Medicine and Health Sciences Commons^™

Pain Assessment Tools For Use In Infants: A Meta-Review, Diana Arabiat, Evalotte Mörelius, Kreshnik Hoti, Jeffery Hughes

Research outputs 2022 to 2026

Background: Identifying pain in infants is challenging due to their inability to self-report pain, therefore the availability of valid and reliable means of assessing pain is critical. Objective: This meta-review sought to identify evidence that could guide the selection of appropriate tools in this vulnerable population. Methods: We searched Scopus, Medline, Embase, CINAHL, MIDRIS, EMCare and Google Scholar for eligible systematic reviews. Eligible reviews documented psychometric properties of available observational tools used to assess pain in infants. Results: A total of 516 reviews were identified of which 11 met our inclusion criteria. We identified 36 pain assessment tools (evaluated in …

Decision-Making In Nursing Research And Practice—Application Of The Cognitive Continuum Theory: A Meta-Aggregative Systematic Review, Tricia O'Connor, Jo Gibson, Joanne Lewis, Karen Strickland, Catherine Paterson

Research outputs 2022 to 2026

Aim: To explore how the Cognitive Continuum Theory has been used in qualitative nursing research and to what extent it has been integrated in the research process using the Qualitative Network for Theory Use and Methodology (QUANTUM). Background: Theory, research and nursing are intrinsically linked, as are decision-making and nursing practice. With increasing pressure on nurses to improve patient outcomes, systematic knowledge regarding decision-making is critical and urgent. Design: A meta-aggregative systematic review. Methods: Databases: CINAHL, Medline, PsycINFO, Embase and PubMed were searched from inception until May 2022 for peer-reviewed research published in English. Seven studies were included and assessed …

The Cancer Nursing Workforce In Australia: A National Survey Exploring Determinants Of Job Satisfaction, Natalie Bradford, Elizabeth Moore, Karen Taylor, Olivia Cook, Lucy Gent, Theresa Beane, Natalie Williams, Kimberly Alexander, Erin Pitt, Jemma Still, Cameron Wellard, Gemma Mcerlean, Deborah Kirk, Leanne Monterosso, Alexandra Mccarthy, Zerina Lokmic-Tomkins, Jessica Balson, Priscilla Gates

Research outputs 2022 to 2026

Background: To maintain and improve the quality of the cancer nursing workforce, it is crucial to understand the factors that influence retention and job satisfaction. We aimed to investigate the characteristics of cancer nurses in Australia and identify predictors of job satisfaction. Methods: We analysed data from an anonymous cross-sectional survey distributed through the Cancer Nurses Society Australia membership and social media platforms from October 2021 to February 2022. The survey was compared to national nursing registration data. Data were analysed with non-parametric tests, and a stepwise, linear regression model was developed to best predict job satisfaction. Results: Responses were …

Implementation And Utilisation Of Australian Critical Care Practice Standards: What Do We Know?, Yolanda Cox, Justin L. C. Bilszta, Debbie Massey

Research outputs 2022 to 2026

Background: The Australian College of Critical Care Nurses published the third edition of practice standards (PSs) for specialist critical care nurses in 2015. Higher-education providers currently use these standards to inform critical care curricula; however, how critical care nurses perceive and use PSs in clinical practice is unknown. Objectives: The objective of this study was to explore critical care nurses' perceptions about the Australian College of Critical Care Nurses PS for specialty critical care nursing, to understand how the PSs are used in clinical practice, and what opportunities exist to support their implementation. Methods: An exploratory qualitative descriptive design was …

Preliminary Efficacy, Feasibility And Safety Of Intra-Umbilical Oxytocin To Reduce The Time To Placental Delivery At Caesarean Section: An Exploratory Randomized Trial, Katrin Middleton, Fungai Mbengo, Thandisizwe R. Mavundla, George J. Hofmeyr

Research outputs 2022 to 2026

Background: Delayed placental separation either after vaginal birth or caesarean birth is an important cause of postpartum haemorrhage, among other causes such as uterine atony. Intra-umbilical oxytocin has been shown to reduce the time to placental delivery after vaginal birth. However, the efficacy of intra-umbilical oxytocin to reduce the time to placental delivery following caesarean section birth is not known. Objectives: To explore the preliminary efficacy, feasibility and safety of intra-umbilical oxytocin to reduce the time to placental delivery at caesarean section. Methods: A double-blind, placebo-controlled, exploratory randomized clinical trial was conducted at a tertiary hospital in the Eastern Cape …

Chromosomal Aberrations In Pediatric Patients With Moderate/Severe Developmental Delay/Intellectual Disability With Abundant Phenotypic Heterogeneities: A Single-Center Study, Dan Wu, Yi Wu, Yulong Lan, Shaocong Lan, Zhiwei Zhong, Duo Li, Zexin Zheng, Hongwu Wang, Lian Ma

Research outputs 2022 to 2026

Background: This study aimed to examine the clinical usefulness of chromosome microarray (CMA) for selective implementation in patients with unexplained moderate or severe developmental delay/intellectual disability (DD/ID) and/or combined with different dysphonic features in the Han Chinese population. Methods: We retrospectively analyzed data on 122 pediatric patients with unexplained isolated moderate/severe DD/ID with or without autism spectrum disorders, epilepsy, dystonia, and congenital abnormalities from a single-center neurorehabilitation clinic in southern China. Results: A total of 46 probands (37.7%) had abnormal CMA results among the 122 study patients. With the exclusion of aneuploidies, uniparental disomies, and multiple homozygotes, 37 patients harbored …

“I Believe…” - Graduating Midwifery Students’ Midwifery Philosophies And Intentions For Their Graduate Year: A Longitudinal Descriptive Study, Kate Dawson, Heather Wallace, Sara Bayes

Research outputs 2022 to 2026

Objective: Midwifery graduates may experience transition shock that makes them question their fit for their workplace and the profession and in extreme cases, may lead to them leaving. Understanding graduate midwives’ worldviews, job intentions and work experiences is important to inform retention strategies. Factors such as having a strong professional identity and experiencing strong job satisfaction are important for midwife retention. Conversely, stress, trauma and work-life imbalances are examples of factors that lead to attrition from midwifery. Transition shock experienced by some graduates can exacerbate these factors if not managed effectively. This study aimed to identify causes and impact of …

A Socioecological Description Of The Influencing Factors To Midwives’ Management Of Preeclampsia In A Ghanaian Tertiary Hospital, Isabella Garti, Michelle Gray, Angela Bromley, Benjamin Tan

Research outputs 2022 to 2026

Introduction: In low-resource settings, midwives are the first contact for women with preeclampsia and lead the coordination of care. Unfavourable preeclampsia outcomes create a burden for women, families, and the health system. It is therefore important to understand the unique context of midwives’ practice and the complex factors that influence the delivery of maternal healthcare. Aim: This qualitative study explored the perspectives of key stakeholders in a tertiary hospital in Ghana regarding the facilitators and barriers influencing midwives’ provision of preeclampsia care using a socioecological model. Methods: Semi-structured interviews were conducted with 42 participants comprising senior managers (n = 7) …

Nurses’ Education, Knowledge And Perceptions Of Peripheral Intravenous Catheter Management: A Web-Based, Cross-Sectional Survey, Debbie Massey, Marie Cooke, Gillian Ray-Barruel, Nicole Marsh, Amanda J. Ullman, Alison Craswell, Marianne Wallis

Research outputs 2022 to 2026

Background: Peripheral intravenous catheters (PIVCs) are the most used invasive medical device. Unfortunately, PIVCs fail for a variety of reasons and failure often results in serious adverse events leading to patient discomfort, infection, delays in treatment, increased healthcare costs, and even death. In Australia, qualified nurses assess, manage, and remove a PIVC as part of their clinical role. To date, no study has described the current state of knowledge and confidence (self-efficacy) about PIVCs from the perspectives of qualified nurses working in Australian hospital settings. Aims: To describe the current state of knowledge and confidence (self-efficacy) about PIVC management from …

Exploring Assessment Policies For Clinical Practice: A Scoping Review Of The Literature, Lynda J. Hughes, Amy N. B. Johnston, Jacqueline H. Byrne, Debbie Massey

Research outputs 2022 to 2026

Background: Assessment of pre-registration nursing students in clinical practice is an essential process, ensuring students who graduate meet standards for practice and competently and safely care for patients under their care. However, such assessment remains challenging for individuals and organisations. Aim: We aimed to investigate what is known about the application of clinical placement assessment policies guiding pre-registration nursing programmes. Methods: Arskey and O'Malley’s five-stage method for scoping reviews was employed. Health and education databases were searched in July 2020 and December 2021. Identified papers were screened. The Joanna Briggs Institute's critical appraisal tools were used to appraise the quality …

Application Of Classic Grounded Theory In Nursing Studies: A Qualitative Systematic Review Protocol, Justine Connor, Tracy Flenady, Trudy Dwyer, Debbie Massey

Research outputs 2022 to 2026

Introduction Classic grounded theory (CGT) is a valuable method for nursing research, but the application of CGT methodology in nursing studies has not been specifically investigated. With the increasing use of CGT in nursing research, attention is now focusing on the quality of studies using this methodology. In this systematic review, we aim to develop an understanding of the application of CGT methodology, specifically appraising the quality of the methodology's application in the field of nursing research. Methods and analysis The reporting of this review will be guided by the Preferred Reporting Items for Systematic and Meta-Analysis guidelines statement and …

Getting A Grip On Safewards: The Cross Impact Of Clinical Supervision And Safewards Model On Clinical Practice, Jennifer Hamilton, Amanda Cole, Richard Bostwick, Irene Ngune

Research outputs 2022 to 2026

The Safewards model is used across various mental health settings to reduce incidents of conflict and containment and its efficacy in reducing the use of seclusion and restraint, improving patients' experiences of care, and enhancing safety within clinical settings is well documented (Bowers, Journal of Psychiatric & Mental Health Nursing, 21, 2014, 499). However, there are barriers to successful implementation, including level of staff buy-in (Baumgardt et al., Frontiers in Psychiatry, 10, 2019, 340; Price et al., Mental Health Practice, 19, 2016, 14). This mixed-method study assessed the impact of adopting a Safewards model within a clinical supervision framework in …

Support Needs Of People With Younger Onset Parkinson's Disease: An Interpretative Phenomenological Analysis, Clare Stephenson, Allyson Flynn, Anthony Overs, Karen Strickland

Research outputs 2022 to 2026

Background: People with younger onset Parkinson's disease reported trouble navigating the health system and managing their Parkinson's disease symptoms. This impacted their everyday responsibilities, such as maintaining employment, caring for children, or meeting financial commitments. Aim: To understand the experiences of the unmet support needs of people diagnosed with younger onset Parkinson's disease and allow a deeper understanding of their lived experiences. Methods: Data were collected by interviewing four participants about their perceptions of the current supports available. Interpretative phenomenological analysis was applied for in-depth exploration of the participant's experience, allowing the participant and the researcher to ‘make sense’ of …

Differences In Birth Weight Between Immigrants' And Natives' Children In Europe And Australia: A Lifecycle Comparative Observational Cohort Study, Sandra Florian, Mathieu Ichou, Lidia Panico, Stéphanie Pinel-Jacquemin, Tanja G. M. Vrijkotte, Margreet W. Harskamp-Van Ginkel, Rae-Chi Huang, Jennie Carson, Loreto Santa Marina Rodriguez, Mikel Subiza-Pérez, Martine Vrijheid, Sílvia Fernández-Barrés, Tiffany C. Yang, John Wright, Eva Corpeleijn, Marloes Cardol, Elena Isaevska, Chiara Moccia, Marjolein N. Kooijman, Ellis Voerman, Vincent Jaddoe, Marieke Welten, Elena Spada, Marisa Rebagliato, Andrea Beneito, Luca Ronfani, Marie-Aline Charles

Research outputs 2022 to 2026

Objective:

Research on adults has identified an immigrant health advantage, known as the 'immigrant health paradox', by which migrants exhibit better health outcomes than natives. Is this health advantage transferred from parents to children in the form of higher birth weight relative to children of natives?

Setting:

Western Europe and Australia.

Participants:

We use data from nine birth cohorts participating in the LifeCycle Project, including five studies with large samples of immigrants' children: Etude Longitudinale Française depuis l'Enfance - France (N=12 494), the Raine Study - Australia (N=2283), Born in Bradford - UK (N=4132), Amsterdam Born Children and their Development …

Effect Of Antenatal Milk Expression Education On Lactation Outcomes In Birthing People With Pre-Pregnancy Body Mass Index ≥ 25: Protocol For A Randomized, Controlled Trial, Jill R. Demirci, Melissa Glasser, Debra L. Bogen, Susan M. Sereika, Dianxu Ren, Kristin Ray, Lisa M. Bodnar, Therese A. O'Sullivan, Katherine Himes

Research outputs 2022 to 2026

Background: Birthing people with pre-pregnancy body mass indices (BMIs) ≥ 25 kg/m2, particularly those without prior breastfeeding experience, are at increased risk for suboptimal lactation outcomes. Antenatal milk expression (AME) may be one way to counteract the negative effects of early infant formula supplementation common in this population. Methods: This ongoing, randomized controlled trial in the United States evaluates the efficacy of a telelactation-delivered AME education intervention versus an attention control condition on lactation outcomes to 1 year postpartum among 280 nulliparous-to-primiparous, non-diabetic birthing people with pre-pregnancy BMI ≥ 25 kg/m2. The assigned study treatment is delivered via four weekly …

Navigating Midwifery Solidarity: A Feminist Participatory Action Research Framework, Katherine Buchanan, Elizabeth Newnham, Sadie Geraghty, Lisa Whitehead

Research outputs 2022 to 2026

Background:

A core aspect of midwifery philosophy is the optimisation of normal physiology; however, this has been challenged as a radical idea in the medicalisation of birth. Research has demonstrated the benefits of midwifery in improving outcomes for both mothers and babies. The understanding of midwifery benefits fails to reach wider sociocultural contexts as births becomes more medicalised. Midwifery research requires an action arm, to help translate theory to practice and mobilise midwives in solidarity with women towards action and change.

Aim:

The aim of this article is to describe a Feminist Participatory Action Research (FPAR) by establishing the philosophical …

Nurses' Understanding And Management Of Iron Deficiency In Australia: A Cross-Sectional, Exploratory Study, Therese A. O'Sullivan, Pradeep H. Jayasuriya, Natalie Tsalis, Nina Calogero, Ramesh Manocha

Research outputs 2022 to 2026

Objectives: To assess the experiences and knowledge of nurses in the area of iron deficiency. Design: A cross-sectional, exploratory study using online survey. Setting: Data were collected from nurses working at various primary, secondary and tertiary Australian health practices and organisations. Participants: Australian nurses currently in practice. Method: Australian nurses currently in practice were invited to complete an online survey about their work background, personal experiences with iron deficiency and iron-deficiency identification and treatment. The survey included a nine-item questionnaire to assess knowledge of iron-deficiency risk factors and biochemistry. Results: A total of 534 eligible nurses participated in the survey. …

An Examination Of Primary Health Care Nursing Service Evaluation Using The Donabedian Model: A Systematic Review, Kylie Mccullough, Lesley Andrew, Angela Genoni, Melissa Dunham, Lisa Whitehead, Davina Porock

Research outputs 2022 to 2026

Nurses are key to the delivery of global primary health care services. However, there appears to be a lack of evaluation of primary health care nursing delivery models in the published literature. This evaluation is vital to the improvement of patient experiences, national and global health outcomes, and the justification of future investment in primary health care nursing services. The purpose of this review was to explore and analyze the literature that reports on the evaluation of primary health care nursing services, to ascertain the nature and utility of these evaluation methods, and identify opportunities for future research in this …

Woman-Centred Ethics: A Feminist Participatory Action Research [Journal Article], Kate Buchanan, Sadie Geraghty, Lisa Whitehead, Elizabeth Newnham

Research outputs 2022 to 2026

Introduction: Contemporary ethical issues in the maternity system are nuanced, complex and layered. Medicalisation and the reported rise in incidence of mistreatment and birth trauma, has been described as unethical. Some authors suggest bioethical principles are limited in terms of guiding everyday care of pregnancy and birth. There is currently no known published research which explores what birthing people say is ethical. Aims: This study sought to explore women's experience of maternity care from an ethical perspective. Method: A Feminist Participatory Action Research (FPAR) was conducted over three years, in two phases. A Community Action Research Group (CARG) was formed …

Measuring Success: Program Fidelity Of Queensland's Child Health Home Visiting Services. A Document Analysis, Nicole Latham, Jeanine Young, Josephine Wilson, Michelle Gray

Research outputs 2022 to 2026

Background: The Family CA.R.E. (Community-based Assistance Resourcing and Education) program was introduced in Queensland two decades ago. It aimed to redress health inequalities for infants from families experiencing specific social stressors. The program has been locally adapted over time and has not been evaluated against the original program. This study assessed the extent to which selected hospital and health services in Queensland, Australia have modified the original Family C.A.R.E. program. Methods: Altheide's model was used to facilitate a critical document analysis of policies and guidelines for adapted Family C.A.R.E. home visiting programs in use by hospital and health services (target …

What Is Known About Midwives' Well-Being And Resilience? An Integrative Review Of The International Literature, Lynnelle Moran, Kim Foster, Sara Bayes

Research outputs 2022 to 2026

Background: Internationally, the midwifery workforce is facing a professional crisis due to numerous organizational and individual factors that have led to midwives leaving the profession. These factors include high levels of workplace stress, systemic barriers to providing woman and person-centered care, trauma, and burnout. The COVID-19 pandemic magnified these pre-existing stressors and adversities and has further disrupted midwives' ability to practice within their professional norms. In order to understand how midwives can be better supported, there is a need to understand what contributes to and detracts from their well-being and resilience. Aim: To investigate and synthesize the extant international knowledge …

Development Of A Tool To Identify Barriers And Enablers To Practice Innovation In Midwifery: A Participatory Action Research Study, Sara D. Davis, Sara Bayes, Sadie Geraghty

Research outputs 2022 to 2026

Introduction: Transferring research evidence into midwifery practice is fraught with challenges and obstacles. Implementation tools can streamline the process and are most effective when they are discipline-specific; however, there are currently no midwifery specific implementation tools. The aim of this study was to develop a midwifery specific tool to identify barriers and enablers to evidence-informed practice change within the clinical setting. Methods: Participatory action research methodology was employed to ensure potential end-users contributed to content and format of the tool. Purposeful sampling ensured participants were selected from a range of midwifery practice settings in Western Australia and the United Kingdom. …

Altered Dietary Behaviour During Pregnancy Impacts Systemic Metabolic Phenotypes, Charlotte E. Rowley, Samantha Lodge, Siobhon Egan, Catherine Itsiopoulos, Claus T. Christophersen, Desiree Silva, Elizabeth Kicic-Starcevich, Therese A. O’Sullivan, Julien Wist, Jeremy Nicholson, Gary Frost, Elaine Holmes, Nina D’Vaz

Research outputs 2022 to 2026

Rationale: Evidence suggests consumption of a Mediterranean diet (MD) can positively impact both maternal and offspring health, potentially mediated by a beneficial effect on inflammatory pathways. We aimed to apply metabolic profiling of serum and urine samples to assess differences between women who were stratified into high and low alignment to a MD throughout pregnancy and investigate the relationship of the diet to inflammatory markers. Methods: From the ORIGINS cohort, 51 pregnant women were stratified for persistent high and low alignment to a MD, based on validated MD questionnaires. 1H Nuclear Magnetic Resonance (NMR) spectroscopy was used to investigate the …

Changes In Parental Anxiety And Intention To Demand Antibiotics: A Longitudinal Study Among Parents During The Covid-19 Pandemic, Aaron L. Alejandro, Mieghan Bruce, Wei W. C. Leo

Research outputs 2022 to 2026

Aims: Assessing the effects of the COVID-19 pandemic on parental anxiety and preferences for antibiotic treatment can help inform antibiotic stewardship strategies. Therefore, this study aimed to examine COVID-19 pandemic-related changes in parental anxiety levels, their intentions to demand antibiotics and frequencies of practising preventative behaviours. Design: This longitudinal quantitative study compared two groups of parents, those from Victoria and Western Australia, who experienced high and low COVID-19 risk, respectively. Methods: Participants were recruited through an online panel to complete three waves of surveys between October 2020 and August 2021. Anxiety scores and frequency of preventative behaviours were analysed using …

Hidden And Unacknowledged: The Mental Health And Psychosocial Interventions Delivered By School Nurses In Western Australia, Anita Moyes, Shirley Mcgough, Dianne Wynaden

Research outputs 2022 to 2026

Schools are an important setting for the early identification, assessment and intervention of mental health problems in children and young people. Internationally, many nurses work in schools, but the role of this group with young people experiencing mental health problems has had only limited investigation. This study explored the activities school nurses undertook with young people experiencing mental health problems in Australia. Reporting was guided by the COREQ checklist. Thirty-one nurses participated in a semi-structured interview. Data were analysed using the constant comparative method of analysis as developed by Glaser and Strauss (1967). The findings identified that nurses working in …

Midwives’ Experiences Of The Consequences Of Navigating Barriers To Maternity Care, Yakubu Ismaila, Sara Bayes, Sadie Geraghty

Research outputs 2022 to 2026

Midwives in Low- and middle-income countries, experience myriad barriers that have consequences for them and for maternity care. This article provides insight into the consequences of the barriers that Ghanaian midwives face in their workplaces. Glaserian Grounded Theory methodology using semi-structured interviews and non-participant observations was applied in this study. The study participants comprised of 29 midwives and a pharmacist, a social worker, a health services manager, and a National Insurance Scheme manager in Ghana. Data collection and analysis occurred concurrently while building on already analyzed data. In this study it was identified that barriers to Ghanaian midwives’ ability to …

Factors Associated With Risk Of Falling Among Younger Inpatients In A Mental Health Setting—A Systematic Review, Irene Ngune, Seng Giap Marcus Ang, Gelaye Nadew, Rosemary Saunders

Research outputs 2022 to 2026

Aim: To synthesise evidence related to risk factors of falls among younger mental health inpatients age ≤ 65 years old. Background: Hospitalised patients with mental illness are at increased risk of falling. Specific risk factors for falls for younger inpatients are poorly understood. Design: Systematic review. Methods: Medline, CINAHL, APA PsycINFO, Scopus and Web of Science were searched for studies published in English till December 2022. The review followed the 2020 PRISMA checklist. Odds ratios and P values of significant risk fall factors and the frequency of factors related to circumstances of falls were extracted. Results: Nine studies were included …

A Hybrid Systematic Narrative Review Of Instruments Measuring Home-Based Care Nurses' Competency, Khairul D. B. Rusli, Wei L. Chua, Wei H. D. Ang, Seng G. M. Ang, Ying Lau, Sok Y. Liaw

Research outputs 2022 to 2026

Aim: The aim of the study was to identify and synthesize the contents and the psychometric properties of the existing instruments measuring home-based care (HBC) nurses' competencies. Design: A hybrid systematic narrative review was performed. Review Methods: The eligible studies were reviewed to identify the competencies measured by the instruments for HBC nurses. The psychometric properties of instruments in development and psychometric testing design studies were also examined. The methodological quality of the studies was evaluated using the Medical Education Research Study Quality Instrument and COSMIN checklist accordingly. Data Sources: Relevant studies were searched on CINAHL, MEDLINE (via PubMed), EMBASE, …

Evidence-Based Guidelines For Intrapartum Maternal Hydration Assessment And Management: A Scoping Review, Lauren Kearney, Alison Craswell, Nellie Dick, Debbie Massey, Rachael Nugent

Research outputs 2022 to 2026

Problem: Inconsistent practice relating to intrapartum hydration assessment and management is reported, and potential harm exists for laboring women and birthing persons. Background: Labor and birth are physically demanding, and adequate nutrition and hydration are essential for labor progress. A lack of clear consensus on intrapartum hydration assessment and management during labor and birth currently exists. In addition, there is an inconsistent approach to managing hydration, often including a mixture of intravenous and oral fluids that are poorly monitored. Aim: The aim of this scoping review was to identify and collate evidence-based guidelines for intrapartum hydration assessment and management of …

Developing Nurse-Sensitive Outcomes In Acute Inpatient Mental Health Settings—A Systematic Review, Irene Ngune, Helen Myers, Amanda Cole, Peter Palamara, Robina Redknap, Michael Roche, Diane Twigg

Research outputs 2022 to 2026

Background: While nurse-sensitive outcomes (NSOs) are well established in numerous health settings, to date there is no indicator suite of NSOs for inpatient mental health settings. Aim: To assess the relationship between nursing variables and patient outcomes in acute inpatient mental health settings to determine which outcomes can be used as indicators of the quality of nursing care. Methods: Databases accessed were CINAHL, MEDLINE, PsycINFO and EMBASE, last searched in May 2022. The review followed the 2020 PRISMA checklist for systematic reviews. Papers published between 1995 and 2022, conducted in acute mental health care units were included. The quality of …