilience by RPNs working in the home and community care sector was guided by the day-to-day experiences of providing care for clients and the conditions of being a mobile health care provider. However, nurses may sense when they need to support their 'self' and must be empowered to request and receive support to do so.
Sections du résumé
BACKGROUND
BACKGROUND
The context of practice is often not explicit in the discourse around the personal and professional resilience of nurses. The unique factors related to providing nursing care in home and community care may provide novel insight into the resilience of this health workforce. Therefore, this research addressed how nurses build and maintain resilience working in the home and community care sector.
METHOD
METHODS
A qualitative study was conducted between November 2022 to August 2023 using 36 in-depth interviews (29 registered practical nurses [RPNs], five supervisors of RPNs, two family/care partners (FCPs) of clients receiving home and community care services). Analysis was consistent with a grounded theory approach including coding and comparative methods.
RESULTS
RESULTS
The factors of personal and professional resilience were not distinct but rather mixed together in the experience of nurses having resilience working in the home and community care sector. The process of building and maintaining resilience as home and community care nurses was informed by three categories: (1) The conditions of working in HCC; (2) The rapport RPNs held with FCPs; and (3) The nurses' ability for supporting the 'self'. Multiple components to inform these categories were identified and illustrated by the words of the nurse participants.
CONCLUSION
CONCLUSIONS
The process of building and maintaining resilience by RPNs working in the home and community care sector was guided by the day-to-day experiences of providing care for clients and the conditions of being a mobile health care provider. However, nurses may sense when they need to support their 'self' and must be empowered to request and receive support to do so.
Identifiants
pubmed: 39350131
doi: 10.1186/s12913-024-11635-3
pii: 10.1186/s12913-024-11635-3
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
1157Subventions
Organisme : Social Sciences and Humanities Research Council of Canada
ID : 892-2021-3066
Organisme : Social Sciences and Humanities Research Council of Canada
ID : 892-2021-3066
Organisme : Social Sciences and Humanities Research Council of Canada
ID : 892-2021-3066
Organisme : Social Sciences and Humanities Research Council of Canada
ID : 892-2021-3066
Organisme : Social Sciences and Humanities Research Council of Canada
ID : 892-2021-3066
Organisme : Social Sciences and Humanities Research Council of Canada
ID : 892-2021-3066
Organisme : Social Sciences and Humanities Research Council of Canada
ID : 892-2021-3066
Organisme : Social Sciences and Humanities Research Council of Canada
ID : 892-2021-3066
Organisme : Social Sciences and Humanities Research Council of Canada
ID : 892-2021-3066
Organisme : Social Sciences and Humanities Research Council of Canada
ID : 892-2021-3066
Organisme : Social Sciences and Humanities Research Council of Canada
ID : 892-2021-3066
Informations de copyright
© 2024. The Author(s).
Références
Gruber EM, Zeiser S, Schröder D, Büscher A. Workforce issues in home-and community‐based long‐term care in Germany. Health Soc Care Community. 2021;29:746–55. https://doi.org/10.1111/hsc.13324 .
doi: 10.1111/hsc.13324
pubmed: 33629450
Health Policy. Research, and Professional Development. HealthCareCAN. 2023. https://www.healthcarecan.ca/ . Cited 2024 May 3.
Jarrín OF, Pouladi FA, Madigan EA. International priorities for home care education, research, practice, and management: qualitative content analysis. Nurse Educ Today. 2019;73:83–7. https://doi.org/10.1016/j.nedt.2018.11.020 .
doi: 10.1016/j.nedt.2018.11.020
pubmed: 30550942
Government of Canada. Aging and chronic diseases: A profile of Canadian seniors. 2020. https://www.canada.ca/en/public-health/services/publications/diseases-conditions/aging-chronic-diseases-profile-canadian-seniors-report.html#a3 . Cited 2024 May 29.
United Nations Statistical Commission. Minimum Set of Gender Indicators: Living arrangements of older persons around the world. https://gender-data-hub-2-undesa.hub.arcgis.com/pages/1a6de3fc6e4e4803b368750324c58797 . Cited 2024 May 29.
Ontario Health atHome. Home care. https://ontariohealthathome.ca/home-care/?_gl=1*rxiof6*_ga*MjA4ODMxOTExMy4xNzIzMTQ4NjU1*_ga_NYSBV1JG59*MTcyMzE0ODY1NS4xLjAuMTcyMzE0ODY1NS4wLjAuMA . Cited 2024 August 8.
WeRPN. The state of nursing in Ontario: A 2022 review. 2022 May. https://www.werpn.com/wp-content/uploads/2022/08/WeRPN_The-State-of-Nursing-in-Ontario-A-2022-Review-Report.pdf
Kim E, Choi H, Yoon JY. Who cares for visiting nurses? Workplace violence against home visiting nurses from public health centers in Korea. Int J Environ Res Public Health. 2020;17:4222. https://doi.org/10.3390/ijerph17124222 .
doi: 10.3390/ijerph17124222
pubmed: 32545730
pmcid: 7344994
Henshall C, Davey Z, Jackson D. The implementation and evaluation of a resilience enhancement programme for nurses working in the forensic setting. Int J Ment Health Nurs. 2020;29:508–20. https://doi.org/10.1111/inm.12689 .
doi: 10.1111/inm.12689
pubmed: 31930654
Lambert VA, Lambert CE, Itano J, Inouye J, Kim S, Kuniviktikul W et al. Cross-cultural comparison of workplace stressors, ways of coping and demographic characteristics as predictors of physical and mental health among hospital nurses in Japan, Thailand, South Korea and the USA (Hawaii). Int J Nurs Stud. 2004;41:671–684. https://doi.org/10.1016/j.ijnurstu.2004.02.003 PMID: 15240091.
Norouzinia R, Yarmohammadian MH, Ferdosi M, Masoumi G, Ebadi A. Development and psychometric evaluation of the emergency nurses’ professional resilience tool. PLoS ONE. 2022;17:e0269539. https://doi.org/10.1371/journal.pone.0269539 .
doi: 10.1371/journal.pone.0269539
pubmed: 35671289
pmcid: 9173641
Flanagan NA, Flanagan TJ. An analysis of the relationship between job satisfaction and job stress in correctional nurses. Res Nurs Health. 2002;25:282–94. https://doi.org/10.1002/nur.10042 . PMID: 12124722.
doi: 10.1002/nur.10042
pubmed: 12124722
Lin CC, Liang HF, Han CY, Chen LC, Hsieh CL. Professional resilience among nurses working in an overcrowded emergency department in Taiwan. Int Emerg Nurs. 2019;42:44–50. https://doi.org/10.1016/j.ienj.2018.05.005 .
doi: 10.1016/j.ienj.2018.05.005
pubmed: 29954706
Heath C, Sommerfield A, von Ungern-Sternberg BS. Resilience strategies to manage psychological distress among healthcare workers during the COVID‐19 pandemic: a narrative review. Anaesthesia. 2020;75:1364–71. https://doi.org/10.1111/anae.15180 .
doi: 10.1111/anae.15180
pubmed: 32534465
pmcid: 7323405
Shin N, Choi YJ. Professional quality of life, resilience, posttraumatic stress and leisure activity among intensive care unit nurses. Int Nurs Rev. 2023. https://doi.org/10.1111/inr.12850 .
doi: 10.1111/inr.12850
pubmed: 37216665
Ang SY, Uthaman T, Ayre TC, Lim SH, Lopez V. Differing pathways to resiliency: a grounded theory study of enactment of resilience among acute care nurses. Nurs Health Sci. 2019;21:132–8. https://doi.org/10.1111/nhs.12573 .
doi: 10.1111/nhs.12573
pubmed: 30328236
Connelly DM, Garnett A, Snobelen N, Guitar N, Flores-Sandoval C, Sinha S, et al. Resilience amongst Ontario registered practical nurses in long‐term care homes during COVID‐19: a grounded theory study. J Adv Nurs. 2022;78:4221–35. https://doi.org/10.1111/jan.15453 .
doi: 10.1111/jan.15453
pubmed: 36218159
pmcid: 9828338
Robertson HD, Elliott AM, Burton C, Iversen L, Murchie P, Porteous T, et al. Resilience of primary healthcare professionals: a systematic review. Br J Gen Pract. 2016;66:e423–33. https://doi.org/10.3399/bjgp16X685261 .
doi: 10.3399/bjgp16X685261
pubmed: 27162208
pmcid: 4871308
Ontario Health atHome. About us. 2024. https://ontariohealthathome.ca/about-us/ . Cited 2024 May 3.
Home Care Ontario. Safe, strong and stable: The future of Ontario’s home care system (Home Care Ontario 2021–2022 Pre-Budget Submission). 2021. https://www.homecareontario.ca/docs/default-source/ohca-submissions/2021-prebudget-submission-home-care-ontario.pdf?sfvrsn=14 . Cited 2024 May 3.
Casey LT, Star. A crisis for home care’: droves of workers leave for hospitals, nursing homes. 2021. https://www.thestar.com/news/gta/a-crisis-for-home-care-droves-of-workers-leave-for-hospitals-nursing-homes/article_d40a4c9c-63e7-5381-83b1-34823388fec4.html . Cited 2024 May 3.
Both-Nwabuwe JMC, Dijkstra MTM, Klink A, Beersma B. Maldistribution or scarcity of nurses? The devil is in the detail. J Nurs Manag. 2018;26:86–93. https://doi.org/10.1111/jonm.12531 .
doi: 10.1111/jonm.12531
pubmed: 29114954
Nelson R. Trends in home care—the coming resource crisis. AJN. 2019;119:16–7. https://doi.org/10.1097/01.NAJ.0000605312.38403.04 .
doi: 10.1097/01.NAJ.0000605312.38403.04
pubmed: 31764040
Romanow RJ. Building on values: the future of health care in Canada. Final report of the Commission on the Future of Health Care in Canada. Saskatoon: Commission on the Future of Health Care in Canada; 2000.
McKay SM, Mondor L, Warren C, Bronskill S, Guilcher SJT, Senthinathan A, Zagrodney KAP, Nichol KA, King EC. How did home care service delivery change in Ontario from 2013–2022? A retrospective study using administrative data. Canadian Association of Health Services & Policy Research (CAHSPR) Annual Conference; 2024. pp 14–16.
Canadian Union of Public Employees. More than 60% of registered practical nurses are being driven out of health care by understaffing and low pay, putting patient care at risk. 2023. https://cupe.ca/more-60-registered-practical-nurses-are-being-driven-out-health-care-understaffing-and-low-pay . Cited 2024 May 3.
Government of Ontario. Hazards and issues in the health and community care sector. 2023. https://www.ontario.ca/page/hazards-and-issues-health-and-community-care-sector#section-10 . Cited 2024 May 3.
Irani E, Hirschman KB, Cacchione PZ, Bowles KH. How home health nurses plan their work schedules: a qualitative descriptive study. J Clin Nurs. 2018;27:4066–76. https://doi.org/10.1111/jocn.14548 .
doi: 10.1111/jocn.14548
pubmed: 29893442
pmcid: 6175632
Dall’Ora C, Ball J, Reinius M, Griffiths P. Burnout in nursing: a theoretical review. Hum Resour Health. 2020;18:1–17. https://doi.org/10.1186/s12960-020-00469-9 .
doi: 10.1186/s12960-020-00469-9
Najafi Ghezeljeh T, Keyvanloo Shahrestanaki S, Amrollah Majdabadi Kohne Z, Fakhari E. Home care nurses’ perception of the challenges they faced during the COVID-19 pandemic: a qualitative study. BMC Nurs. 2022;21:314. https://doi.org/10.1186/s12912-022-01082-y .
doi: 10.1186/s12912-022-01082-y
Murat M, Kose S, Savaser S. Determination of stress, depression and burnout levels of front-line nurses during the COVID-19 pandemic. Int J Ment Health Nurs. 2021;3:533–43. https://doi.org/10.1111/inm.12818 .
doi: 10.1111/inm.12818
Ganann R, Weeres A, Lam A, Chung H, Valaitis R. Optimization of home care nurses in Canada: a scoping review. Health Soc Care Community. 2019;27:e604–21. https://doi.org/10.1111/hsc.12797 .
doi: 10.1111/hsc.12797
pubmed: 31231890
pmcid: 6851676
Alves CDLM, Aguiar RS. Damage to the health of nursing workers due to the Covid-19 pandemic: an integrative review. Enfermería Global. 2022;21:551–66. https://doi.org/10.6018/eglobal.501511 .
doi: 10.6018/eglobal.501511
Fitzpatrick J, Pignatiello G, Kim M, Jun J, O’Mathúna D, Duah H, et al. Moral injury, nurse well-being, and resilience among nurses practicing during the COVID-19 pandemic. JONA: J Nurs Adm. 2022;52:392–8. https://doi.org/10.1097/NNA.0000000000001171 .
doi: 10.1097/NNA.0000000000001171
Hamano J, Tachikawa H, Takahashi S, Ekoyama S, Nagaoka H, Ozone S, et al. Exploration of the impact of the COVID-19 pandemic on the mental health of home health care workers in Japan: a multicenter cross-sectional web-based survey. BMC Prim Care. 2022;23:1–11. https://doi.org/10.1186/s12875-022-01745-4 .
doi: 10.1186/s12875-022-01745-4
Nyashanu M, Pfende F, Ekpenyong M. Exploring the challenges faced by frontline workers in health and social care amid the COVID-19 pandemic: experiences of frontline workers in the English Midlands region, UK. J Interprof Care. 2020;34:655–61. https://doi.org/10.1080/13561820.2020.1792425 .
doi: 10.1080/13561820.2020.1792425
pubmed: 32674701
College of Nurses of Ontario. Nursing data dashboard. 2023. https://data.cno.org/ . Cited 2024 May 3.
Gilmour H. Unmet home care needs in Canada. 2018. https://www150.statcan.gc.ca/n1/pub/82-003-x/2018011/article/00002-eng.htm . Cited 2024 May 3.
Home and Community Care Support Services. About us. 2023. https://healthcareathome.ca/about-us/#:~:text=Home%20and%20Community%20Care%20Support%20Services%20provided%20care%20to%20more,28%2C700%20long%2Dterm%20care%20placements . Cited 2024 May 3.
Lankshear S, Rush J, Weeres A, Martin D. Enhancing role clarity for the practical nurse. J Nurs Adm. 2016;46:300–7. https://doi.org/10.1097/NNA.0000000000000349 .
doi: 10.1097/NNA.0000000000000349
pubmed: 27163875
Canadian Nurses’ Association. Code of ethics for registered nurses. 2017. https://www.cna-aiic.ca/en/nursing/regulated-nursing-in-canada/nursing-ethics . Cited 2024 May 3.
Prentice D, Moore J, Crawford J, Lankshear S, Limoges J. Collaboration among registered nurses and licensed practical nurses: a scoping review of practice guidelines. Nurs Res Pract. 2020;1–7. https://doi.org/10.1155/2020/5057084 .
Jones CB, Toles M, Knafl GJ, Beeber AS. An untapped resource in the nursing workforce: licensed practical nurses who transition to become registered nurses. Nurs Outlook. 2018;66:46–55. https://doi.org/10.1016/j.outlook.2017.07.007 .
doi: 10.1016/j.outlook.2017.07.007
pubmed: 29306576
Brown C, Baker M, Jessup M, Marshall AP. EN2RN - transitioning to a new scope of practice. Contemp Nurse. 2015;50:196–205. https://doi.org/10.1080/10376178.2015.1111766 .
doi: 10.1080/10376178.2015.1111766
pubmed: 26513692
Hewlett R. Where to now for enrolled nurses? Nurs NZ (Wellington, NZ: 1995). 1995;2021(27):31–31.
King RL, Taylor B, Laker S, Wood E, Senek M, Tod A, et al. A tale of two bridges: factors influencing career choices of trainee nursing associates in England: a longitudinal qualitative study. Nurs Open. 2022;9:2486–94. https://doi.org/10.1002/nop2.1266 .
doi: 10.1002/nop2.1266
pubmed: 35666045
pmcid: 9374398
Ruotsalainen S, Jantunen S, Sinervo T. Which factors are related to Finnish home care workers’ job satisfaction, stress, psychological distress and perceived quality of care?-a mixed method study. BMC Health Serv Res. 2020;20:1–3.
doi: 10.1186/s12913-020-05733-1
Charmaz K. The power of constructivist grounded theory for critical inquiry. Qual Inq. 2017;23:34–45. https://doi.org/10.1177/1077800416657105 .
doi: 10.1177/1077800416657105
Bryant A, Charmaz K, editors. The SAGE handbook of current developments in grounded theory. London: SAGE Publications, Limited; 2019.
Bowen GA. Naturalistic inquiry and the saturation concept: a research note. Qual Res. 2008;8:137–42. https://doi.org/10.1177/1468794107085301 .
doi: 10.1177/1468794107085301
Charmaz K. Constructing grounded theory: a practical guide through qualitative analysis. London: SAGE; 2006.
Noy C. Sampling knowledge: the hermeneutics of snowball sampling in qualitative research. Int J Soc Res Methodol. 2008;11:327–44. https://doi.org/10.1080/13645570701401305 .
doi: 10.1080/13645570701401305
Charmaz K. Grounded theory: Objectivist and constructivist methods. Handb Qual Res. 2000;2(1):509–35.
QSR International Pty Ltd. NVivo. 2023. https://help-nv.qsrinternational.com/14/win/Content/about-nvivo/about-nvivo.htm . Cited 2024 May 29.
Charmaz K. Chapter 8: the genesis, grounds, and growth of constructivist grounded theory. In: Morse JM, Bowers BJ, Charmaz K, Clarke AE, Corbin J, Porr CJ, et al. editors. Developing grounded theory: the second generation revisited. 2nd ed. Routledge; 2021. https://doi.org/10.4324/9781315169170 .
doi: 10.4324/9781315169170
Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57.
doi: 10.1093/intqhc/mzm042
pubmed: 17872937
Oliver C, Care FC. Global shortage of nurses. Montreal (QC): McGill University Health Centre; 2019.
Chamanga E, Dyson J, Loke J, McKeown E. Factors influencing the recruitment and retention of registered nurses in adult community nursing services: an integrative literature review. Prim Health Care Res Dev. 2020;21. https://doi.org/10.1017/S1463423620000353 .
Cooper AL, Brown JA, Rees CS, Leslie GD. Nurse resilience: a concept analysis. Int J Ment Health Nurs. 2020;29(4):553–75. https://doi.org/10.1111/inm.12721 .
doi: 10.1111/inm.12721
pubmed: 32227411
Cooper AL, Brown JA, Leslie GD. Nurse resilience for clinical practice: an integrative review. J Adv Nurs. 2021;77:2623–40. https://doi.org/10.1111/jan.14763 .
doi: 10.1111/jan.14763
pubmed: 33559262
Cooper AL, Leslie GD, Brown JA. Defining the influence of external factors on nurse resilience. Int J Ment Health Nurs. 2022;31:1523–33. https://doi.org/10.1111/inm.13059 .
doi: 10.1111/inm.13059
pubmed: 36008889
pmcid: 9805183
McGarry BE, Gandhi AD, Syme M, Berry SD, White EM, Grabowski DC. Association of state COVID-19 vaccine mandates with staff vaccination coverage and staffing shortages in US nursing homes. JAMA Health Forum. 2022;3:e222363–222363. https://doi.org/10.1001/jamahealthforum.2022.2363 .
doi: 10.1001/jamahealthforum.2022.2363
pubmed: 35983581
pmcid: 9338409
Hignett S, Otter ME, Keen C. Safety risks associated with physical interactions between patients and caregivers during treatment and care delivery in home care settings: a systematic review. Int J Nurs Stud. 2016;59:1–14. https://doi.org/10.1016/j.ijnurstu.2016.02.011 .
doi: 10.1016/j.ijnurstu.2016.02.011
pubmed: 27222445
Fernández-Medina IM, Ruíz-Fernández MD, Gálvez-Ramírez F, Martínez-Mengíbar E, Ruíz-García ME, Jiménez-Lasserrotte MDM, et al. The experiences of home care nurses in regard to the care of vulnerable populations: a qualitative study. Healthc (Basel). 2021;10(1):21. https://doi.org/10.3390/healthcare10010021 .
doi: 10.3390/healthcare10010021
Penz K, Duggleby W. Harmonizing hope: a grounded theory study of the experience of hope of registered nurses who provide palliative care in community settings. Palliat Support Care. 2011;9(3):281–94.
doi: 10.1017/S147895151100023X
pubmed: 21838949
Liu Y, Aungsuroch Y. Work stress, perceived social support, self-efficacy and burnout among Chinese registered nurses. J Nurs Manag. 2019;27:1445–53. https://doi.org/10.1111/jonm.12828 .
doi: 10.1111/jonm.12828
pubmed: 31306524
Takase M. A concept analysis of turnover intention: implications for nursing management. Collegian. 2010;17(1):3–12. https://doi.org/10.1016/j.colegn.2009.05.001 .
doi: 10.1016/j.colegn.2009.05.001
pubmed: 20394269
Wood R, Bandura A. Impact of conceptions of ability on self-regulatory mechanisms and complex decision making. J Pers Soc Psychol. 1989;56(3):407–15. https://doi.org/10.1037/0022-3514.56.3.407 .
doi: 10.1037/0022-3514.56.3.407
pubmed: 2926637
Van Waeyenberg T, Decramer A, Anseel F. Home nurses’ turnover intentions: the impact of informal supervisory feedback and self-efficacy. J Adv Nurs. 2015;71(12):2867–78. https://doi.org/10.1111/jan.12747 .
doi: 10.1111/jan.12747
pubmed: 26268070
Guo Y-F, Cross W, Plummer V, Lam L, Luo Y-H, Zhang J-P. Exploring resilience in Chinese nurses: a cross-sectional study. J Nurs Manag. 2017;25(3):223–30. https://doi.org/10.1111/jonm.12457 .
doi: 10.1111/jonm.12457
pubmed: 28164403
American Psychological Association. Resilience. https://www.apa.org/topics/resilience#:~:text=Resilience%20is%20the%20process%20and,to%20external%20and%20internal%20demands . Cited 2024 May 29.
Rutter M. Resilience as a dynamic concept. Dev Psychopathol. 2012;24(2):335–44. https://doi.org/10.1017/S0954579412000028 .
doi: 10.1017/S0954579412000028
pubmed: 22559117
Wei H, Roberts P, Strickler J, Corbett RW. Nurse leaders’ strategies to foster nurse resilience. J Nurs Manag. 2019;27(4):681–7. https://doi.org/10.1111/jonm.12736 .
doi: 10.1111/jonm.12736
pubmed: 30449038
Feo R, Rasmussen P, Wiechula R, Conroy T, Kitson A. Developing effective and caring nurse-patient relationships. Nurs Stand. 2017;31(28):54. https://doi.org/10.7748/ns.2017.e10735 .
doi: 10.7748/ns.2017.e10735
pubmed: 28271761
Howlett M. Looking at the ‘field’through a zoom lens: methodological reflections on conducting online research during a global pandemic. Qual Res. 2022;22:387–402. https://doi.org/10.1177/1468794120985691 .
doi: 10.1177/1468794120985691
pubmed: 35663097
pmcid: 9095994