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Articles 1 - 30 of 79
Full-Text Articles in Medicine and Health Sciences
Expressive Therapies And Resiliency – Resistance In Mental Health: A Literature Review, Gabrielle Lopez
Expressive Therapies And Resiliency – Resistance In Mental Health: A Literature Review, Gabrielle Lopez
Expressive Therapies Capstone Theses
This review evaluates the current literature on psychological resistance amongst human service professionals experiencing burnout and the effect of Expressive Arts interventions on resiliency. Concepts include identifying the main symptoms, risk factors, causes, and treatments for burnout in education faculty, medical staff, and clinicians. Qualitative, quantitative, and meta-analysis studies are included to identify the most prevalent intervention frameworks for reducing stress including Arts-Based and Mindfulness-compassion based techniques. The effectiveness of Arts-based tools on strengthening identity, self-esteem, emotional regulation, and meaning-making in combating burnout is presented. Based on analysis of the literature, the author proposes a three-step intervention framework for utilizing …
An Evidence-Based Approach For Decreasing Burnout In Health Care Workers, Leonor T. Salalila
An Evidence-Based Approach For Decreasing Burnout In Health Care Workers, Leonor T. Salalila
Student Scholarly Projects
Practice Problem: Health care worker (HCW) burnout is a pervasive phenomenon within the healthcare industry, affecting professionals across various disciplines. Emotional exhaustion is a prominent feature, leading to feelings of being emotionally drained, overwhelmed, and unable to cope effectively with the demands of the job. Additionally, burnout often results in a significant lack of motivation among HCWs, who may struggle to find meaning and purpose in their work, exacerbating feelings of frustration and disillusionment. Consequences extend beyond individual well-being, impacting healthcare organizations with reduced work efficacy, low productivity, increased absenteeism, and high turnover rates. Addressing burnout requires a multifaceted approach, …
Virtual Delivery Of Stress Management And Resiliency Training (Smart) During The Covid-19 Pandemic To Hematology/Oncology Fellows: A Pilot Study, Colt Williams, Sherry Chesak, Deirdre R. Pachman, Ross Dierkhising, Laura Rhee, Konstantinos Leventakos
Virtual Delivery Of Stress Management And Resiliency Training (Smart) During The Covid-19 Pandemic To Hematology/Oncology Fellows: A Pilot Study, Colt Williams, Sherry Chesak, Deirdre R. Pachman, Ross Dierkhising, Laura Rhee, Konstantinos Leventakos
Journal of Wellness
Introduction: Medical trainees experience a high degree of stress that predisposes them to burnout. This pilot study tested a scalable approach to deliver a validated resilience program (Stress Management and Resiliency Training (SMART)) among Hematology/Oncology fellows at an academic medical center.
Methods: This was a mixed-methods, prospective, single-arm clinical trial involving Hematology/Oncology fellows at Mayo Clinic in Rochester, MN, USA. Four one-hour training sessions were conducted virtually with 26 fellows. Stress, burnout, and emotional resilience were measured at baseline, three months, and six months post-intervention using the Perceived Stress Scale (PSS-10), Maslach Burnout Inventory (MBI-HSS), and Connor-Davidson Resilience …
Examining The Evidence Base For Burnout, Renzo Bianchi, Irvin Schonfeld
Examining The Evidence Base For Burnout, Renzo Bianchi, Irvin Schonfeld
Publications and Research
Burnout has elicited growing interest among occupational health specialists in recent decades. Since 2019, the World Health Organization has characterized burnout as a syndrome resulting from chronic, unmanageable workplace stress. Accordingly, three symptoms define the entity: (i) feelings of energy depletion or exhaustion; (ii) increased mental distance from one’s job or feelings of negativism or cynicism towards one’s job; and (iii) a sense of ineffectiveness and lack of accomplishment. We call into question the definition of burnout embodied in the Maslach Burnout Inventory and incorporated into the ICD-11. We draw stakeholders’ attention to the fact that burnout’s symptoms and etiology …
Examining The Evidence Base For Burnout, Renzo Bianchi, Irvin Sam Schonfeld
Examining The Evidence Base For Burnout, Renzo Bianchi, Irvin Sam Schonfeld
Publications and Research
Burnout has elicited growing interest among occupational health specialists in recent decades. Since 2019, the World Health Organization has characterized burnout as a syndrome resulting from chronic, unmanageable workplace stress. According to the ICD-11, three symptoms define the entity: feelings of exhaustion, increased mental distance from one’s job, and a sense of ineffectiveness at work, all of which correspond to the structure of the Maslach Burnout Inventory. The ICD-11 includes burnout among the factors that influence health status. This paper calls into question that conceptualization based on a number of lines of evidence. The evidence includes the following: burnout was …
Adverse Childhood Experiences And Resilience In Medical School Students: A Scope Of Medical Literature, Andrea Soto Abarca, Yvette Cortino, Juan Carlos Lopez Alvarenga, Maya Guevara
Adverse Childhood Experiences And Resilience In Medical School Students: A Scope Of Medical Literature, Andrea Soto Abarca, Yvette Cortino, Juan Carlos Lopez Alvarenga, Maya Guevara
Research Symposium
Background: Adverse childhood experiences (ACEs) represent types of childhood trauma that are associated with long-term negative effects on health and wellbeing. An elevated number of ACEs can lead to depression, suicidality, alcoholism, and substance use. Factors that can protect a person from increased health risks include resilience, which is broadly defined as the ability to bounce back from adversity. Few studies have analyzed the exposure of ACEs in medical students, however, there is extensive literature on how low levels of resilience are linked to higher rates of depression, fatigue, and burnout among medical students. Little is known about the …
Using Drama Therapy To Foster Peer Support Among Nurse Leaders, Chyela Rowe
Using Drama Therapy To Foster Peer Support Among Nurse Leaders, Chyela Rowe
Expressive Therapies Dissertations
This study explored the use of drama therapy to support the social-emotional experiences of nurse leaders at a mid-sized regional hospital system in the Southeastern United States. Nurse leaders have experienced profound changes to their work environments in recent years and burnout has been at an all-time high among healthcare workers globally. Organizational supports for nurses and nurse leaders are both inadequate to meet the needs and under-resourced. The research questions explored 1) whether the drama therapy peer support initiative improved outcomes and 2) whether there was a significant relationship between measures, and 3) what nurse leaders described as facilitators …
Burnout In Medical Assistants In Primary Care: Can Mindfulness Be A Solution?, Natalee D. Calais
Burnout In Medical Assistants In Primary Care: Can Mindfulness Be A Solution?, Natalee D. Calais
Electronic Theses and Dissertations
Burnout is described as feelings associated with emotional exhaustion, depersonalization of patients, and a loss of sense of personal accomplishment and it is unique to healthcare workers. Current research highlights this condition among physicians, nurses, and mid-level providers; however, insufficient research exists regarding the effects of burnout on medical assistants. Research led to mindfulness as a possible solution defined as an intentional regulation of attention and awareness of the present moment. This project sought to see if mindfulness practices could be utilized to mitigate the effects of burnout in medical assistants. It was hypothesized that mindfulness could be a solution. …
Occupational Depression In Italy: Associations With Health, Economic, And Work-Life Characteristics, Renzo Bianchi, Caterina Fiorilli, Giacomo Angelini, Nicoletta Dozio, Carlo Palazzi, Gloria Palazzi, Benedetto Vitiello, Irvin Sam Schonfeld
Occupational Depression In Italy: Associations With Health, Economic, And Work-Life Characteristics, Renzo Bianchi, Caterina Fiorilli, Giacomo Angelini, Nicoletta Dozio, Carlo Palazzi, Gloria Palazzi, Benedetto Vitiello, Irvin Sam Schonfeld
Publications and Research
Background: The Occupational Depression Inventory (ODI) reflects a new approach to job-related distress centered on work-attributed depressive symptoms. The instrument was developed with reference to the characterization of major depression found in the DSM-5. The ODI has been validated in English, French, and Spanish. This study (a) investigated the psychometric and structural properties of the ODI’s Italian version and (b) inquired into the nomological network of occupational depression. Methods: A convenience sample of 963 employed individuals was recruited in Italy (69.9% female; mean age = 40.433). We notably relied on exploratory structural equation modeling bifactor analysis, common-practice …
Burned-Out With Burnout? Insights From Historical Analysis, Renzo Bianchi, Katarzyna Wac, James Francis Sowden, Irvin Sam Schonfeld
Burned-Out With Burnout? Insights From Historical Analysis, Renzo Bianchi, Katarzyna Wac, James Francis Sowden, Irvin Sam Schonfeld
Publications and Research
Fierce debates surround the conceptualization and measurement of job-related distress in occupational health science. The use of burnout as an index of job-related distress, though commonplace, has increasingly been called into question. In this paper, we first highlight foundational problems that undermine the burnout construct and its legacy measure, the Maslach Burnout Inventory (MBI). Next, we report on advances in research on job-related distress that depart from the use of the burnout construct. Tracing the genesis of the burnout construct, we observe that (a) burnout’s definition was preestablished rather than derived from a rigorous research process and (b) the MBI …
A Resident Retreat With Emergency Medicine Specific Mindfulness Training Significantly Reduces Burnout And Perceived Stress, James O'Shea, Mark Dannenfelser, Melissa White, Anwar Osborne, Timothy P. Moran, Michelle D. Lall
A Resident Retreat With Emergency Medicine Specific Mindfulness Training Significantly Reduces Burnout And Perceived Stress, James O'Shea, Mark Dannenfelser, Melissa White, Anwar Osborne, Timothy P. Moran, Michelle D. Lall
Journal of Wellness
Introduction: We hypothesize that a resident retreat with mindfulness training tailored for Emergency Medicine (EM) physicians can significantly reduce levels of burnout and perceived stress in EM residents.
Methods: We conducted an intervention study of 60 EM residents undergoing an annual resident retreat with a 2.5-hour mindfulness training. The retreat was a department-funded 2-day off-site experience with a wellness theme. The training was developed and delivered by an EM physician (JO'S) who is a Mindfulness-Based Stress Reduction (MBSR) teacher trainee, and a certified MBSR teacher (MD). The training focused on techniques that can be used on shift, such as mindful …
J Mich Dent Assoc July 2022
The Journal of the Michigan Dental Association
Monthly, The Journal of the Michigan Dental Association brings news, information, and feature articles to our state's oral health community and the MDA's 6,200+ members. No publication reaches more Michigan dentists! In this July 2022 issue, the reader will find the following original content:
- A cover feature on negotiating reimbursement rates with PPO contracts.
- A cover feature on guarding against employee embezzlement.
- A 10-Minute EBD on rampant caries management and prevention with ADHD patients taking stimulant medications.
- A Back Page look at the 2022 MDA award winners.
- News you need: an Editorial, guidance on dental practice cybersecurity, and regular department …
Professional Quality Of Life In Respiratory Therapists: A Cross-Sectional Study Of The Prevalence And Predictors For Compassion Satisfaction, Burnout, And Secondary Traumatic Stress, Sarah Pehlke
Graduate Theses, Dissertations, and Capstones
Background: Research on professional quality of life (QOL) variables in healthcare providers proliferated following the onset of the COVID-19 pandemic. Evidence suggests that caregiving careers have positive and negative effects (Beck, 2011). Insufficient research describes these effects in respiratory therapists (RTs), a group of healthcare practitioners who often work in high-stress situations and provide care to high-acuity patient populations.
Purpose: This study evaluated the prevalence and predictors of professional QOL factors, compassion satisfaction (CS), burnout, and secondary traumatic stress (STS), in staff RTs in the United States.
Methods: RTs were invited to participate in a cross-sectional survey evaluating demographics, workplace …
The Impact Of Student Trauma: A Quantitative Investigation On Secondary Traumatic Stress And It's Effects On Nursing Faculty, Devon L. Luthens
The Impact Of Student Trauma: A Quantitative Investigation On Secondary Traumatic Stress And It's Effects On Nursing Faculty, Devon L. Luthens
Education Doctorate Dissertations
The increase in student trauma and mental illness is putting direct care professionals such as educators at risk of secondary traumatic stress. The purpose of this quantitative survey method research was to explore how nursing faculty within the Minnesota State system were affected by their work with traumatized students and if they experienced significant distress or impairment. The theoretical framework guiding this dissertation was the McCann and Pearlman’s Constructivist Self Development (CSD) theory. There were two research questions that led this study: Does the amount of exposure to student trauma relate to the level of secondary traumatic stress experienced by …
Alzheimer's And Patient Caregiver Burnout: A Review Of The Literature, Madeline Hekeler
Alzheimer's And Patient Caregiver Burnout: A Review Of The Literature, Madeline Hekeler
James Madison Undergraduate Research Journal (JMURJ)
The term “silent epidemic” is fitting for Alzheimer’s disease (AD), as its negative impact is widely felt but rarely discussed. Burnout among AD caregivers has become an epidemic of its own as caregivers experience an increase in health risks, stress, and financial burden. This literature review focuses on caregiver burnout and how imperative it is that caregivers are better supported in their role. Researchers have developed instruments to assess and intervene in caregiver burnout that have shown effectiveness among caregivers and their families.Nevertheless, further longitudinal research is warranted regarding more effective interventions, including stress management and social support mechanisms.
Adverse Childhood Experiences And Resilience In Medical School Students: A Scope Of Medical Literature, Andrea Soto Abarca, Yvette Cortino, Juan C. Lopez-Alvarenga, Maya Guevara
Adverse Childhood Experiences And Resilience In Medical School Students: A Scope Of Medical Literature, Andrea Soto Abarca, Yvette Cortino, Juan C. Lopez-Alvarenga, Maya Guevara
MEDI 9331 Scholarly Activities Clinical Years
Background: Adverse childhood experiences (ACEs) represent certain types of childhood trauma that are associated with long-term negative effects on health and wellbeing. The elevated number of ACEs can lead to depression, suicidality, alcoholism, and substance use. Factors that can protect a person from increased health risks include resilience, which is broadly defined as the ability to overcome challenges or bounce back from adversity. Few studies have analyzed the exposure of ACEs in medical students, however, there has been extensive literature on how low levels of resilience are linked to higher rates of depression, fatigue, and burnout among medical students. …
Reducing Burnout Through Guaranteed Breaks In Nurses In The Acute Care Setting: A Benchmark Study, Stefan D. Arias
Reducing Burnout Through Guaranteed Breaks In Nurses In The Acute Care Setting: A Benchmark Study, Stefan D. Arias
MSN Capstone Projects
This benchmark study attempts to promulgate the issue of burnout and the importance of addressing at least one way to mitigate further damage to the profession of nursing.
Physical Therapy And Occupational Therapy Well-Being, Jenna Pilkington, Dara Musher-Eizenman, Cindi Baum, Elizabeth Emley
Physical Therapy And Occupational Therapy Well-Being, Jenna Pilkington, Dara Musher-Eizenman, Cindi Baum, Elizabeth Emley
Honors Projects
There is a lack of research in the professions of physical therapy and occupational therapy. To be more specific, the areas of stress and burnout have been topics of research within the healthcare field for medical physicians and nurses, but currently there is little research looking at stress and burnout for physical therapists and occupational therapists. (Anderson 2015; Berry 2019). The current study aims to look at the emotional connections between patients and professions, along with the related emotional stress experienced by these professionals. A survey was administered to 59 physical therapists and occupational therapists for the purpose to give …
Burnout In The Nursing Profession: Extant Knowledge And Future Directions For Research And Practice, Sara Labelle
Burnout In The Nursing Profession: Extant Knowledge And Future Directions For Research And Practice, Sara Labelle
Communication Faculty Articles and Research
Burnout is a psychological state resulting from prolonged psychological or emotional job stress, and is a culmination of three factors: emotional exhaustion, depersonalization, and reduced personal accomplishment. Due to the nature of the “people-work” they must constantly perform, along with a highly stressful and unpredictable work environment, nurses have alarmingly high rates of burnout among members of their profession. Given the importance of research on burnout to understanding the context-specific stressors and challenges of nursing, this review offers a synthesis of research published in the last decade in both nursing and communication journals, with an emphasis on discussing opportunities for …
Who Needs To Be “Burned-Out”? Time For A New Approach To Job-Related Distress, Renzo Bianchi, Irvin Sam Schonfeld
Who Needs To Be “Burned-Out”? Time For A New Approach To Job-Related Distress, Renzo Bianchi, Irvin Sam Schonfeld
Publications and Research
Burnout is a popular indicator of job-related distress, notably in research on the ill-being of medical professionals. The burnout construct is, however, plagued by definitional and measurement problems. Often unnoticed, these problems undermine findings and conclusions emanating from burnout research. The definitional and measurement problems affecting the burnout construct hamper knowledge growth, waste resources, and impede our ability to make informed decisions and take effective action to support personnel. It is time for occupational health specialists to abandon the idea of burnout and focus on occupational depression.
Physician Burnout Among West Virginia Primary Care Providers, Kevin S. Mccann, Adam Baus, Joanna Bailey, Laura Boone, Jennifer Boyd, Martha Cook-Carter, Dan Doyle
Physician Burnout Among West Virginia Primary Care Providers, Kevin S. Mccann, Adam Baus, Joanna Bailey, Laura Boone, Jennifer Boyd, Martha Cook-Carter, Dan Doyle
Marshall Journal of Medicine
Introduction
Work related burnout is highly prevalent in US physicians and linked to adverse effects on patients, providers and organizations. This study measures burnout in West Virginia (WV) primary care providers, allowing for comparison of results to a similar, recent study of US physicians.
Methods
Anonymous survey through email that included Maslach Burnout Inventory, demographic, workload, and practice characteristics. Responses were analyzed using JMP Pro 13. Analysis used JMP Pro 13 for descriptive statistics, chi-square and regression modeling.
Results
Subjects = 110, female/male ratio 1.4, all primary care physicians (PCP), or advanced practice registered nurses or physician assistants (APRN/PA). PCP …
Medical Schools Ignore The Nature Of Consciousness At Great Cost, Anoop Kumar
Medical Schools Ignore The Nature Of Consciousness At Great Cost, Anoop Kumar
Journal of Wellness
The essential question of the relationship between consciousness and matter is ignored in medical school curricula, leading to a machine-like view of the human being that contributes to physician burnout and intellectual dissatisfaction. The evidence suggesting that the brain may not be the seat of consciousness is generally ignored to preserve the worldview of the primacy of matter. By investigating new frameworks detailing the nature of consciousness at different levels of hierarchy, we can bring intellectual rigor to a once opaque subject that supports a fundamental reality about our experience: We are human beings, not only human bodies.
Do You K Now D.O.?: Pre Medical Students’ Knowledge Of Osteopathic Medicine And Its Relation To Burnout, Philip Collins, Laura Collins, Gianna Bowler Darrow, Jennifer C Sepede
Do You K Now D.O.?: Pre Medical Students’ Knowledge Of Osteopathic Medicine And Its Relation To Burnout, Philip Collins, Laura Collins, Gianna Bowler Darrow, Jennifer C Sepede
Rowan-Virtua Research Day
It is estimated that in the near future there will be a shortage of physicians available to keep up with the needs of a growing older population. To try to account for this, medical schools are expanding class sizes and new schools are being created. While both allopathic and osteopathic schools are expanding, osteopathic schools are doing so a much faster rate. Unfortunately, it seems many students enter their undergraduate careers unaware of osteopathic medicine despite having an interest in medical school. Undergraduate student interest in becoming a medical doctor continues to rise, but so too does the difficulty of …
Comparison Of Alexithymia And Burnout Amid Perceived Stress Levels Of Nursing Students, Kamela Harmon
Comparison Of Alexithymia And Burnout Amid Perceived Stress Levels Of Nursing Students, Kamela Harmon
Scholar Week 2016 - present
Graduate level nursing students are exposed to overload and exhaustion due to academic and professional demands, increasing exposure to stressors resulting in elevated levels of perceived stress, burnout, and alexithymia. This quantitative research, utilizing an online methodology at a midwestern university, explored the prevalence of perceived stress, compassion satisfaction (CS), compassion fatigue (CF), burnout, and alexithymia among master’s level nursing students. The descriptive analysis utilized the Pearson correlation coefficient (Pearson r) by use of the Perceived Stress Scale (PSS-10), the Professional Quality of Life Scale (ProQOL), and the Toronto Alexithymia Scale (TAS-20). The researcher discovered statistically significant negative correlations …
Psychiatrist Burnout, Irvin Sam Schonfeld, Renzo Bianchi
Psychiatrist Burnout, Irvin Sam Schonfeld, Renzo Bianchi
Publications and Research
We critique a paper published by Summers et al. (2020) and papers in general that, because of flawed methods, arrive at exceedingly high estimates of burnout in psychiatrists and other professionals.
The Occupational Depression Inventory—A Solution For Estimating The Prevalence Of Job-Related Distress, Renzo Bianchi, Irvin Sam Schonfeld
The Occupational Depression Inventory—A Solution For Estimating The Prevalence Of Job-Related Distress, Renzo Bianchi, Irvin Sam Schonfeld
Publications and Research
We are concerned about researchers’ reliance on the burnout construct and the MBI-GS to estimate the prevalence of job-related distress. In this paper, we first describe some of the problems plaguing the burnout construct and its measures. Then, we present the Occupational Depression Inventory, a new instrument designed to help occupational health specialists get a clearer view of the mental health status of the workforce (Bianchi and Schonfeld, 2020).
The Science Of Happiness And Its Effect On Professional Quality Of Life In Mental Health Providers, Mona E. Yeary
The Science Of Happiness And Its Effect On Professional Quality Of Life In Mental Health Providers, Mona E. Yeary
DNP Research Projects
Abstract
OBJECTIVE: The science of happiness is part of the field of positive psychology, which should not be confused with positive thinking, self-help, or religious beliefs, but is considered a scientific evidence- based practice. The purpose of this quantitative, descriptive, study was to examine the relationship of education on the science of happiness and a gratitude intervention on subjective happiness and professional quality of life of mental health care providers.
METHODS: The mental healthcare providers for this study included psychiatrists, advanced practice nurses, physician’s assistants, psychologists, social -work and registered nurses in a large medical system in Tennessee …
A Solution For Breaking The Impasse Of Burnout Measurement, Renzo Bianchi, Irvin Sam Schonfeld
A Solution For Breaking The Impasse Of Burnout Measurement, Renzo Bianchi, Irvin Sam Schonfeld
Publications and Research
In view of the profound problems affecting burnout’s conceptualization and measurement and because there is now robust evidence that burnout is a depressive condition, we recommend that occupational health specialists shift their focus from burnout to depression. A measure of job-related depressive symptoms, the Occupational Depression Inventory (ODI), has recently been developed. Advantageously, the ODI resolves many of the persistent problems linked to burnout while being consistent with burnout researchers’ original aim of assessing a work-attributed form of distress. The ODI includes a diagnostic algorithm that allows investigators to estimate the prevalence of depressive disorders that individuals specifically ascribe to …
Occupational Depression, Cognitive Performance, And Task Appreciation: A Study Based On Raven’S Advanced Progressive Matrices, Renzo Bianchi, Irvin Sam Schonfeld
Occupational Depression, Cognitive Performance, And Task Appreciation: A Study Based On Raven’S Advanced Progressive Matrices, Renzo Bianchi, Irvin Sam Schonfeld
Publications and Research
The Occupational Depression Inventory (ODI) was recently developed to assess depressive symptoms that individuals specifically attribute to their work. Research on the criterion validity of the instrument is still in its infancy. In this study, we examined whether the ODI predicted performance on, and appreciation of, a cognitively challenging test. In light of the link established between clinical depression and neuropsychological impairment, and considering that individuals with depressive symptoms are more likely to feel helpless under challenging circumstances, we hypothesized that occupational depression would be associated with poorer cognitive performance and a darkened appreciation of the task undertaken. We relied …
Is Burnout A Depressive Condition? A 14-Sample Meta-Analytic And Bifactor Analytic Study, Renzo Bianchi, Jay Verkuilen, Irvin S. Schonfeld, Jari J. Hakanen, Markus Jansson-Fröjmark, Guadalupe Manzano-García, Eric Laurent, Laurenz L. Meier
Is Burnout A Depressive Condition? A 14-Sample Meta-Analytic And Bifactor Analytic Study, Renzo Bianchi, Jay Verkuilen, Irvin S. Schonfeld, Jari J. Hakanen, Markus Jansson-Fröjmark, Guadalupe Manzano-García, Eric Laurent, Laurenz L. Meier
Publications and Research
There is no consensus on whether burnout constitutes a depressive condition or an original entity requiring specific medical and legal recognition. In this study, we examined burnout–depression overlap using 14 samples of individuals from various countries and occupational domains (N = 12,417). Meta-analytically pooled disattenuated correlations indicated (a) that exhaustion—burnout’s core—is more closely associated with depressive symptoms than with the other putative dimensions of burnout (detachment and efficacy) and (b) that the exhaustion–depression association is problematically strong from a discriminant validity standpoint (r = .80). The overlap of burnout’s core dimension with depression was further illuminated in 14 exploratory structural …